The epidemiology, antibiotic resistance and post-discharge course of peritonsillar abscesses in London, Ontario

Background: Peritonsillar abscesses (PTA) are a common complication of tonsillitis. Recent global epidemiological data regarding PTAs have demonstrated increasing antimicrobial resistance patterns. No similar studies have been conducted in Canada and no Canadian study has examined the post-discharge course of treated patients. Methods: A prospective observational study of the epidemiology, antibiotic resistance and post-discharge course of patients presenting with a peritonsillar abscess to the Emergency Department in London, Ontario over one year. A follow-up telephone survey was conducted 2-3 weeks after abscess drainage. Results: 60 patients were diagnosed with an abscess, giving an incidence of 12/100,000. 46 patients were enrolled in the study; the average duration of symptoms prior to presentation was 6 days, with 51% treated with antibiotics prior to presentation. Streptococcus pyogenes and Streptococcus anginosus were present in 56% of isolates and of those, 7/23 (32%) of specimens demonstrated resistance to clindamycin. Eight patients were treated with clindamycin and had a culture that was resistant, yet only one had recurrence. Telephone follow-up was possible for 38 patients: 51% of patients reported a return to solid food within 2 days, and 75% reported no pain by 5 days. Resolution of trismus took a week or longer for 51%. Interpretation: Clindamycin resistance was identified in a third of Streptococcus isolates, which should be taken into account when prescribing antibiotics. Routine culture appears unnecessary as patients recover quickly from outpatient drainage and empiric therapy, with less pain than expected, but trismus takes time to resolve. © 2013 Sowerby et al.; licensee BioMed Central Ltd

Does endoscopic sinus surgery alter the biomechanics of the orbit?

© 2020 The Author(s). Objective: The purpose of this study is to determine if removal of ethmoid cell septations as commonly performed in endoscopic sinus surgery leads to a change in orbital wall fracture patterns and the force required to create them. Methods: Six fresh-frozen cadaveric heads were acquired and underwent endoscopic uncinectomy, maxillary antrostomy, and anterior and posterior ethmoidectomy on one, randomized, side. The contralateral sinuses were used as intra-specimen control. Hyaluronic acid gel globe injections were performed to simulate normal intra-ocular pressure. Post-op CT scans confirmed no orbital fractures or violation of the lamina papyracea prior to trauma testing. Orbital trauma was induced using a guided weight-drop technique. Both orbits were tested in random order, and sequentially higher drops were performed until both the test and control side demonstrated an orbital fracture on CT scan. Results: In all six heads, the post-sinus surgery side incurred a medial orbital wall fracture, and no orbital floor fractures were identified. On the other hand, on the control side, all six heads incurred orbital floor fractures at drop heights equal to, or higher than, the surgical side. Fisher\u27s exact test demonstrated a significant difference in fracture pattern (p \u3c 0.001). Conclusions: To our knowledge, this is the first demonstration that the structures removed during sinus surgery may act as a buttress for the medial orbital wall. The anatomic changes of sinus surgery may alter the biomechanics of the orbit and affect the pattern of subsequent traumatic blowout fractures

Assessing the Risk of SARS-CoV-2 Transmission via Surgical Electrocautery Plume

This quality improvement study used a nonhuman subject research approach to examine whether SARS-CoV-2 from aerosolized virus is present in and potentially transmissible from a electrocautery plume in surgery

International registry of otolaryngologist–head and neck surgeons with COVID-19

Background: It has become clear that healthcare workers are at high risk, and otolaryngology has been theorized to be among the highest risk specialties for coronavirus disease 2019 (COVID-19). The purpose of this study was to detail the international impact of COVID-19 among otolaryngologists, and to identify instructional cases. Methods: Country representatives of the Young Otolaryngologists–International Federation of Otolaryngologic Societies (YO-IFOS) surveyed otolaryngologists through various channels. Nationwide surveys were distributed in 19 countries. The gray literature and social media channels were searched to identify reported deaths of otolaryngologists from COVID-19. Results: A total of 361 otolaryngologists were identified to have had COVID-19, and data for 325 surgeons was available for analysis. The age range was 25 to 84 years, with one-half under the age of 44 years. There were 24 deaths in the study period, with 83% over age 55 years. Source of infection was likely clinical activity in 175 (54%) cases. Prolonged exposure to a colleague was the source for 37 (11%) surgeons. Six instructional cases were identified where infections occurred during the performance of aerosol-generating operations (tracheostomy, mastoidectomy, epistaxis control, dacryocystorhinostomy, and translabyrinthine resection). In 3 of these cases, multiple operating room attendees were infected, and in 2, the surgeon succumbed to complications of COVID-19. Conclusion: The etiology of reported cases within the otolaryngology community appear to stem equally from clinical activity and community spread. Multiple procedures performed by otolaryngologists are aerosol-generating procedures (AGPs) and great care should be taken to protect the surgical team before, during, and after these operations

