Vestibular evoked myogenic potential testing for the diagnosis of conductive hearing loss: Survey of pediatric otolaryngologists’ knowledge and beliefs

ObjectivesTo assess physicians’ knowledge and beliefs regarding vestibular evoked myogenic potential (VEMP) testing in children.MethodsA survey was delivered via email in html format to 1069 members of the American Academy of Otolaryngology – Head and Neck Surgery who identified as pediatric otolaryngologists. Study data were collected and managed using the Research Electronic Data Capture (REDCap) tools.Results443 (41.4%) physicians opened the email. 190 (42.9% of opens) initiated the survey, of which 117 (61.9%) fully completed the survey of the physicians who responded to a question regarding knowledge of VEMP, 16% of respondents had never heard of the test. 16% of participants would use it in the setting of diagnosing pediatric conductive hearing loss. Responses regarding the youngest age at which VEMP is possible ranged from younger than 6 months through greater than 13 years of age. Beliefs regarding utility and reliability of VEMP varied, with ‘unsure’ as the most frequent response. Additionally, only 26% of pediatric otolaryngologists indicated some access to the test.ConclusionThe knowledge and availability of VEMP testing in the pediatric otolaryngology community varies widely.     

Turbinate surgery in pediatric patients: A worldwide survey

ObjectiveImpaired nasal breathing is a common condition among pediatric patients, being rhinitis the most common cause. In recent years, turbinate surgery, mainly turbinate radiofrequency ablation (TRA), has increased in popularity amongst pediatric otolaryngologists and rhinologists as a safe and useful technique to address turbinate hypertrophy in pediatric patients. The present paper is designed with the aim of assessing the current worldwide clinical practice regarding turbinate surgery in pediatric patients.MethodsThe questionnaire was developed based on previous researches, by a group of 12 experts from the rhinology and pediatric otolaryngology research group belonging to the Young Otolaryngologists of the International Federation of Otorhinolaryngological societies (YO-IFOS). The survey was then translated to 7 languages and sent to 25 scientific otolaryngologic societies around the globe.Results15 scientific societies agreed to distribute the survey to their members. There were 678 responses from 51 countries. From them, 65% reported to usually perform turbinate surgery in pediatric patients. There was a statistically significant increased likelihood of performing turbinate surgery for those practicing rhinology, sleep medicine, and/or pediatric otolaryngology compared to other subspecialties. The main indication to perform turbinate surgery was nasal obstruction (93.20%); followed by sleep disordered breathing (53.28%), chronic rhinosinusitis (28.70%) and facial growth alterations (22.30%).ConclusionsThere is no general consensus on the indications and ideal technique for turbinate reduction in children. This dissension arises mainly from the lack of scientific evidence. The points with highest agreement (>75%) between respondents is the use of nasal steroids prior to surgery; reintroducing nasal steroids in allergic patients; and performing turbinate surgery as day-case surgery.     

Assessing work-related musculoskeletal symptoms among otolaryngology residents

Purpose

Previous studies have suggested that musculoskeletal symptoms are common among practicing otolaryngologists. Early training can be the ideal time to foster knowledge of ergonomics and develop safe work habits, however, little data exists regarding musculoskeletal symptoms in residents. The purpose of this study was to identify and characterize musculoskeletal symptoms in a preliminary sample of otolaryngology residents.

Corticosteroid utilization among otolaryngologists for the treatment of acute upper respiratory tract infections

PurposeTo determine the effects of knowledge and practice variations on prescribing patterns of systemic corticosteroids (SC) for acute upper respiratory tract infections (URTI).Materials and methodsA cross-sectional evaluation of practicing otolaryngologists in the United States through the use of a 16-question Knowledge, Attitude, and Practice survey. The survey was self-administered through email delivery to practicing members of the American Academy of Otolaryngology–Head and Neck Surgery.ResultsOf 349 respondents, the majority were attending physicians in private practice and used SC 25% to 50% of the time. There was a higher rate of SC use by clinicians in the Southeast United States (adjusted odds ratio [aOR], 2.10; 95% confidence intervals [95% CI], 1.18–3.72) and by those in private practice (aOR, 2.67; 95% CI, 1.63–4.37). Levels of SC knowledge did not vary across respondents; however, knowledge was associated with increased use of SC. Only 62.8% of respondents answered all 4 Knowledge questions correctly and this was associated with a 3.5-fold decrease in SC use (aOR, 0.29; 95% CI, 0.19–0.44). Attitudes toward SC use reflected prescribing practices and were also linked to levels of knowledge, as respondents with less knowledge were more likely to have a favorable outlook toward use of SC.ConclusionUse of SC for treatment of acute URTI is associated with clinician demographics and knowledge. Otolaryngologists are more likely to use SC for acute URTI in the Southeast United States and in private practice. Knowledge and provider education are key factors in prescribing patterns.     

