Factors affecting bacterial biofilm expression in chronic rhinosinusitis and the influences on prognosis

Purpose

The purpose of the study was to investigate the expression of bacterial biofilm (BF) for chronic rhinosinusitis (CRS) and to find out factors affecting BF expression and the influences on its prognosis.

Materials and Methods

All specimens were analyzed by a scanning electron microscope and bacterial cultivation from a panel of 93 patients with CRS, 20 with nasal septum deviation, and 17 with nasal bone fractures as the control group. Referring to the grade classification criteria from the sinusitis-specific questionnaire Sino-Nasal Outcome Test-20, patients were assessed preoperatively based on common clinical manifestations. Patients were followed up for condition improvement as assessed by visual analogue scale and nasal endoscopic examination.

Results

In the experimental group, among all the patients, 3 were lost (lost 3.2%). Bacterial biofilm was positive in 64 (71.1%) of 90 patients. Mucosal cilia were observed in varying degrees of injury. Bacterial culture was positive in 60 (66.7%) patients. In the control group, no BF was found and no bacterium was cultured. Bacterial biofilm expression was correlated with the bacterial culture. The BF(+) patients' visual analogue scale scores 6 months and 1 year postoperation were lower than the BF(−) patients' scores (P < .05). The BF(+) patients' Lund-Kennedy scores at 6 months and 1 year postoperation were higher than the BF(−) patients' scores (P < .05).

Conclusions

Bacterial biofilm is involved in the pathogenesis of CRS and is associated with the bacterial culture. Bacterial biofilm has a certain impact on patients' prognosis.     

Homoplasmy of the G7444A mtDNA and heterozygosity of the GJB2 c.35delG mutations in a family with hearing loss

Objective

Mitochondrial mutations have been shown to be responsible for syndromic as well as non-syndromic hearing loss. The G7444A mitochondrial DNA mutation affects COI/the precursor of tRNA^Ser(UCN), encoding the first subunit of cytochrome oxidase. Here we report on the first Greek family with the G7444A mitochondrial DNA mutation.

Methods

Clinical, cytogenetic, and molecular methods were employed in this study.

Results

We describe the high variability of phenotypes among three family members harboring the G7444A mutation and also the frequent GJB2 c.35delG mutation of the nuclear genome in heterozygosity. Their phenotypes ranged from normal hearing to deafness, while the proband presented with several other symptoms.

Conclusions

The G7444A mitochondrial DNA mutation has been reported in only a few cases worldwide, alone or in cosegregation with other mitochondrial DNA mutations, but to our knowledge, never before in coexistence with the GJB2 c.35delG mutation.     

Identification of adenoid biofilms with middle ear pathogens in otitis-prone children utilizing SEM and FISH

Objectives

Biofilms have been implicated in the development of several chronic infections. We sought to demonstrate middle ear pathogens in adenoid biofilms using scanning electron microscopy (SEM) and fluorescent in situ hybridization (FISH) with confocal laser scanning microscopy (CLSM).

Methods

Comparative micro-anatomic investigation of adenoid mucosa using SEM and FISH with confocal scanning laser microscopic (CLSM) imaging from patients with recurrent acute otitis media (RAOM).

Results

All otitis-prone children demonstrated biofilm surface area presence greater than 85% by SEM. FISH accompanied by CLSM imaging also demonstrated patchy biofilms All biofilms contained middle ear pathogens and were frequent in polymicrobial distributions: 4 of 6, 4 of 6 and 3 of 6 samples contained Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, respectively.

Conclusions

Dense adenoid biofilms may act as a reservoir for reinfection of the tubotympanum. Aspiration of planktonic middle ear pathogens existing in resistant adenoid biofilms during a viral upper respiratory tract infection may be an important event in the development of RAOM.     

Does rapid maxillary expansion increase nasopharyngeal space and improve nasal airway resistance?

Objective

To evaluate the effect of rapid maxillary expansion (RME) on the dimension of the nasopharyngeal space and its relation to nasal airway resistance.

Methods

Twenty-five school-age children (from 7 to 10 year-old) with mouth and/or mixed breathing, with mixed dentition and uni- or bilateral posterior crossbite involving the deciduous canines and the first permanent molars, were evaluated. RME was placed and remained during 90 days. Rhinomanometry and orthodontic documentation were performed at four different times, i.e., before (T₁), immediately after (T₂), 90 days (T₃) and 30 months (T₄) after RME.