The subtle nuances of intranasal corticosteroids

Abstract Background In the specialty of Otolaryngology – Head and Neck Surgery, intranasal corticosteroids are the mainstay treatment for inflammatory processes within the nasal cavity. All too often, physician prescribing patterns are based on previous training, personal experience, and interactions with industry. The purpose of this commentary is to review the nuances of each intranasal corticosteroid. Commentary There are nine intranasal corticosteroids approved for use in Canada. Each are discussed in detail, including their indication, bioavailability, effects on intranasal environment, and factors around patient adherence. Off-label use of budesonide irrigations is also discussed and cost information is presented in reference format for all available intranasal corticosteroids. Conclusion Although the efficacy of each intranasal corticosteroid has been shown to be similar, prescribing should be tailored based on bioavailability, intranasal environment, and factors that impact patient adherence such as dosing, cost and tolerability. Graphical abstrac

Variability in instructions for performance of nasopharyngeal swabs across Canada in the era of COVID-19 – what type of swab is actually being performed?

Abstract Background The primary method of surveillance for the presence of SARS-CoV-2 is with nasopharyngeal swabs. Given the significant demand for nasopharyngeal swabs, a large number of previously untrained and unfamiliar staff are now performing this test. It was noted that there was significant heterogeneity in instructions for performing nasopharyngeal swabs in Canada, in contrast to the guidance provided by the Centers for Disease Control and Prevention (CDC), and the Pan American Health Organization (PAHO). The objective of this study was to review the instructions provided across Canada and contrast them to those of the CDC and PAHO. Methods A standard series of steps for nasopharyngeal swab performance was outlined based on the CDC, PAHO, and New England Journal of Medicine instructions. A comprehensive search was performed in August 2020 to identify nasopharyngeal swab guidelines provided by public health in the provinces and territories of Canada. Regional health authority guidance was also collected. Instructions provided were contrasted against the standardized steps. Results Instructions were identified for all provinces and territories, and for 81 regional health authorities. From the provincial and territorial guidelines, 10/13 (77%) cleared the nasal passages before swab insertion, 11/13 (85%) tilted the patient’s head back slightly, 12/13 (92%) inserted the swab parallel to the palate, but only 3/13 (23%) inserted the swab to at least a depth of two-thirds the distance between the patient’s nose and ear. A clear majority (81%) of regional health authority guidelines followed their respective provincial guidelines. For depth of insertion, Quebec provided a pictogram but no distance or technique for estimation. Six provinces and territories - Northwest Territories, Nunavut, Ontario, Saskatchewan, Prince Edward Island and Alberta - recommended 4 cm or one-half the distance from nostrils to ear. British Columbia and Manitoba recommended a 7 cm depth of insertion. Nova Scotia recommended one-half to two-thirds the distance from nose to ear. Lastly, Newfoundland, New Brunswick and the Yukon recommended an insertion from nose to the external ear canal. Conclusion There is significant heterogeneity in guidance for nasopharyngeal swab performance across Canada. The instructions provided by the majority of provinces and territories in Canada would not be effective in reaching the nasopharynx. Graphical abstrac

Cost minimization analysis of nasopharyngoscope reprocessing in community practice

Abstract Background Reprocessing of nasopharyngoscopes represents a large financial burden to community physicians. The aim of this study was to perform a cost analysis of nasopharyngoscope reprocessing methods at the community level. Methods Electronic surveys were distributed by email to community otolaryngologists. Surveys were comprised of 14 questions assessing clinic size, nasopharyngoscope volume, scope reprocessing method and maintenance. Four manual techniques were evaluated: (1) soak with ortho-phthalaldehyde solution (Cidex-OPA; Advanced Sterilization Products, Johnson and Johnson Inc., Markham, Canada), (2) soak with accelerated hydrogen peroxide solution (Revital-Ox; Steris Canada Inc., Mississauga, Canada), (3) disinfection with chlorine dioxide wipe (Tristel Trio Wipes System; Tristel plc., Cambridgeshire, UK), (4) UV-C light system (UV Smart, Delft, The Netherlands). All costs are reported in CAD, and consumable and capital costs for reprocessing methods were obtained from reported vendor prices. Time costs were derived from manufacturer recommendations, the Ontario Medical Association Physician’s Guide to Uninsured Services, and the Ontario Nurses Association Collective Agreement. Cost analyses determined the most cost-effective reprocessing method in the community setting. Sensitivity analyses assessed the impact of reprocessing volume and labour costs. Results Thirty-six (86%) otolaryngologists responded and answered the survey. The cost per reprocessing event for Cidex-OPA, Revital-Ox, Tristel and UV system were $38.59,$26.47, $30.53, and$22.74 respectively when physicians reprocessed their endoscopes themselves. Sensitivity analyses demonstrated that Revital-Ox was the least costly option in a low volume, however, the UV system remained the most cost effective in higher volumes. The cost per reprocessing event when done by clinic staff was $5.51,$4.42, $11.23 and$6.21 for Cidex-OPA, Revital-Ox, Tristel and the UV system. Conclusions The UV light system appears to be the most cost-effective method in high volumes of reprocessing, and Revital-Ox is cheaper in lower volumes and when performed by clinic staff rather than physicians. It is important to consider the anticipated work volume, shared clinic space and number of co-workers prior to choosing a reprocessing method. Graphical Abstrac