Management of laryngopharyngeal reflux in Brazil: a national survey

IntroductionStudies assessing the management of laryngopharyngeal reflux by otolaryngologists have reported an important heterogeneity regarding the definition, diagnosis, and treatment, which leads to discrepancies in the management of the patient. Information about the current knowledge and practices of Brazilian otolaryngologists in laryngopharyngeal reflux is lacking.ObjectiveTo investigate the trends in management of laryngopharyngeal reflux disease among Brazilian otolaryngologists.MethodsA survey was sent by email to the members of the Brazilian Association of Otolaryngology-Head Neck Surgery. This survey has initially been conducted by the laryngopharyngeal reflux study group of young otolaryngologists of the International Federation of Otolaryngological Societies.ResultsAccording to the survey responders, the prevalence of laryngopharyngeal reflux was estimated to be 26.8% of patients consulting in otolaryngology and the most common symptoms were globus sensation, throat clearing, cough and stomach acid reflux. Nasal obstruction, Eustachian tube dysfunction, acute and chronic otitis media, vocal fold nodules and hemorrhage were considered not associated with laryngopharyngeal reflux by the majority of responders. About 2/3 of Brazilian otolaryngologists based the diagnosis of laryngopharyngeal reflux on the assessment of both symptoms and findings and a positive response to empiric therapeutic trials. Proton pump inhibitor utilized once or twice daily, was the most commonly used therapeutic scheme. Only 21.4% of Brazilian otolaryngologists have heard about nonacid and mixed laryngopharyngeal reflux and the awareness about the usefulness of multichannel intraluminal impedance pH monitoring (MII-pH) was minimal; 30.5% of responders did not consider themselves as well-informed about laryngopharyngeal reflux.ConclusionAlthough the laryngopharyngeal reflux-related symptoms, main diagnostic and treatment approaches referred by Brazilian otolaryngologists are consistent with the literature, the survey identified some limitations, such as the insufficient awareness of the role of laryngopharyngeal reflux in many otolaryngological conditions and of the possibility of non-acid or mixed reflux in refractory cases. Future studies are needed to establish international recommendations for the management of laryngopharyngeal reflux disease.     

Laterality and severity of nasal obstruction does not correlate between physicians and patients,nor among physicians

BackgroundNasal obstruction is a common patient complaint and has a variety of etiologies, and a specific anatomical abnormality can often be found within the nasal cavity on physical examination. In practice, this observed pathology does not always correlate with the laterality, severity, and exact intranasal site of the patients' perceived obstruction.ObjectivesWe seek to answer the following questions: 1) Does a physician's evaluation of nasal obstruction correlate with subjective patient complaints? 2) Is there reasonable correlation between physicians of similar training in the routine evaluation of nasal obstruction?MethodsFirst, we asked patients presenting to the otolaryngology clinic with a primary complaint of nasal obstruction to fill out a modified NOSE survey. Nasal endoscopy was performed on all subjects to assess all potential sites of obstruction. We then determined whether there is an association between patient complaints and findings on physical examination. Second, we determined if there is correlation between similarly trained physicians in their interpretation of a basic nasal examination. Otolaryngologists were shown a series of standardized videos of an endoscopic nasal examination that were recorded with a primary complaint of nasal obstruction. Findings were reported in an anonymous online survey focusing on laterality, severity, and specific site of perceived obstruction.ResultsA total of 38 patients were included in the first part of the study. The Cohen's kappa coefficient was used to determine the interrater agreement between the patient and physician in the degree of nasal obstruction. The kappa coefficient was 0.03 (p value 0.372) for the comparison of the left-sided scores (fair agreement), and 0.16 (p value 0.014) for the right-sided scores (slight agreement). A comparison was also done between the side of the nose the patient felt was most obstructed to the most obstructed side found on physical exam by the otolaryngologist. Thirteen of the 38 patients (34%) had perceived nasal obstruction on the opposite side of that noted to be most obstructed on physical exam. Despite this, the kappa coefficient in this comparison was 0.43 (p value <0.001) revealing moderate agreement between the two groups. Seventeen otolaryngologists participated in the second part of the study. Data extrapolated revealed very little agreement among the physicians in reporting which side of the nose was most obstructed, what anatomical structure contributed to the obstruction the most, and what percentage obstruction was present.DiscussionBased on our findings, patients can reasonably determine based on their symptoms which side is most obstructed, but symptoms do not correlate with severity of obstruction when compared to physical exam. There is also very little consistency between otolaryngologists in their assessment of the degree of nasal obstruction on exam. The results of this study may have far-reaching implications for patient management, surgical intervention, and medicolegal documentation as it relates to the current surgical treatment of nasal obstruction.     