Results

Differences in nasopharyngeal area and in nasal airway resistance were observed only 30 months after RME, and could be explained by facial growth, and not because of the orthodontic procedure.

Conclusion

RME does not influence on nasopharyngeal area or nasal airway resistance in long-term evaluation.     

The phenotypic and genetic biofilm formation characteristics of coagulase-negative staphylococci isolates in children with otitis media

Objective

Medical biofilms are involved in a number of chronic infections including otitis media with effusion and chronic rhinosinusitis, which are common pediatric infectious diseases. The purpose of the study was to analyze the phenotypic and genotypic indicators of biofilm formation of coagulase negative staphylococci isolates in children with otitis media with effusion, and in children with chronic rhinosinusitis as a comparison group by using three different detection methods.

Methods

Forty nine children aged from 2 to 6 years old, diagnosed with otitis media with effusion were enrolled to the study. The comparative group consisted of twenty three strains of coagulase-negative staphylococci from the strains collection isolated from nose swabs from children 3 to 7 years old suffering from rhinosinusitis for longer than 12 weeks. Cultured strains were tested for biofilm formation ability with three tests: Congo red agar, tissue culture plate methods and detection of ica operon.

Results

Out of 97 ear effusion specimens, obtained from 49 children suffering from OME, 38 were found positive in conventional culture resulting in isolation of 50 different bacterial species. Nested-PCR method confirmed bacterial presence in 95 (97.9%) cases. Among 50 different bacterial species isolated, 30 (30.9%) CNS and 20 (20.6%) other than CNS species.Detection of slime producing phenotype of CNS was performed with CRA plate test. Among OME isolates, 11 (36.7%) were CRA plate test positive. In case of isolates from CRS, 8 (34.8%) strains revealed black coloration on CRA.Using TCP method, strong adherence to microtiter plate was observed in two Staphylococcus epidermidis strains from OME and two S. epidermidis from CRS.By using the ica operon test, the genotypic ability to form biofilm was identified in 7 (23.3%) S. epidermidis strains cultured from ears effusion and in 3 (13%) strains from nose swabs.

Conclusions

CNS strains revealed genotypic and phenotypic features responsible for the ability to form the biofilm in vivo. The presence of ica genes and phenotypic ability to form a biofilm by CNS strains emphasizes the pathogenic character of these strains in some cases of otitis media with effusion.     

Single-shot, low-dose intratympanic gentamicin in Ménière disease: role of vestibular-evoked myogenic potentials and caloric test in the prediction of outcome

Objective

The aim of this study was to assess the efficacy and safety of single and low-dose intratympanic gentamicin therapy in patients with Ménière disease and who were monitored both with caloric tests and vestibular-evoked myogenic potentials (VEMPs) to see if VEMPs have an additional role in predicting the efficacy of the drug.

Study design

This is a prospective cohort study.

Setting

Tertiary referral center is the study setting.

Patients

Twenty-five intractable Ménière disease patients were included as the study group.

Intervention(s)

Low-dose (16 mg/mL), single-shot intratympanic gentamicin was applied. VEMP and caloric test were applied 2 weeks after the application.

Main outcome measure(s)

Safety and efficacy of protocol were evaluated at the sixth month postoperatively with tonal audiogram and visual analog scale, respectively.

Results

Mean average pure-tone hearing threshold at 0.5, 1, 2, 4, and 8 kHz was 49.6 and 51.0 dB before and after the application, respectively (P > .05). Mean pretreatment and posttreatment visual analog scale scores of patients were 17.6 mm (10-30 mm) and 74.6 mm (41-100 mm), respectively (P < .01). Posttreatment VEMPs were absent in 17, deteriorated in 2, and not changed in 6 patients. VEMP was a significant predictor of posttreatment visual analog scale score, whereas caloric test was not (P < .01).

Conclusions

Low-dose, single-shot intratympanic gentamicin treatment proved to be effective and safe among intractable Ménière patients. VEMPs obtained at posttreatment second week were significant predictors of patients posttreatment sixth-month dizziness status and vertigo control.     

Treatment patterns of pediatric nontuberculous mycobacterial (NTM) cervical lymphadenitis as reported by nationwide surveys of pediatric otolaryngology and infectious disease societies

Objective

To describe physician diagnostic and therapeutic strategies for pediatric nontuberculous mycobacterial (NTM) lymphadenitis, a disease for which surgical excision is recommended.

