Objective To demonstrate DNA sequencing analysis (DNAsa) of sinus cultures in patients with CRS is a reliable method of detecting pathogens in polymicrobial CRS infections. Methods After obtaining Institutional Review Board approval for this prospective cohort study, we selected a random sample of 50 patients with CRS at Medstar Georgetown University Hospital between September 2016 and March 2017. We defined CRS as a history of rhinosinusitis refractory to maximal medical therapy and prior endoscopic sinus surgery. Patients demonstrating active purulence in a sinus cavity were prospectively selected to undergo standard hospital cultures (SHC) and DNAsa cultures. Organisms identified in both methods were compared for each patient. Results Specimens were obtained from 29 female and 16 male patients with a mean age of 50 years. A total of 45 cultures were included in our final analysis; five cultures were excluded after inappropriate laboratory processing. Results from these patients were compared and analyzed. Cohen's weighted kappa analysis showed agreement between the two testing methods in identifying predominant microorganisms. DNAsa detected 31.9% more microorganisms compared to SHC ( P < 0.05). When multiple microorganisms were detected, DNAsa yielded more positive results compared to SHC ( P < 0.05). Conclusions DNAsa detects all microorganisms identified by SHC as well as predominant microorganisms not detected by SHC. Thus molecular pathogen identification may be more reliable for identifying multiple microorganisms as compared to standard culture techniques that identify only one or two microorganisms. In recalcitrant cases of CRS, DNAsa may provide better guidance in selection of appropriate antimicrobial treatment.
Importance Tracheotomy is one of the riskiest procedures for composite morbidity within pediatric otolaryngology. During the postoperative period, each time the tracheostomy tube is manipulated, there is opportunity for morbidity (e.g. a patient is vulnerable to accidental decannulation and airway loss). Objective To identify areas of improvement in caring for “fresh tracheostomy” patients by determining the number of times a tracheostomy tube is manipulated from placement until discharge. The hypothesis is that the more a tracheostomy is manipulated, the higher probability of morbidity. Methods A quality improvement initiative was conducted to map the care of patients who underwent tracheostomy placement over 12 months. Tracheostomy care and manipulation by all providers were reviewed. Complications, wound care, and respiratory treatments were also evaluated. Results Patients were hospitalized for an average of 39 days (7–140) following tracheostomy. The first tracheostomy tube change occurred on average 6 days (5–10) following placement. Tracheostomy tubes were manipulated an average of 6 (2.5–11.9) times a day to amount to 216 (51–1091) times between placement and discharge. Bedside nurses and respiratory therapists were responsible for 95% of these actions; physicians accounted for 4%. There were 6 tracheostomy related complications. Three were accidental decannulations resulting in cardiopulmonary arrest. One of these caused long term patient morbidity. Patients with more than 4 manipulations per day during the 2 weeks following tracheostomy tube placement, were more likely to have a tracheostomy related complication than those with less than 4 (OR: 12.5; 95% CI: 1.2–130.6; P = 0.0349). Interpretation While uncommon, complications related to tracheostomy can have serious long term effects and at best prolongs length of stay for patients. Reducing the number of tracheostomy manipulations may provide safer postoperative care ultimately reducing morbidity and potentially mortality; children on average have 6 tracheotomy manipulations/day with only 2% being by the physician.
exploration and sedated ABR testing. Prior to auditory testing, a myringotomy was made on the right side and clear fluid pulsated from the middle ear space. The ABR testing results showed moderate sensorineural hearing loss on the left side and severe sensorineural hearing loss on the right.While the patient was sedated, neurosurgery specialists were consulted and a lumbar drain was placed to divert CSF. The middle ear was next explored via a postauricular, tympanomeatal flap approach. Evaluation of the middle ear showed clear fluid coming from the round window niche and the oval window. The incudostapedial joint was disarticulated and the incus was removed to facilitate adequate exposure of the posterior mesotympanum. Cerebrospinal fluid was noted to be pulsating through the footplate. The stapes was down fractured and removed to facilitate packing. A large congenital dehiscence was noted in the stapes footplate (Figure 2). The oval window and vestibule were packed with small pieces of autologous temporalis muscle and Surgicel (Ethicon). The Eustachian tube was also sealed in a similar fashion. Cerebrospinal fluid was still noted to be welling up into the field, and a fistula was noted through a patent round window that was also packed with Surgicel and temporalis muscle. A temporalis fascia graft was placed in a medial underlay fashion to close the myringotomy.The remainder of the hospital course was unremarkable; the lumbar drain was clamped on day 5 and removed on day 7 without evidence of CSF leak. The patient was discharged on postoperative day 8 and has had no evidence of meningitis in over 2 years of follow-up. Auditory brainstem response testing results 1 year after surgery demonstrated mild sensorineural hearing loss on the left side and severe sensorineural hearing loss on the right.Discussion | Recurrent meningitis in an otherwise healthy child should raise suspicion for CSF fistula. Identification of the fistula with prompt control of the leak is necessary to prevent additional episodes of meningitis. Our patient was found to have a congenital dehiscence in the stapedial footplate and round window. Dehiscence at both sites emphasizes the need to thoroughly examine the middle ear to avoid missing a rare concomitant second leak.
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