Chronic Ear Surgery Research Articles

Facial nerve monitoring in chronic ear surgery: US practice patterns

Objective: The use of intraoperative facial nerve monitoring (IOFNM) improves facial nerve outcomes in acoustic neuroma surgery, but the role of IOFNM in chronic ear surgery (CES) is poorly defined. This study was performed to identify IOFNM practice patterns in the United States for CES. Methods: A 10-item survey was mailed to a random sample of 500 active members of the American Academy of Otolaryngology-Head and Neck Surgery. Results: The overall response rate was 45.2%. Of the respondents, 75% had access to IOFNM, and of this group, 66% used IOFNM at least some of the time. Otolaryngologists trained in the 1990s ( P < 0.0001), those in an academic setting ( P = 0.02), and those who perform more otologic than other types of surgery ( P = 0.004) were more likely to use IOFNM. Although most respondents had access to IOFNM, only 32% thought that IOFNM should be required for CES. Conclusions: The majority of otolaryngologists who perform CES have access to IOFNM and will use it at least some of the time. IOFNM use is especially prevalent in otolaryngologists who have trained recently and in more experienced otologic surgeons. However, there are strong feelings against requiring IOFNM for CES. (Otolaryngol Head Neck Surg 2002;126:108-114.)

Intraoperative Facial Nerve Monitoring for Chronic Ear Surgery

Intraoperative Facial Nerve Monitoring for Chronic Ear Surgery

High incidence of complications encountered in chronic otitis media surgery in a U.S. metropolitan public hospital

Objectives: To examine the incidence and nature of complicating factors in surgery for chronic otitis media (COM) in a metropolitan public hospital in the United States. Methods: A retrospective review was performed over 2 years in a metropolitan public hospital to identify cases of surgery for chronic ear disease with the following complicating factors: intracranial or extracranial abscess, labyrinthine fistula, dural dehiscence with or without associated encephalocele or meningocele, or extensive involvement of the facial nerve by cholesteatoma with or without paralysis. Results: Thirty-three of 90 consecutive operations for COM (37%) met criteria for complicated chronic otitis media (CCOM). The majority (85%) of patients had cholesteatoma involvement. Most patients (73%) were managed by an extended modified radical mastoidectomy. An additional 31 procedures were required in these 33 patients for control of complications. There was no iatrogenic sensorineural hearing loss or facial paralysis. Conclusions: The incidence of CCOM in this large, U.S. metropolitan public hospital is similar to that observed in developing nations. CCOM significantly complicates chronic ear surgery and substantially increases the use of resources. Maintaining functional hearing is possible, but difficult, and should be considered secondary to prevention of further complications and eradication of disease. Access to health care and proper follow-up are crucial in prevention of CCOM. (Otolaryngol Head Neck Surg 2001;125:623-7.)

Current use of implants in middle ear surgery.

The authors report the results of a survey of members of the American Otological Society (AOS) and the American Neurotology Society (ANS) regarding their use of prostheses currently available for ossiculoplasty and stapedectomy. These findings are compared with a similar study presented by one of the authors in 1989. Questionnaires were sent to the entire membership of the AOS and ANS with questions regarding biomaterial and prosthesis usage for stapes and chronic ear surgery, as well as satisfaction with each type of prosthesis used. Of the 575 questionnaires mailed, 274 (47%) were returned. Only 248 of the respondents performed middle ear surgery (43%), and their responses constitute the database for this study. For those respondents performing stapes surgery in both 1989 and 1999, the mean number of cases per year has increased from 32 to 37 (p < or = 0.004). The mean number of chronic ear cases has also increased from 95 in 1989 to 110 in 1999 (p < or = 0.001). As a biomaterial, hydroxyapatite prostheses are used by most surgeons (82%), followed by autograft and homograft bone (72%), autograft and homograft cartilage (62%), and Plastipore (59%). (Although 62% of respondents use cartilage, only 4.4% ranked it first in preference.) In 1989, bone was used most (93%), followed by cartilage (78%) and Plastipore (81%). Hydroxyapatite, which had just been introduced as a biomaterial, was used by only 9% of respondents. For stapes prostheses in 1999, the majority of respondents used stainless steel/platinum (71%), bucket handle (69%), or partial fluoroplastic (56%) prostheses. There was a high overall satisfaction rate in the use of most of these prostheses (> 85%), with several exceptions. The lowest satisfaction rate was 71% for Plastipore partial ossicular replacement prosthesis and total ossicular replacement prosthesis. Usage and satisfaction rates are presented for specific types of implants and compared with the earlier survey findings. The current use of implants in middle ear surgery demonstrates a specific pattern with a high degree of user satisfaction. The preference for implants by respondents has remained stable over the past 10 years; there has been a decrease in the percentage of use of bone, cartilage, and Plastipore with a corresponding increase in the use of hydroxyapatite.

