External auditory canal after stapedotomy: packing or not?

Abstract

Sir, Although stapes surgery currently represents one of the most common surgical procedures in ENT practice, there is still an unsolved debate about the necessity of packing the external auditory canal (EAC) after surgery [1[e1]]. Some of the questions are: packing the EAC or not? In case of packing, what kind of packing is most convenient? Reabsorbable material or removable tampon? What about Wxing the tympanomeatal Xap with Fibrin Glue “Tissucol”? The Wrst author has performed more than 300 stapedotomies in the last 15 years, using mostly ear packing at the end of the surgical procedure, while the last author has operated more than 3,000 stapedotomies in the last 30 years, using mostly Wbrin glue in the last 10 years. The comparison of our diVerent experiences, together with those of the other authors who have assisted the two surgeons, leads to the following common considerations. Ear packing performed with reabsorbable tampon, like absorbable gelatin sponge (Gelfoam), assures an excellent hemostatic eVect and allows repositioned tympanomeatal Xap to heal in the correct position [2]. The following inconveniences have been observed: the mechanical interposition of gelatin between the skin edges may interfere with healing (http[K2]://www.pWzer.com/pWzer/main.jsp); gelatin may represent a nest for infection and has been reported to potentiate bacterial growth (http[K3]:// www.pWzer.com/pWzer/main.jsp); toxic shock syndrome has been reported in association with the use of Gelfoam in nasal surgery [3]; fever, failure of absorption, and hearing loss have been reported in association with the use of Gelfoam during tympanoplasty (http[K4]://www.pWzer. com/pWzer/main.jsp). However, it is not recommended that gelatine sponge is saturated with an antibiotic solution or dusted with antibiotic powder (http[K5]://www.pWzer.com/ pWzer/main.jsp). Ear packing with removable tampon, like non-absorbable sponge (Merocel tampon), assures an excellent absorption of post-operative excess Xuids and provides the expansion of the canal with an anatomically correct healing of tissues. It can also help to keep antibiotics in contact with the surgical site and its removal (3–7 days after surgery) is atraumatic. Conversely, like reabsorbable tampon, non-absorbable sponge tampon can give rise to local infection or formation of granulation tissue. Moreover, both packing strategies cause aural fullness, described by the patient as uncomfortable [1, 4]. Not packing does not allow a control of post-operative hemostasis and of tissue healing as precise as in the case of packing, especially in the stapes procedures without ear drilling canal and performing endoaural approach advocated by Fisch. In the case of signiWcant post-operative drainage, the tympanomeatal Xap can be displaced from its correct position and middle ear infection with sensorineural hearing loss can result [1]. Fibrin glue (Tissucol) used to Wx the repositioned tympanomeatal Xap encourages healing in its correct anatomical position. Moreover, since no packing is performed, the patient’s postoperative comfort is greatly enhanced and hearing improves directly after surgery [1]. The risk of infection is theoretically reduced by the absence of post-operative stagnation of Xuids. Without F. Salvinelli · M. Casale (&) · V. Rinaldi Department of Otolaryngology, Interdisciplinary Center for Biomedical Research (CIR), University “Campus Bio-Medico” School of Medicine, Via Longoni, 69/83, 00155 Rome, Italy e-mail: m.casale@unicampus.it