Methods

We surveyed members of the Infectious Diseases Society of America Emerging Infections Network (EIN) and the American Society of Pediatric Otolaryngology (ASPO). We asked them to report clinical and microbiologic details of recent cases of NTM lymphadenitis seen in their practices.

Results

200 physicians reported a total of 277 NTM lymphadenitis cases. Cervical lymph nodes (84%) were most frequently involved, and a majority of patients were non-Hispanic white (62%) males (54%) with median age 3.0 years. Tissue culture (61%) or polymerase chain reaction (12%) was utilized most frequently to confirm NTM etiology. In most (59%) cases, an etiologic organism was not identified. In cases, where an NTM organism isolate was identified, Mycobacterium avium complex (n = 82, 72%) was the most common. Surgical excision followed by adjunctive antibiotic therapy was favored in the majority (59%) of cases where a treatment method was reported. The use of surgical excision alone or antibiotic therapy alone was reported respectively in 24% and 17% of cases. Antibiotics were prescribed without diagnostic confirmation of infectious organisms in 28% of cases.

Conclusion

Pediatric otolaryngologists and infectious disease specialists frequently treat cervical lymphadenitis empirically as NTM disease without bacteriologic confirmation. Antibiotic therapy is frequently employed with or without surgical excision.     

The role of HPV type in Recurrent Respiratory Papillomatosis

Objective

Human Papillomavirus (HPV) 6 and 11 are the aetiological agents responsible for Recurrent Respiratory Papillomatosis (RRP). There is general consensus that HPV11 results in more aggressive disease compared to HPV6.

Method

Pubmed was searched using the terms respiratory papillomatosis, HPV 6 and HPV11. Comparisons were made in the outcomes of HPV6 versus HPV11 positive RRP disease.

Results

There are numerous sub-types or variants of both HPV6 and HPV11. These sub-types have different activities at least in-vitro. The numbers of different HPV types within RRP tissue may be more extensive than initially appeared. This depends specifically upon the HPV types tested for.

Conclusion

The clinical differences between HPV6 and HPV11 disease may not be accurately predictable as these viruses exist in numerous sub-types. Also, RRP tissue may contain more than one subtype or even be co-infected with other viruses that may influence outcome. In-vitro studies upon cell lines are a reasonable starting point for evaluation of these differences.     

Topical sucralfate for pain after oral CO2 laser surgery: a prospective, randomized, controlled trial

Purpose

The aim of this study was to assess the effect of topical sucralfate on postoperative pain scores and other secondary outcomes including the frequency and duration of analgesic use and postoperative bleeding episodes after CO₂ laser treatment of oral leukoplakia.

Patients and Methods

In this prospective trial, a total of 80 patients were randomized into the sucralfate group (n = 40) or the control group (n = 40). Postoperative pain scores, the frequency and duration of analgesic requirements, and postoperative wound bleeding episodes were compared between the 2 groups from the operative day to postoperative day 6.

Results

Patients in the sucralfate group experienced significantly less postoperative pain on postoperative days 1 and 2. Although there was no significant difference in frequency and duration of analgesic use between the 2 groups, a trend toward lower frequency and fewer days of analgesic use in the sucralfate group was observed.

Conclusions

This study demonstrated the efficacy of topical sucralfate application in diminishing postoperative pain after CO₂ laser therapy for oral leukoplakia. Topical sucralfate can be considered a feasible adjuvant medication for the control of pain after CO₂ laser treatment of oral leukoplakia.     

Cutaneous Merkel cell carcinoma

Purpose

The aim of this study was to describe the treatment outcomes of patients with cutaneous Merkel cell carcinoma managed with curative intent.

Materials and Methods

Between December 1984 and November 2009, 40 patients with previously untreated Merkel cell carcinoma were managed with curative intent with radiotherapy alone (3 patients) or combined with surgery (37 patients). Adjuvant chemotherapy was administered to 11 patients. Primary sites were the following: head and neck, 32 patients; extremities, 6 patients; and trunk, 2 patients. Patients were staged according to the Yiengpruksawan staging system: stage I, local disease; stage II, regional disease; and stage III, distant metastases. Twenty-four patients had stage I disease, and 16 patients had stage II disease. Median follow-up on all patients was 3.0 years (range, 0.6-15.6 years). Median follow-up on survivors was 4.2 years (range, 2.2-14.2 years).