Variability in instructions for performance of nasopharyngeal swabs across Canada in the era of COVID-19 – what type of swab is actually being performed?

Background: The primary method of surveillance for the presence of SARS-CoV-2 is with nasopharyngeal swabs. Given the significant demand for nasopharyngeal swabs, a large number of previously untrained and unfamiliar staff are now performing this test. It was noted that there was significant heterogeneity in instructions for performing nasopharyngeal swabs in Canada, in contrast to the guidance provided by the Centers for Disease Control and Prevention (CDC), and the Pan American Health Organization (PAHO). The objective of this study was to review the instructions provided across Canada and contrast them to those of the CDC and PAHO. Methods: A standard series of steps for nasopharyngeal swab performance was outlined based on the CDC, PAHO, and New England Journal of Medicine instructions. A comprehensive search was performed in August 2020 to identify nasopharyngeal swab guidelines provided by public health in the provinces and territories of Canada. Regional health authority guidance was also collected. Instructions provided were contrasted against the standardized steps. Results: Instructions were identified for all provinces and territories, and for 81 regional health authorities. From the provincial and territorial guidelines, 10/13 (77%) cleared the nasal passages before swab insertion, 11/13 (85%) tilted the patient’s head back slightly, 12/13 (92%) inserted the swab parallel to the palate, but only 3/13 (23%) inserted the swab to at least a depth of two-thirds the distance between the patient’s nose and ear. A clear majority (81%) of regional health authority guidelines followed their respective provincial guidelines. For depth of insertion, Quebec provided a pictogram but no distance or technique for estimation. Six provinces and territories - Northwest Territories, Nunavut, Ontario, Saskatchewan, Prince Edward Island and Alberta - recommended 4 cm or one-half the distance from nostrils to ear. British Columbia and Manitoba recommended a 7 cm depth of insertion. Nova Scotia recommended one-half to two-thirds the distance from nose to ear. Lastly, Newfoundland, New Brunswick and the Yukon recommended an insertion from nose to the external ear canal. Conclusion: There is significant heterogeneity in guidance for nasopharyngeal swab performance across Canada. The instructions provided by the majority of provinces and territories in Canada would not be effective in reaching the nasopharynx. Graphical abstract: [Figure not available: see fulltext.

Contemporary decongestant practices of Canadian otolaryngologists for endoscopic sinus surgery

Abstract Background Cocaine has traditionally been the topical decongestant most frequently used for visualization of the surgical field in Endoscopic Sinus Surgery (ESS). Alternatives include xylometazoline, oxymetazoline, and epinephrine. The understanding of the safety profile of each agent is changing, as are the practices of Otolaryngologists-Head & Neck Surgeons. The objective of this study is to determine decongestant use practices in ESS across Canada, which has not previously been studied. Methods A cross-sectional survey design using a 24-item electronic questionnaire was distributed to actively practicing members of the Canadian Society of Otolaryngology-Head and Neck Surgery via email. A French translated version of the survey was also available. Questions explored the respondents’ demographics and decongestion practices for ESS. Results Ninety-six surveys from otolaryngologists practicing in Canada were completed (19% response rate). The average time in practice was 16.5 years (range 1–50 years, SD 12.0 years). Twenty-six (27%) of respondents use some form of cocaine solution for topical decongestion in ESS. Over a total of over 1500 combined practice-years, eight respondents (8%) personally experienced an adverse event that could be attributed to cocaine, including two mortalities. One cardiac even was directly attributable to the patients’ use of recreational cocaine in the immediate pre-operative period. Conclusion The popularity of cocaine for topical decongestion in ESS in present-day Canada is less than in surveys from other countries. However, there are few reported adverse events with long-term consequences that are attributable to intraoperative cocaine. Considering the beneficial effects of cocaine for visualization and pain control, this change in practice warrants further investigation