Incidence and trends of middle ear cholesteatoma surgery and mastoidectomy in Australia-A national hospital morbidity database analysis

OBJECTIVE

To investigate the incidence of middle ear cholesteatoma surgery and assess trends in mastoidectomy procedures in Australia.

STUDY DESIGN

Cross-sectional population-based study using data from the National Hospital Morbidity Database.

METHODS

Admitted care episodes containing the principal diagnosis of middle ear cholesteatoma were analyzed for two 12-month periods of 2007-2008 and 2017-2018. Surgical admissions involving mastoidectomy were identified by procedure codes. Incidence rate per 100,000 person-years were compared between study periods.

RESULTS

Of the 3855 middle ear cholesteatoma admissions, 3558 (92.3%) involved surgery, with the incidence rate for cholesteatoma surgical admissions estimated at 8.6 per 100,000 (95% CI: 8.2-9.0) and 8.1 per 100,000 (95% CI: 7.7-8.5) for 2017-2018 and 2007-2008, respectively. Population aged 10-19 years had the highest age-specific incidence rate at 12.5 per 100,000 (95% CI: 11.3-13.9) for 2017-2018. The 60 years and over age groups had the highest decennial percentage increase. Mastoidectomy procedures were consistently used in over half of all surgical admissions. An increase in the rate of canal wall up (CWU) mastoidectomy procedure related admissions was observed (rate ratio of 1.62 [95%CI: 1.41-1.86], P <.001) and was offset by a decreased rate of canal wall down (CWD) procedure associated admissions (0.69 [95% CI: 0.61-0.78], P <.001]).

CONCLUSIONS

The incidence rate of cholesteatoma surgery in Australia is estimated at 8.6 per 100,000. Mastoidectomy continues to play an essential role in cholesteatoma surgery with a trend favoring CWU over CWD mastoidectomy. Level of evidence: 4.

Chronic Rhinosinusitis: Potential Role of Microbial Dysbiosis and Recommendations for Sampling Sites

Chronic rhinosinusitis (CRS) is an inflammatory condition that affects up to 12% of the human population in developed countries. Previous studies examining the potential role of the sinus bacterial microbiota within CRS infections have found inconsistent results, possibly because of inconsistencies in sampling strategies. The aim of this study was to determine whether the sinus microbiome is altered in CRS and additionally if the middle meatus is a suitable representative site for sampling the sinus microbiome. Swab samples were collected from 12 healthy controls and 21 CRS patients, including all eight sinuses for CRS patients and between one and five sinuses for control subjects. The left and right middle meatus and nostril swabs were also collected. Significant differences in the sinus microbiomes between CRS and control samples were revealed using high-throughput 16S rRNA gene sequencing. The genus Escherichia was over-represented in CRS sinuses, and associations between control patients and Corynebacterium and Dolosigranulum were also identified. Comparisons of the middle meatuses between groups did not reflect these differences, and the abundance of the genus Escherichia was significantly lower at this location. Additionally, intra-patient variation was lower between sinuses than between sinus and middle meatus, which together with the above results suggests that the middle meatus is not an effective representative sampling site.

Endoscopic Resection of Juvenile Nasopharyngeal Angiofibroma

Objectives

A 2-surgeon technique has been proposed that allows resection of juvenile nasopharyngeal angiofibroma (JNA) with extension into the infratemporal fossa by utilizing a septal incision for passage of a retracting instrument from the opposite nostril. This technique, however, does not overcome the problem of limited space within the nasal cavity for the tumor to be retracted. Therefore, the tumor has to be divided to allow for its removal. We are proposing a different 2-surgeon technique as an alternative operative technique for the resection of JNA.

Methods

A new technique of endoscopic resection of JNA involves a transseptal posterior perforation. This perforation allows retraction of the tumor into the opposite nasal cavity by the second surgeon. The retraction of the tumor creates space for its resection.

Results

Nineteen patients (all male) underwent this 2-surgeon technique for resection of JNA. The follow-up period ranged up to 9 years, and no recurrence was recorded.

Conclusions

Longer-term follow-up is needed to assess recurrence rate and morbidity with this technique. However, in our small series, the 2-surgeon technique via posterior septal perforation was associated with low morbidity and recurrence rates.