KTP-532-Laser-Assisted Tympanoplasty

Objectives: The aim of this paper was to give a general review on appropriate applications (cutting, vaporization, coagulation) of the KTP laser in chronic ear surgery. Patients: Between December 1997 and December 2000, 46 laser-assisted tympanoplasties were carried out by the first author. Out of the 46 patients, 29 were female and 17 were male. The patients ranged in age from 4 to 66 years with a median of 32.5 years. Methods: The power of the laser applied was between 1 and 3 W, usually being 2 W. The mode of the application was either continuous or pulsing. In case of the latter mode, the length of the pulse was generally 0.2 s. The laser light was directed to the microscopic field with a flexible fiber scope by means of a hand-held probe. The diameter of the fiber scope was 0.2 mm. Results: Of the 32 patients who underwent combined-approach tympanoplasties, 19 had already undergone a second-look procedure. Residual cholesteatoma pearls were found in 2 cases (10%). The remaining 14 patients underwent laser-assisted myringoplasties. Neither facial palsy nor sensorineural hearing loss occurred. No postoperative infection or vertigo was noted. Five patients experienced moderate postoperative pain after the third postoperative day. Conclusions: The authors’ impression is that the KTP laser allows excellent haemostasis during chronic ear surgery and enables the surgeon to obtain a more effective disease removal in a bloodless field. Using the laser, cochlear trauma can be avoided.

Outpatient tympanomastoidectomy: factors affecting hospital admission.

Outpatient tympanomastoidectomy is common in many medical centers. However, failure of same-day discharge is often the result of postoperative nausea and vomiting (PONV). Many times this leads to hospital admission after tympanomastoidectomy, and it is often difficult to predict before surgery whether PONV will be an issue that impedes same-day discharge. To determine the clinical factors correlated with the incidence of PONV requiring hospital admission after chronic ear surgery by hypothesizing that the complexity of a particular case, as measured using a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge. Retrospective medical chart review of 103 patients having mastoidectomy with tympanoplasty for chronic otitis media over a 2-year period. We recorded patient age, clinical data, surgical times, types of agents used for induction and maintenance of anesthesia, use of prophylactic antiemetic drugs, types and doses of analgesic agents, and PONV. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required hospital admission. One third of patients studied were safely discharged from the hospital the day of surgery, and 92% were discharged within 23 hours. The most common cause for observation admission to the hospital was PONV. The only variable in multivariate analysis that significantly correlated with PONV mandating hospital admission after tympanomastoid surgery was a history of motion sickness or PONV (odds ratio, 5.21; P =.02). Although severity of disease did not correlate with length of hospital stay, it directly correlated with length of surgery. A history of PONV or motion sickness is predictive of PONV and length of hospital stay. Routine planning for a 23-hour overnight observation stay seems warranted for all patients undergoing tympanomastoidectomy, despite severity of disease.

Double cartilage block ossiculoplasty in chronic ear surgery.

Multiple techniques of ossicular reconstruction have been advocated for hearing rehabilitation in the setting of chronic otitis media No single method can adequately address the clinical spectrum of disease severity. In the situation of a severely diseased ear requiring a canal wall down (CWD) mastoidectomy in the presence of an intact stapes superstructure, the authors have employed a double cartilage block (DCB) ossiculoplasty. The technique and short-term results are reviewed. Retrospective chart review in a tertiary referral otologic practice. Twenty-three patients underwent a CWD tympanomastoidectomy with DCB ossiculoplasty. Ages ranged from 6 to 85 years (mean, 36.1 y). The majority of ears were actively draining at the time of surgery (83%) and most procedures were revisions of prior mastoidectomies (74%). Audiometric data (mean postoperative follow-up, 19.5 mo) were calculated according to 1995 American Academy of Otolaryngology-Head and Neck Surgery guidelines. Audiometric results were available in 20 patients. The mean air-bone gap (ABG) was 23.8 dB after surgery. Closure of the ABG to within 20 dB was achieved in 10 of 20 patients (50%). No cases of DCB extrusion have occurred to date. The DCB represents an excellent alternative to biocompatible prostheses for ossicular reconstruction in the setting of severe chronic ear disease. As with all methods of ossiculoplasty, long-term follow-up will be necessary to determine if this technique remains stable in the hostile environment in which it has been employed.