Recognizing odontogenic sinusitis: A national survey of otolaryngology chief residents

PurposeOdontogenic sinusitis is underrepresented in sinusitis literature as well as in the otolaryngology teaching curriculum sponsored by the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngologists and residents in training may therefore have a decreased awareness of the condition. The objective of this study was to survey otolaryngology chief residents toward the ends of their training to determine how often they considered odontogenic sinusitis as a cause of unilateral sinus disease.Materials and methodsAn online REDCap survey was conducted from December 2018 to January 2019. Online surveys were emailed to 119 Otolaryngology residency program directors in the United States of America, which were then forwarded to their chief residents. Surveys included 3 demographic and 4 clinical questions. Clinical questions included 3 computed tomography-based questions requiring either differential diagnoses or most likely diagnosis, and 1 question on residents' perceived prevalence of odontogenic sinusitis as a cause of unilateral sinus opacification. Answer choices were tabulated and compared based on geographic region and post-residency career plans.ResultsOf 293 chief residents emailed, 94 completed the survey (32.1%). While answer choices on imaging-based questions varied, odontogenic sinusitis was generally underrecognized. Approximately 70% of residents felt odontogenic sinusitis represented 0%–40% of unilateral sinus opacification. There were no statistically significant differences in answers based on geographic distribution or post-residency career plans.ConclusionsOtolaryngology chief residents recognized odontogenic sinusitis with variable accuracy on imaging, and generally underestimated its prevalence as a cause of unilateral sinus opacification. Efforts should be made to teach otolaryngology residents about odontogenic sinusitis.     

Elective management of the clinically negative neck by otolaryngologists in patients with oral tongue cancer

BACKGROUND: The treatment of patients with squamous cell carcinoma of the head and neck who have a clinically negative (cN0) neck remains controversial. Furthermore, the treatment delivered to patients with a cN0 neck by practicing otolaryngologists is not known. OBJECTIVE: To determine the variability in the management of the cN0 neck in the otolaryngology community. DESIGN, SETTING, AND PARTICIPANTS: A random survey of 763 board-certified otolaryngologists in the United States. MAIN OUTCOME MEASURES: Physician respondents' preferences for observation vs treatment of the cN0 neck and the treatment modalities chosen. RESULTS: Forty-one percent of the surveyed physicians responded. Nearly 10% of the respondents observed all patients with a cN0 neck. Otolaryngologists who treat 35 or more new patients with cancer each year were more likely to perform elective treatment of the neck for a T2 lesion of the oral tongue than those who treat 10 or fewer patients each year (P =.03). They were also more likely to treat patients with a cN0 neck when the risk of occult cervical metastases was greater than 15% to 20% (P =.04). A comprehensive neck dissection was the preferred lymphadenectomy procedure for 21% of the otolaryngologists surveyed. CONCLUSIONS: Variations in the treatment of the cN0 neck are associated with differences in the frequency of treatment of patients with head and neck cancer by otolaryngologists. Uniformity of care must be established within the otolaryngology community by developing widely accepted evidence-based guidelines and referring patients to surgeons who routinely treat head and neck cancer.     