Bacterial Communities Vary between Sinuses in Chronic Rhinosinusitis Patients

Chronic rhinosinusitis (CRS) is a common and potentially debilitating disease characterized by inflammation of the sinus mucosa for longer than 12 weeks. Bacterial colonization of the sinuses and its role in the pathogenesis of this disease is an ongoing area of research. Recent advances in culture-independent molecular techniques for bacterial identification have the potential to provide a more accurate and complete assessment of the sinus microbiome, however there is little concordance in results between studies, possibly due to differences in the sampling location and techniques. This study aimed to determine whether the microbial communities from one sinus could be considered representative of all sinuses, and examine differences between two commonly used methods for sample collection, swabs, and tissue biopsies. High-throughput DNA sequencing of the bacterial 16S rRNA gene was applied to both swab and tissue samples from multiple sinuses of 19 patients undergoing surgery for treatment of CRS. Results from swabs and tissue biopsies showed a high degree of similarity, indicating that swabbing is sufficient to recover the microbial community from the sinuses. Microbial communities from different sinuses within individual patients differed to varying degrees, demonstrating that it is possible for distinct microbiomes to exist simultaneously in different sinuses of the same patient. The sequencing results correlated well with culture-based pathogen identification conducted in parallel, although the culturing missed many species detected by sequencing. This finding has implications for future research into the sinus microbiome, which should take this heterogeneity into account by sampling patients from more than one sinus.

Intracranial and internal jugular vein thrombosis secondary to ENT infections: a report of 3 cases

We report 3 cases of rare, life-threatening intracranial and internal jugular vein (IJV) thrombosis that were caused by common ENT infections. These infections included otitis media in a 6-year-old girl, tonsillitis in a 21-year-old woman, and odontogenic sepsis in a 56-year-old woman. All 3 patients were treated with culture-directed systemic antibiotics; 2 of them also required surgical drainage (the child and the older adult). The 2 adults also received therapeutic anticoagulation, which was continued until venous recanalization was documented; the duration of combined antibiotic and anticoagulation treatment was 6 weeks. All 3 patients made uneventful recoveries. Significant morbidities associated with intracranial and IJV thrombosis were avoided as a result of prompt diagnosis and judicious treatment.

Dermoid cysts of the Eustachian tube: a transnasal excision

Congenital dermoid cysts are benign developmental lesions and are a well-recognised entity in head and neck surgery. First reported in 1828 by Berger et al., these lesions have been referred to as dermoids, hairy polyps, teratoid tumours with varying classification systems. This has caused confusion in the medical literature with a lack of consensus regarding optimal diagnosis and management. Within the Eustachian tube, there have been 16 reported cases in the English literature demonstrating the rarity of these lesions. The aim of this report is to present a case of histopathologically confirmed Eustachian tube dermoid, confirm the current classification system and demonstrate the challenges they can pose given the relative inaccessibility of such lesions.

Endoscopic Resection of Juvenile Nasopharyngeal Angiofibroma

Objectives:

A 2-surgeon technique has been proposed that allows resection of juvenile nasopharyngeal angiofibroma (JNA) with extension into the infratemporal fossa by utilizing a septal incision for passage of a retracting instrument from the opposite nostril. This technique, however, does not overcome the problem of limited space within the nasal cavity for the tumor to be retracted. Therefore, the tumor has to be divided to allow for its removal. We are proposing a different 2-surgeon technique as an alternative operative technique for the resection of JNA.

Methods:

A new technique of endoscopic resection of JNA involves a transseptal posterior perforation. This perforation allows retraction of the tumor into the opposite nasal cavity by the second surgeon. The retraction of the tumor creates space for its resection.

Results:

Nineteen patients (all male) underwent this 2-surgeon technique for resection of JNA. The follow-up period ranged up to 9 years, and no recurrence was recorded.

Conclusions:

Longer-term follow-up is needed to assess recurrence rate and morbidity with this technique. However, in our small series, the 2-surgeon technique via posterior septal perforation was associated with low morbidity and recurrence rates.

Endoscopic resection of juvenile nasopharyngeal angiofibroma

OBJECTIVES

A 2-surgeon technique has been proposed that allows resection of juvenile nasopharyngeal angiofibroma (JNA) with extension into the infratemporal fossa by utilizing a septal incision for passage of a retracting instrument from the opposite nostril. This technique, however, does not overcome the problem of limited space within the nasal cavity for the tumor to be retracted. Therefore, the tumor has to be divided to allow for its removal. We are proposing a different 2-surgeon technique as an alternative operative technique for the resection of JNA.

METHODS

A new technique of endoscopic resection of JNA involves a transseptal posterior perforation. This perforation allows retraction of the tumor into the opposite nasal cavity by the second surgeon. The retraction of the tumor creates space for its resection.

RESULTS

Nineteen patients (all male) underwent this 2-surgeon technique for resection of JNA. The follow-up period ranged up to 9 years, and no recurrence was recorded.

CONCLUSIONS

Longer-term follow-up is needed to assess recurrence rate and morbidity with this technique. However, in our small series, the 2-surgeon technique via posterior septal perforation was associated with low morbidity and recurrence rates.

