This is the first, explicit, evidence-based clinical practice guideline on acute otitis externa, and the first clinical practice guideline produced independently by the AAO-HNSF.

\s=b\Of 1,300 consecutive head-injured patients admitted to the hospital over a 20-month time period, 118 were found to have skull fractures, of which 22% involved the temporal bone. These figures form part of a larger study of 90 temporal bone fractures treated over a six-year period from 1975 through 1981. The most common cause of a temporal bone fracture was a motor vehicle accident occurring in 40/90 (44%) patients. Pertinent physical findings, occurring alone or in combination, were a hemotympanum, bleeding from the ear canal, tympanic membrane perforation, facial paralysis, and CSF otorrhea. The diagnosis of temporal bone fractures is best made clinically and radiographically. The early care of temporal bone fractures is directed toward the treatment of CSF otorrhea and immediate onset facial paralysis. The delayed care is primarily concerned with hearing rehabilitation. (Arch Otolaryngol 1983;109:285-288)

Objective. This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. This update provides evidence-based recommendations to manage acute otitis externa (AOE), defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The variations in management of AOE and the importance of accurate diagnosis suggest a need for updating the clinical practice guideline. The primary outcome considered in this guideline is clinical resolution of AOE.Purpose. The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE. Differential diagnosis will be discussed, but recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. This guideline is intended for primary care and specialist clinicians, including otolaryngologists-head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse practitioners, and physician assistants. This guideline is applicable in any setting in which patients with diffuse AOE would be identified, monitored, or managed.Action Statements. The development group made strong recommendations that (1) clinicians should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain and (2) clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The development group made recommendations that (1) clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal; (2) clinicians should assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); (3) clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE; (4) clinicians should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed; (5) clinicians should prescribe a non-ototoxic preparation when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube; and (6) clinicians should reassess the patient who fails to respond to the initial therapeutic option within 48 to 72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. Keyw...

Adenoidectomy is a commonly performed procedure. The advent of endoscopic sinus surgery has popularized the use of endoscopes. Endoscopic-assisted adenoidectomy (EAA) is a natural progression of this technology to allow a more complete adenoidectomy. Two hundred thirty-six patients undergoing adenoidectomy were evaluated with an endoscopic technique. A routine transoral adenoidectomy was performed first. Then a 4-mm 0 degrees telescope was used transnasally, and residual adenoid tissue was removed from the anterior superior nasopharynx. Invariably, residual adenoid tissue was found after transoral adenoidectomy. The EAA technique is minimally invasive, adds less than 5 minutes to the procedure, and is not associated with excessive bleeding. Readily available telescope and endoscopic equipment is used. The EAA technique is advocated for use as an adjunct to a more complete adenoidectomy.

This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Damage to the thyroid gland may occur in patients undergoing treatment for head and neck neoplasms. This injury may result from damage incurred during surgery, from radiation therapy, or a combination of the two. Development of hypothyroidism is often insidious with potential harmful effects. An experimental study was performed to study the effects of hypothyroidism in pigs whose skin closely approximates that of the human. Wound tensile strength and flap necrosis were studied in the hypothyroid animal treated by surgery, radiation, and a combination of the two. The results of this study indicate that hypothyroidism alone has no significant unfavorable impact on wound tensile strengths or flap survival. When combined with preoperative radiation, however, there are statistically significant deleterious effects on both wound tensile strengths and flap survival. Histologically, collagen fibers within the wound appear shorter and thinner, which probably accounts for decreased wound tensile strengths. A clinical review of 62 head and neck cancer patients was also conducted. Within the study group, 10% of patients developed abnormally low thyroxine measurements, whereas 15% developed high thyroid-stimulating hormone levels as the only evidence of early primary hypothyroidism. Hypothyroidism was not statistically related to tumor size, nodal status, clinical staging, or treatment group (surgery alone, radiation alone, or combination surgery and radiation). A previously unreported finding is that patients who develop a second primary tumor are significantly at risk for developing hypothyroidism. All patients diagnosed with a head and neck cancer should undergo baseline thyroid function testing, including measurement of TSH, and have serial repeat testing after treatment. Thyroid function determination should be mandatory in patients undergoing oncologic salvage procedures or treatment of a second primary tumor.

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Under pressure to avoid readmissions, hospitals are increasingly employing hospital-initiated postdischarge interventions (HiPDI), such as home visits and follow-up phone calls, to help patients after discharge. This study was conducted to assess the effectiveness of HiPDI on reducing hospital readmissions using a systematic review of clinical trials published between 1990 and 2014. We analyzed twenty articles on HiPDI (from 503 reviewed abstracts) containing 7,952 index hospitalizations followed for a median 3 months (range 1-24) after discharge for readmission. The two most common HiPDI included follow-up phone calls (n = 14, 70%) or home visits (n = 11, 55%); eighty-five percent (n = 17) of studies had multiple HiPDI. In meta-analysis, exposure to HiPDI was associated with a lower likelihood of readmission (odds ratio [OR], 0.8 [95% CI, 0.7-0.9]). Patients receiving ≥2 postdischarge home visits or ≥2 follow-up phone calls had the lowest likelihood of readmission (OR, 0.5 [95% CI, 0.4-0.8]). Hospital-initiated postdischarge interventions seem to have an effect on reducing hospital readmissions. Together, multiple home visits and follow-up phone calls may be the most effective HiPDI to reduce hospital readmission.