Annals of Otology Rhinology and Laryngology最新文献

Objective: Gradenigo Syndrome (GS), a rare complication of petrous apicitis secondary to acute otitis media, is characterized by (an often incomplete) triad of otorrhea, abducens nerve palsy, and facial pain along the trigeminal nerve distribution. There are several causative pathogens of petrous apicitis, including Streptococcus and Staphylococcus species, while Pseudomonas aeruginosa is the most common. However, the case report literature often describes antibiotic management of GS with antibiotics that do not cover Pseudomonas, potentially predisposing to further intracranial complications or mortality. The purpose of this work was to describe a case of pediatric Gradenigo Syndrome, successfully treated with sufficiently broad-spectrum antibiotics.

Methods: This is case report.

Results: A previously healthy 5-year-old boy with a history of swimming presented with esotropia and acute otitis media. Initial symptoms included otorrhea, otalgia, and pruritis, which were refractory to ciprofloxacin-dexamethasone drops. He subsequently developed a right sixth nerve palsy, suggestive of Gradenigo Syndrome, and neuroimaging showed evidence of petrous apicitis, clival osteomyelitis, and internal carotid artery stenosis. The causative organism was not elucidated to laboratory error. Given this uncertainty, he was successfully treated with empiric intravenous ceftazidime and cefazolin. After 16 weeks, he recovered fully without the need for surgery.

Conclusions: In the setting of delayed or absent culture results with suspicion of skull-base infection, our case supports the use of empiric antibiotic therapy with sufficient coverage of all common pathogens including Streptococcus/Staphylococcus and Pseudomonas aeruginosa species, the latter of which is often not adequately covered by antibiotic regimens described in the literature.

Background: Paranasal sinus mucoceles, by virtue of extension into the orbit or cranial vault, can lead to significant ocular, nasal, or neural complications. There is limited comprehensive data on the presentation, management, and outcomes of cases with intraorbital or intracranial extension. A thorough analysis is essential to enhance clinical practices and improve patient outcomes.

Objective: This retrospective case series investigates the clinical presentations, radiological features, and surgical outcomes of 10 patients with paranasal sinus mucoceles exhibiting intraorbital or intracranial extensions.

Methods: Ten diagnosed cases of paranasal sinus mucoceles with intraorbital or intracranial extensions, as identified on CT or MRI imaging, were selected and retrieved from the electronic database of an academic-affiliated hospital from July 2013 to December 2023. Data were analyzed using descriptive statistics with IBM SPSS version 23.0 software.

Results: The study revealed a mean patient age of 65 years, with females (60%) affected more than males (40%). The ethmoidal and frontal sinuses were predominantly involved, with varied clinical symptoms ranging from periorbital pain to visual disturbances. Radiologically, CT and MRI scans depicted extensive sinus involvement, often with intraorbital (50%), intracranial (20%), or combined (30%) extensions. Surgical interventions, primarily endoscopic sinus surgery, resulted in favorable outcomes, including symptom resolution, minimal complications, and no recurrence.

Conclusion: This case series emphasizes the importance of thorough preoperative evaluation, individualized surgical approaches, and vigilant postoperative care in managing mucoceles with orbital and cranial involvement. Further research with larger cohorts and extended follow-up periods is essential to refine treatment strategies and enhance patient outcomes for this complex pathology.

Purpose: Although the effectiveness of molecular antibodies has been established, evidence is still lacking on objective predictors of response. The aim of this study was to assess whether the extent of previous endoscopic sinus surgeries, assessed by means of the Amsterdam Classification of Completeness of Endoscopic Sinus Surgery (ACCESS) score, may influence clinical outcomes in refractory CRSwNP patients treated with dupilumab.

Materials and methods: A consecutive sample of patients treated with dupilumab for previously operated recalcitrant CRSwNP were enrolled in the study. Every patient was required to undergo a CT scan at baseline (T0), at 3 (T1), and 12 (T2) months after treatment start. ACCESS score was calculated at baseline, whilst at every timepoint patients underwent assessment of Nasal-Polyp-Score (NPS), Lund-Kennedy-Score (LKS), and had to fill in the 22-item Sinonasal-Outcome-Test (SNOT-22) and Visual-Analog-Scales (VAS) for sinonasal symptoms. Favorable outcome was considered based on EUFOREA guidelines, namely improving at least 3 of the followings: (i) NPS; (ii) SNOT-22; (iii) VAS-olfaction; and (iv) need for systemic corticosteroids.