Harmonic scalpel tonsillectomy versus monopolar diathermy tonsillectomy: a prospective study

For tonsillectomy, the ultrasonic harmonic scalpel has been purported to cause less tissue injury and postoperative morbidity while providing adequate levels of hemostasis. We undertook a prospective study to compare outcomes in 162 patients who had undergone harmonic scalpel tonsillectomy and 40 patients who had undergone monopolar diathermy tonsillectomy over a 33-month period. We found that patients in the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs. 16.5 ml; p < 0.0001). There was no clinically significant difference between the groups with respect to (1) the amount of operating time, (2) the incidence of postoperative nausea and vomiting, dysphonia, and primary or secondary bleeding, and (3) the amount of time patients needed to resume normal diet and activities.

Harmonic Scalpel Tonsillectomy versus Monopolar Diathermy Tonsillectomy: A Prospective Study

For tonsillectomy, the ultrasonic harmonic scalpel has been purported to cause less tissue injury and postoperative morbidity while providing adequate levels of hemostasis. We undertook a prospective study to compare outcomes in 162 patients who had undergone harmonic scalpel tonsillectomy and 40 patients who had undergone monopolar diathermy tonsillectomy over a 33-month period. We found that patients in the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs. 16.5 ml; p < 0.0001). There was no clinically significant difference between the groups with respect to (1) the amount of operating time, (2) the incidence of postoperative nausea and vomiting, dysphonia, and primary or secondary bleeding, and (3) the amount of time patients needed to resume normal diet and activities.

Complications of occipital bone pneumatization

Four cases of occipital bone pneumatization and subsequent complications are described, which include a pathological fracture of C1 and the occipital bone, spontaneous subcutaneous emphysema and pneumatocele formation. Reviews of the published literature and possible aetiological factors have been discussed.

Endoscopic repair of spontaneous cerebro-spinal fluid rhinorrhoea: a report of 3 cases

Three cases of spontaneous Cerebrospinal Fluid (CSF) rhinorrhea were managed at the National University Hospital, Kuala Lumpur. Case 1 had bilateral leak secondary to empty sella syndrome and the rest two cases had unilateral leak. Four transnasal endoscopic approaches were performed on these three cases since March 1999. The role of intrathecal Sodium Fluorescein is highlighted in localising the CSF fistula. Case 3 required postoperative lumbar drain as an adjunct. No recurrent leak was noted on post operative follow up in Case 2 and 3 ranging from nine to thirty two months. A recurrent left leak at six months was noted in Case 1 which could likely be due to her sudden bout of cough attacks and patient refused further surgical intervention.

The management of postnasal drip

BACKGROUND

Postnasal drip is a symptom that can be very irritating to both patient and doctor.

OBJECTIVE

The aim of this article is to give an approach to diagnosis and treatment of postnasal drip.

DISCUSSION

In order to have an approach to management of this problem the pathophysiology needs to be understood. The causes of increased mucus awareness need to be known. Investigations are aimed at trying to clearly define the cause of the increased mucus and then specific treatment can be given to remedy the situation. Treatment is generally medical, however, surgical treatment is required in certain situations.

Lingual thyroid

Lingual thyroid is a rare cause of dysphagia and airway obstruction. A case is presented, with a discussion of the diagnosis and management.

Endonasal dacryocystorhinostomy--primary and secondary

An endonasal approach was used to restore lacrimal drainage in both primary and secondary obstructions. Patients in the primary group had a history of keloid scar formation, or wished to avoid a scar and declined to have surgery performed via an external approach. Patients in the secondary group had undergone one or more previous unsuccessful lacrimal drainage repairs. A fibreoptic endonasal telescope, linked to a video monitor, and appropriate nasal and lacrimal instruments, were used. The approach proved highly successful, in both anatomical and functional terms, in each group. In the secondary group, the endonasal approach allowed direct visualisation and repair of both nasal and lacrimal causes of failure; this approach is our preference in this group. In the primary group, endonasal instrumentation had no advantage over a conventional external operation, other than avoiding a scar. The application of laser technology may make the endonasal approach a realistic option in primary DCRs as well.

Otitis media

It is obvious to any clinician that otitis media is a major health problem among children. As there are numerous presentations of otitis media, treatment needs to be individualised. The author provides guidelines for the treatment of young patients.

Pneumatic rupture of the posterior pharyngeal wall

A fourth case of pharyngeal injury after an attempt to open a bottle of 'home brew' is presented. For the first time the potential barotrauma causing this injury is recognized. The principles of diagnosis, investigation and treatment are described. Early surgical intervention will minimize contamination and allow adequate drainage of the contaminated space. Early institution of antibiotics will minimize local and generalized toxic phenomena. Alternate routes of alimentation allow local healing and rapid recovery of the patient.