Results

The 5-year outcomes were local control, 92%; regional control, 78%; local-regional control, 79%; distant metastasis-free survival, 57%; cause-specific survival, 45%; and overall survival, 36%. The 5-year outcomes for those with stage I vs stage II disease were the following: local-regional control, 87% and 67% (P = .1607); distant metastasis-free survival, 71% and 37% (P = .0073); cause-specific survival, 58% and 27% (P = .0090); and overall survival, 48% and 18% (P = .0037). Local-regional recurrences were observed in 6 patients; one patient was successfully salvaged. Severe complications were observed in 3 patients.

Conclusions

Radiotherapy alone or combined with surgery results in a high local-regional control rate. The main mode of recurrence is distant. Approximately one half of patients are cured.     

The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients

Objective

To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml).

Study design

A double-blind prospective randomized controlled clinical study.

Methods

In this randomized double-blind study in group I (30 children, mean age 7.5 ± 2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml) and in group II (21 children, mean age 7.9 ± 3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control.

Results

There was statistically significant pain relieving effect in the levobupivacaine group in the first 24 h (p < 0.05). But after 24 h pain relieving effect of levobupivacaine was not significant (p > 0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p > 0.05).

Conclusion

Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.     

Otolaryngologic markers for the early diagnosis of Turner syndrome

Objective

To identify and characterize otolaryngologic markers for the early diagnosis of Turner syndrome (TS).

Study design

Prospective cohort survey.

Methods

Setting: Clinical Center of the National Institutes of Health (NIH). Patients: Ninety-one females, 7-61 years old (average = 28.7 y), enrolled in a multidisciplinary study of karyotype-phenotype correlations in TS. Main outcome measures: Age at diagnosis, X chromosome karyotype, history of chronic or recurrent otitis media (OM), sensorineural hearing loss (SNHL), palate dysmorphism, pinna deformity, pterygium colli, low posterior hairline, low-set ears, and micrognathia.

Results

Sixty-nine (76%) patients had a history of chronic or recurrent OM, 62 (68%) had a dysmorphic palate, 57 (63%) had SNHL, and 90 (99%) had one or more of these findings. 83 (91%; average age at diagnosis = 9.4 y) had one or more external craniofacial signs: pinna abnormalities, pterygium colli, low-set ears, micrognathia or a low posterior hairline. Eight patients (average age at diagnosis = 13.2 y) had no external craniofacial signs, although seven (88%) of these eight patients had a history of chronic or recurrent OM, dysmorphic palate or SNHL. The age at diagnosis was not significantly different between groups with or without external craniofacial signs (P = 0.126).

Conclusions

Patients with mild or incompletely penetrant TS phenotypes often present with otitis media, hearing loss, or both before the diagnosis of TS is established. Palatal dysmorphism, including ogival morphology, is another otolaryngologic marker for TS. Prompt recognition of these manifestations of TS could hasten its diagnosis and appropriate medical care.     

Mandibular osteomyelitis in children mimicking juvenile recurrent parotitis

Objective

To describe pediatric cases with mandibular osteomyelitis initially diagnosed and treated as juvenile recurrent parotitis.

Methods

We reviewed the patient data of all our pediatric patients treated at Helsinki University Central Hospital, a tertiary care hospital, between 1998 and 2010 who had the initial diagnosis of recurrent parotitis which in fact was osteomyelitis.

Results

Over a period of 12 years, six children (aged 5-17 years, five girls) presented with mandibular osteomyelitis primarily diagnosed as recurrent parotitis. Diagnostic delay ranged from 1.5 months to 6.0 years before the final diagnosis of mandibular osteomyelitis confirmed in MRI. Of the six cases undergoing biopsies, bacterial culture showed Actinomyces or Streptococcus viridans in four cases. All patients received antimicrobial treatment. Two received hyperbaric oxygen therapy with no resolution of symptoms. Debridement was performed in these two cases as well, and in the second case persistent symptoms led to bisphosphonate treatment.

Conclusions

Juvenile parotitis is in most cases a clinical diagnosis, and treatment is symptomatic. In contrast, mandibular osteomyelitis is a severe disease requiring lengthy treatment. Because symptoms of these two entities may mimic each other, unclear cases require MRI.     

Supraglottoplasty outcomes in relation to age and comorbid conditions

Objective

To determine if age and comorbid conditions effect outcomes in children undergoing supraglottoplasty for severe laryngomalacia.

Design

Retrospective study.

Setting

Urban tertiary-care children's hospital.