Results: Overall favorable outcome was achieved in 69.1% (n = 38/55) of cases at T1, while in 89.1% (n = 49/55) at T2. There were no differences in baseline characteristics between responders and non-responders at both timepoints. At T1, out of all the included variables, no statistically significant predictor of favorable outcome was observed. Conversely, at T2, ACCESS score was the only confirmed independent predictive factor of response to dupilumab treatment (OR = 0.81 [95% CI = 0.67-0.92], P = .010).

Conclusions: Our findings suggest that the extent of previous endoscopic sinus surgeries may have a role in influencing clinical outcomes in patients with refractory CRSwNP undergoing treatment with dupilumab.

Background: Tracheoesophageal voice puncture and prosthesis (TEP) is a common method of voice restoration following total laryngectomy. A variety of complications, both minor and major, can be associated with the TEP and require timely intervention/management. Some of those complications include premature leakage, periprosthetic leakage, granulation tissue growth, TEP dislodgement, or embedding of the TEP. Patients may present with problems and/or complications with the voice prosthesis in an emergency setting or after clinic hours when a trained speech pathologist is not present or readily available for evaluation and management. This manuscript aims to provide guidance for management of acute TEP complications to otolaryngology responders, especially those who may be less familiar with TEP troubleshooting.

Methods: Experiential and literature review was undertaken by a group of head and neck specialized Speech Language Professionals in high volume Head & Neck Oncology practices, to develop consensus guidelines for emergency TEP management.

Results: TEP emergencies were categorized as (1) leakage through, (2) leakage around, (3) sudden loss of voicing, (4) loss of prosthesis, still in tract, (5) loss of prosthesis, not in tract. Management strategies for each form of emergency were developed to achieve patient safety and stability until definitive measures could be performed by the patient's Speech Language Professional.

Conclusions: The goals of emergency management of TEP problems focused on minimizing risk of aspiration pneumonia, risk of foreign body aspiration, risk of wound complications at the puncture site. A simple management algorithm was developed for emergency or on-call otolaryngology responders.

Objectives: The primary objective was to assess incidence and severity of acute laryngeal injury (ALgI) following intubation at time of tracheostomy using a proposed grading scale. The secondary objective was to evaluate what factors influence the rate of decannulation.

Methods: Single institution cohort study with review of prospectively maintained database including patients from October 2021 to October 2022 who underwent tracheostomy for prolonged intubation/critical illness. Severity of ALgI was graded as mild, moderate, or severe based on intraoperative endoscopic findings (laryngeal mucosal ulceration and/or granulation tissue). Rates of tracheostomy decannulation were collected as the secondary outcome measure.

Results: Twenty-eight patients met criteria for inclusion. About 60.7% (n = 17) patients were female. Average age was 59.0 ± 13.2 years old. Average body mass index was 32.3 ± 14.0 kg/m². The most common endotracheal tube size was 7.5 (range = 6.0-8.0) inner diameter (ID) for men and 7.0 (range = 5.5-8.0) ID for women. Average Charlson Comorbidity Index (CCI) was 4.8 ± 2.4. Length of intubation was 15.7 ± 6.5 days (range = 5-30). Direct laryngoscopy at the time of tracheostomy demonstrated ALgI in 92.8% (n = 26) of patients. This was graded as mild (25.0%, n = 7), moderate (42.9%, n = 12), or severe (25.0%, n = 7). Severe ALgI was correlated with a reduced rate of tracheostomy decannulation compared to no/mild/moderate ALgI (28.5% vs 81.2%, P = .04).

Conclusions: ALgI is highly prevalent in patients undergoing tracheostomy for prolonged intubation. Severe injury is associated with reduced rates of decannulation. Direct laryngoscopy at time of tracheostomy is warranted to diagnose ALgI and guide interventions. Determining the extent of laryngeal injury is prognostic and could help tailor follow-up and management strategies.

Level of evidence: 4.