变应性鼻炎诊疗现状调查

目的 变应性鼻炎(allergic rhinitis,AR)是鼻科常见病之一,但患者的就诊率不高,部分患者对疗效不满意,表明临床诊疗过程中存在亟待改进的问题.本研究针对中国部分大中城市的耳鼻咽喉头颈外科医师进行AR诊疗现状调查,通过剖析存在的问题,为提高临床诊疗水平提供参考.方法 采用问卷调查方式在全国13个省或自治区(63个市)和4个直辖市,针对508名耳鼻咽喉头颈外科医师,调查AR患者门诊状况、诊断状况和治疗状况.结果 AR患者占全部耳鼻咽喉头颈外科门诊患者的比例平均为19%±14%,占全部鼻腔鼻窦疾病门诊患者的35%±17%.既往使用过鼻用糖皮质激素或H1受体拮抗剂等抗过敏药物的患者为42%±26%.可进行皮肤点刺试验和血清特异性IgE检查的医师比例分别为74%和20%.仅依据患者症状和体征诊断,不进行皮肤点刺试验和血清特异性IgE检查等临床检测的比例为6l%±29%,而综合病史和皮肤点刺试验或血清学检测的诊断比例为35%±28%.从医师治疗成人AR患者的药物处方比例来看,鼻用糖皮质激素平均为70%4-27%,口服和鼻用H1受体拮抗剂分别为49%±32%和36%±28%.过敏原特异性皮下免疫治疗占23%4±26%,口服白三烯受体拮抗剂和鼻用色甘酸钠分别为18%±22%和16%±22%.重视复诊随访患者所占比例平均为24%±17%,对复诊和随访重视程度一般的患者所占比例为35%4±19%,而几乎不复诊随访的患者所占比例为39%±24%.结论 AR已成为我国耳鼻咽喉头颈外科门诊患者求诊的主要疾病,但无论是患者对疾病的整体认识,还是专科医师的整体诊治水平,均需要在现有基础上尽快提高.     

Professional diversity and personal commitments of pediatric otolaryngologists

OBJECTIVE: To characterize the time demands and practice patterns of pediatric otolaryngologists. DESIGN: Prospective survey of members from the American Society of Pediatric Otolaryngology. RESULTS: The survey response rate was 54% (n = 136) of practicing members of the American Society of Pediatric Otolaryngology. Respondents described being actively engaged in clinical otolaryngology (99%), hospital or practice administration (71%), private enterprise (17%), research (71%), and teaching (89%) on a weekly basis. Sixty percent considered their time demands to be "too busy"; however, few anticipated changing their activities in 5 years. Among the responding physicians, 90% believed that nonotolaryngology peers within their institutions viewed pediatric otolaryngology favorably whereas only 50% thought that other otolaryngologists held the same opinion. CONCLUSIONS: Pediatric otolaryngologists participate in many activities beyond clinical medicine. While most considered their time demands to be too busy, few anticipated a change in their activities. This may be reflective of a high level of job satisfaction, financial constraints, or the relative youth of the subspecialty.     

Medical management and diagnosis of chronic rhinosinusitis: A survey of treatment patterns by United States otolaryngologists

BACKGROUND: This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States. METHODS: A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology-Head and Neck Surgery; statistical analysis was performed. RESULTS: The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations. CONCLUSION: We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.     