Patients

Children undergoing supraglottoplasty for severe laryngomalacia between February 2004 and July 2008. 56 patients were identified.

Outcome measures

Persistence of upper airway obstruction, revision surgery (supraglottoplasty), and additional surgery (tracheostomy).

Results

33/56 (58.9%) patients had no comorbid conditions and 23/56 (41.1%) patients had comorbid conditions. In noncomorbid patients, 36.4% of those less than 2 months of age at the time of surgery required revision supraglottoplasty, compared to 5.3% of patients between 2 and 10 months (p < 0.05). Compared to the 2-10-month age group, there was a significantly higher percentage of patients with comorbid conditions in the >10-month group (32.1% vs. 79%, p < 0.01). Patients with comorbid conditions were diagnosed at a significantly later age than those without (6 mo vs. 2 mo, respectively), and had significantly higher rates of revision supraglottoplasty (47.8% vs. 18.2%) and tracheostomy (39.1% vs. 0.0%). 70% of children with neurological conditions required revision surgery, with 60% requiring tracheostomy. The revision surgery and tracheostomy rates were significantly higher compared to the noncomorbid group (p < 0.01 and p < 0.0001). Children with cardiac conditions had a higher rate of tracheostomy than noncomorbid children (30% vs. 0%, p < 0.01). 16.7% of children with genetic conditions required supraglottoplasty, and none required tracheostomy.

Conclusions

In noncomorbid patients, those undergoing supraglottoplasty less than 2 months of age had a significantly higher rate of revision supraglottoplasty. Patients with neurologic and cardiac comorbidities require tracheostomy at a significantly higher rate than noncomorbid patients.     

Operating room fires in otolaryngology: risk factors and prevention

Purpose

The aim of the study was to characterize the causes of operating room (OR) fires in otolaryngology.

Materials and methods

A questionnaire was designed to elicit the characteristics of OR fires experienced by otolaryngologists. The survey was advertised to 8523 members of the American Academy of Otolaryngology—Head and Neck Surgery.

Results

Three hundred forty-nine questionnaires were completed. Eighty-eight surgeons (25.2%) witnessed at least one OR fire in their career, 10 experienced 2 fires each, and 2 reported 5 fires each. Of 106 reported fires, details were available for 100. The most common ignition sources were an electrosurgical unit (59%), a laser (32%), and a light cord (7%). Twenty-seven percent of fires occurred during endoscopic airway surgery, 24% during oropharyngeal surgery, 23% during cutaneous or transcutaneous surgery of the head and neck, and 18% during tracheostomy; 7% were related to a light cord, and 1% was related to an anesthesia machine. Eighty-one percent of fires occurred while supplemental oxygen was in use. Common fuels included an endotracheal tube (31%), OR drapes/towels (18%), and flash fire (where no substrate burned) (11%). Less common fuels included alcohol-based preparation solution, gauze sponges, patient's hair or skin, electrosurgical unit with retrofitted insulation over the tip, tracheostomy tube, tonsil sponge, suction tubing, a cottonoid pledget, and a red rubber catheter.

Conclusions

OR fire may occur in a wide variety of clinical settings; endoscopic airway surgery, oropharyngeal surgery, cutaneous surgery, and tracheostomy present the highest risk for otolaryngologists. Electrosurgical devices and lasers are the most likely to produce ignition.     

The efficacy of rhinoplasty alone in facial rejuvenation

Purpose

The aim of the study was to demonstrate whether rhinoplasty alone is a rejuvenating procedure for the aging face.

Materials and methods

Photographs of the right profile of 48 white females older than 55 years were recorded using standardized techniques. Each of the subjects' noses underwent computer-simulated rhinoplasty to conform to aesthetic canons of the ideal nose. Forty-eight evaluators, blinded to the purpose of the study, were shown either the natural right profile or the morphed image. The evaluators then estimated subject age.

Results

Evaluators were divided into younger and older cohorts. Computer-simulated rhinoplasty alone did not prove to be statistically rejuvenating (Hotelling-Lawley Trace, P = .203). This finding held true for both the younger and older cohort of evaluators (P = .98). Although not statistically significant, evaluators estimated the age of the morphed images to be 6.5 years (mean) younger than actual age for all subjects.

Conclusions

Rhinoplasty alone is not statistically rejuvenating in the profile view of white females older than 55 years. However, age estimation may be less accurate than was hypothesized for the profile view, possibly because of other visual queues.