REPLY

Abstract

We would like to thank Dr Kuczkowski and Dr Mikaszewski for their comments as they give us the possibility to clarify some points that probably were not sufficiently highlighted in our work. We congratulate the Polish colleagues for the detailed review of their experience with acute otitis media (AOM); we decided for a point by point reply to their comments. In our study, the epidemiology of otogenic complications of AOM was not developed as it was out of our purposes. We report our experience at the Department of Otolaryngology, Head and Neck Surgery of Padua University, a tertiary referral centre. We deal with patients who come from the whole region Veneto (about 4 500 000 inhabitants), but who have been treated, in the great majority, by general practitioners, general paediatricians and paediatric ENT doctors before coming to our attention, mostly for otitis complications. Even if it is possible to estimate the number of children treated for AOM at our Department, this is not an ideal setting to assess the incidence of AOM or its complications. Considering surgical approach to the second patient, we confirm that complete left mastoidectomy was performed without complete epi-tympanectomy. The first millimetres of tympanic tract of facial nerve resulted dehiscent through antrotomy, just medially to the lateral semicircular canal. We did not complete surgical exploration of facial nerve tympanic tract. High resolution computed tomography (HRCT) offers fine details of the middle ear situation in presence of AOM and is nowadays considered an important investigative tool for surgical indication. Unfortunately HRCT presents some limitations in evaluating the tympanic segment of the facial nerve. Even if the opinion of Swartz1 that facial canal dehiscences are impossible to detect on HRCT was overcome by the rapid technological evolution of computed tomography devices, dehiscences still appear to be extremely difficult to identify.2, 3 Fuse et al.4 reported a correct HRCT diagnosis of the facial canal situation in 75% of the 61 considered patients. The same authors stated that the percentage was lower when only the tympanic portion of the facial nerve was considered. Moreover the patients that we described were infant and children and the small dimensions of the anatomical structures examined did not help the correct diagnosis of these tiny details. Therefore it is not so unusual that in two of our patients the presence of the tympanic wall dehiscence could not be detected at HRCT examination. It is well known that intensive measures to control the infectious process usually allow excellent return of facial function without facial nerve decompression in children. The indication criteria for facial nerve decompression in non-responding patients with complete paralysis are still debated. Electroneurography is a reliable diagnostic tool to differentiate the patients who will have spontaneous recovery from those who are expected to have a poor prognosis.5 For these latter, facial nerve decompression surgery should be considered as the last opportunity to save an already wasted facial function, but the parents of the young patients should be made aware that the untreated outcomes are not known and that the benefits of surgery are proven only by limited series.6, 7 We advocate a randomized study on patients who present >95% fibres degeneration, as it is the only way to set an evidence-based treatment protocol.