Objectives: This study aims to report otologic manifestations in a cohort of patients with aspirin exacerbated respiratory disease (AERD) to determine if severity of sinonasal inflammation is associated with presence of otologic sequalae (OS).

Methods: All AERD patients treated at a tertiary care center between 2009 and 2016 were included in analysis. Demographics, history of hearing loss, Lund-Mackay (LMK) scores, number of previous sinus procedures, CT findings, and pure tone averages (PTA) were compared between patients with and without OS using chi-square test, Fisher's exact test, and Wilcoxon rank sum test.

Results: Of 255 AERD patients, 58.4% were female with a mean age of 48.9 (SD: 13.4) years. The majority (52.2%) had otologic manifestations, most commonly: otitis media requiring antibiotics (n = 89, 34.9%), peripheral vertigo (n = 59, 23.1%), and middle ear effusion (n = 44, 17.3%). A total of 74 patients (29.0%) had hearing loss. PTA ranged from 13.3 to 61.7 dB for the cohort, with no significant difference between those with and without OS. There was no significant difference in LMK in both groups. Patients with OS had a significantly greater number of sinus procedures than those without OS (median = 2.4 and 1.8 respectively; P = .01).

Conclusions: Otologic manifestations are common in patients with AERD. While there was an increased number of sinonasal surgeries performed in the patients with OS, there was no correlation between sinonasal inflammation, and the presence of OS as measured by LMK score or PTA. Otologic signs and symptoms should be considered in patients with AERD to help mitigate patient morbidity.

Level of evidence: III.

Objective: This systematic review was conducted to assess if there are changes in gastroesophageal reflux (GER) outcomes after frenotomy in infants with ankyloglossia.

Methods: Systematic Review. CINAHL, Cochrane, EMBASE, Pubmed, and Scopus were searched from inception to May 20, 2023. Inclusion criteria consisted of all study designs, infants ≤12 months of age with ankyloglossia, and use of quantitative GER measures (esophageal pH manometry (pH) or multi-channel intraluminal impedance (MII), and/or patient-reported symptom scores) pre- and post-frenotomy. Quality assessment and data extraction were performed in duplicate.

Results: Of 37 articles screened, 7 met inclusion criteria (6 prospective cohort studies and 1 RCT). No studies utilized objective measures to quantify reflux, that is MII or pH. The number of infants with ankyloglossia ranged from 47 to 237 (mean age of 4.4-8.3 weeks). Qualitative analysis included all 7 studies which used the GIGER, I-GERQ-R, and GSQ-I scales to assess GER. Parent-reported GER scores decreased post-frenotomy. However, the lack of control groups in the prospective cohort studies precludes conclusive findings that changes are related to frenotomy. Meta-analysis was not possible due to the high risk of bias from limited sample sizes, poor methodology, and lack of adequate control groups.

Conclusion: Limited work has been conducted on the relationship between frenotomy and GER in infants with ankyloglossia. The lack of high-quality studies precludes definitive conclusions, as GER symptoms are known to improve spontaneously with time. Future RCT studies are warranted to further elucidate the effect of frenotomy on symptoms of GER in infants with ankyloglossia.

Level of evidence: III.

Objectives: Midline nasal masses are rare and challenging for surgeons. This study examined the site with the highest risk of recurrence following midline nasal mass excisions.

Methods: Surgical outcomes were retrospectively reviewed following excision of midline nasal masses between 2010 and 2022 in the predominantly pediatric patient cohort. The primary outcome measure was the recurrence rate.

Results: Overall, 22 nasal masses were resected from 20 patients. Of these masses, 16 were nasal dermoid sinus cysts (NDSC), 2 were hamartomas, 1 was an epidermoid cyst, and 1 was a mature teratoma. Five of the nasal masses were classified as intracranial lesions, 11 were classified as intraosseous lesions, and 6 were classified as superficial lesions. The open rhinoplasty approach was chosen in 65% of the surgeries. For the intracranially extended lesions, a combined nasocranial approach was performed. Four revision surgeries were performed due to superficial recurrences at the nasal dorsum of lesions, that were primarily classified as intraosseous lesions.

Conclusions: All recurrences had a superficial extension and were easily excised. Intraosseous NDSC have the highest risk of recurrence, but conversely, they also occur most frequently.