Medicinal use of cocaine: a shifting paradigm over 25 years

OBJECTIVES/HYPOTHESIS: Human cocaine research is predicated on data from the clinical practice of otolaryngology that are more than 25 years old and predate both the cocaine epidemic and the first reported association between cocaine use and myocardial infarction. The authors' objective was to reassess the epidemiology and toxicity of medicinal cocaine use among otolaryngologists and to compare current trends in usage and safety data with previously reported data. STUDY DESIGN: An anonymous closed-question survey replicating the methodology of a previous study was used. METHODS: The survey was mailed to active members of the American Academy of Otolaryngology-Head and Neck Surgery. The survey used a closed-question format asking about the use of cocaine, safety measures taken, and adverse outcomes and included information about practice type and location. Results were compared with previously published data using a chi test with P < .05 considered significant. RESULTS: In all, 7815 surveys were mailed. Four thousand seventeen otolaryngologists returned the survey, representing a 54% response rate. Of the respondents, only 50% had used cocaine in their practice during the previous year. Physicians who had been in practice for less than 10 years were less likely to have used cocaine than those who had been in practice for more than 10 years (78% vs. 93% [P < .001]). Compared with the data reported in 1977, fewer physicians reported ever using cocaine in their practice (88% vs. 92% [P < .001]), fewer physicians had used cocaine in their practice at any time in the previous 10 years (68% vs. 92% [P < .001]), and a greater number of adverse reactions were reported by current respondents (26% vs. 22% [P < .001]). Tachycardia and hypertension were the most commonly reported adverse effects. Other important adverse events included 14 deaths, survivable cardiac arrest, ventricular tachycardia, and seizures. CONCLUSION: The clinical use of cocaine in otolaryngology has decreased significantly in the past 25 years as a result of discontinuation of use by physicians who had previously used cocaine and an increasing number of otolaryngologists who have never used it. This decline may reflect a better understanding of its potential toxicities, problems associated with storing and dispensing of a tightly controlled substance, increased availability of safer alternative medications, or a combination of these.     

Trends in the management of pediatric chronic sinusitis: survey of the American Society of Pediatric Otolaryngology

BACKGROUND: The management of chronic sinusitis (CS) in children has yet to be fully elucidated. The objective of this study is to assess practice trends within the pediatric otolaryngology community for the management of children with CS. METHODS: A multiple choice survey of the members of the American Society of Pediatric Otolaryngology (ASPO) was performed to assess for various factors related to the management of CS in children. RESULTS: A total of 175 ASPO members responded to the survey. The majority of respondents initially treat patients medically with oral antibiotics (95%), topical steroids (90%), and nasal saline sprays (68%). Fifty-five percent performed adenoidectomy as part of the treatment of CS, with 81% performing the operation before endoscopic sinus surgery (ESS). Compared with 3 years before the survey, 47% of respondents performed approximately the same number of ESS cases, whereas 35% reported doing fewer cases annually. Seventy-two percent of practitioners do not routinely perform a second-look surgery. CONCLUSIONS: The majority of pediatric otolaryngologists use oral antibiotics, nasal steroids, and saline lavage, and will perform adenoidectomy when managing patients with CS. More than a third of pediatric otolaryngologists are using more stringent criteria for surgery and performing less extensive surgery than 3 years before the survey. Surgical outcomes for CS do not appear to have changed over the past 3 years.     

Otolaryngology sleep medicine curriculum objectives as determined by sleep experts

Purpose

(1) Ascertain the most important concepts and topics for otolaryngology resident education in sleep medicine and surgery, as determined by faculty who teach sleep medicine to otolaryngology residents. (2) Create learning objectives within the area of otolaryngologic sleep medicine in order to design a sleep medicine curriculum for otolaryngology residents.

Practice of pediatric otolaryngology: results of the future of pediatric education II project

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.     

Infant tracheotomy: results of a survey regarding technique

OBJECTIVE: To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. DESIGN: Survey of physicians. SETTING: Academic medical center. PARTICIPANTS: Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. MAIN OUTCOME MEASURES: Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. RESULTS: A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P < or = .05). CONCLUSIONS: Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.     

Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines

Objective

To evaluate the effect of the recently published guidelines on Tonsillectomy in Children and Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children on physician practice patterns.

Study design

Cross-sectional survey.

Method

Survey of members of the American Academy of Otolaryngology—Head and Neck Surgery.

Setting

Academic tertiary referral center.

Results

A total of 280 physicians completed the survey, with a response rate of 41.7%. 93% of respondents had read the clinical practice guidelines. Many respondents had completed a pediatric otolaryngology fellowship (46%). A large group of physicians (46%) continue to prescribe antibiotics within 24 h after surgery. One-third of respondents stopped prescribing antibiotics because of the guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%). The most common reason cited for admission post-tonsillectomy was age less than 3 (40%). Less than half of physicians prescribe NSAIDs for pain control (43.8%) despite its safety profile, and only 23% reported that the guidelines influenced their use of NSAIDs postoperatively. Most respondents use intra-operative steroids (90%) as recommended.

Conclusion

The guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. The majority of the surveyed otolaryngologists reviewed these guidelines and some have changed their practice secondary to the guidelines. However, many physicians continue to prescribe post-operative antibiotics and do not use NSAIDs.