Intraoperative facial nerve monitoring

The temporal bone region is one of the most anatomically complex areas of the body, and preservation of its many important structures is the foundation of otologic and neuro-otologic surgery. Injury to the facial nerve is an uncommon but devastating complication associated with surgery of the temporal bone and cerebellopontine angle. Since the introduction of facial nerve monitoring, significant strides have been made in assisting the surgeon to avoid injury to the nerve responsible for facial expression. This paper critically reviews the use of intraoperative nerve monitoring in both cerebellopontine angle surgery and chronic ear surgery. Techniques of using the monitoring equipment to accurately predict postoperative facial function are also discussed.

The results of chronic ear surgery in a training programme.

A retrospective study was undertaken of the results of surgery in a series of 782 patients with chronic otitis media. The recurrence rate of cholesteatoma was 20% of patients operated on by trainees and 12% operated on by the faculty. In ears with granulating otitis media, control of infection was achieved by trainees as often as by the faculty. The tympanic membrane healing rate of myringoplasty and tympanoplasty operations was 78% for trainees and 95% for the faculty (P < 0.001). Major surgical complications were relatively rare. It is concluded that the performance of trainees was fairly safe and better than expected, but some failures might have been prevented by closer supervision. Because of the decline in available patients for chronic ear surgery, it is suggested that the training programme should be restructured so that only those trainees who wish to pursue otological surgery as a career are trained in this field.

A simplified approach to partial stapedectomy using the techniques of chronic ear surgery

This article presents the indications for and the technique of partial stapedectomy. This technique emphasizes the same skills used in chronic ear surgery, including incisions, flap elevation, bone exposure, creation of a fenestra, sealing the oval window, and the placement of a Robinson-style prosthesis. This technique can be readily incorporated into the practice of a general otolaryngologist already performing chronic ear surgery. This article presents the indications for and the technique of partial stapedectomy. This technique emphasizes the same skills used in chronic ear surgery, including incisions, flap elevation, bone exposure, creation of a fenestra, sealing the oval window, and the placement of a Robinson-style prosthesis. This technique can be readily incorporated into the practice of a general otolaryngologist already performing chronic ear surgery.

Treatment of chronic otitis externa by KTP/532 laser.

The traditional meatoplasty operations performed for chronic otitis externa, which has entered the 'fibrotic' phase, are often unsatisfactory because the results in terms of canal patency, hearing gain and patient satisfaction are variable. Although the use of laser in chronic ear surgery is well recognized, it has not been previously reported as a meatoplasty technique. Ten KTP laser meatoplasty operations were performed on eight patients with chronic otitis externa. This pilot study shows the technique to be effective, fast and with a high patient satisfaction rate in the short-term (mean follow-up period 9.3 months). The average increase in hearing thresholds was 24 dB HL. Significant patient benefit was obtained in at least six out of eight patients using the Belfast rule of thumb. The technique has many advantages over the traditional meatoplasty operations but the long-term results require evaluation.

Results of bone conduction following surgery for chronic ear disease.

Preoperative and postoperative bone conduction thresholds were compared in 181 chronic ears operated on over a 5-year period between 1990 to 1994. In the majority (92%) of cases the bone conduction thresholds remained unchanged (+/-10 dB). Nine ears (5%) showed better thresholds after surgery, with improvements ranging from 11 dB to 25 dB. This improvement was especially noted in ears with severe tympanic pathology. One ear with a large labyrinthine fistula became totally deaf after surgery. In 5 ears (3%) bone-conduction thresholds deteriorated, but remained measurable at all frequencies tested. In these latter cases this impairment ranged from 11 dB to 27 dB. Cholesteatomatous ears having intact ossicular chains were found to be at the highest risk of inner ear damage when "canal wall-down" mastoidectomies were performed. Methods for prevention of sensorineural hearing loss following chronic ear surgery are discussed.

Does swimming decrease the incidence of otitis media?

To determine the influence of swimming on the incidence of otitis media in children, the authors designed a case control survey involving 32 children, aged 1 to 4 years, who were participating in swimming classes. Thirty control subjects were matched for age, race, and sex. The participants were pooled from the general pediatrics clinic and toddler swimming classes in Nassau County, New York. Parents completed a questionnaire gathering data over a 12-week study period during the winter months. Information was gathered regarding demographics, number of ear infections, history and frequency of swimming during the study period, presence of head submersion, day care center attendance, allergies, chronic medical conditions, otolaryngology consultations, ear surgery, and air travel. Forty-three percent of nonswimmers compared with 19% of swimmers had one or more ear infections during the study period (P < .02). The remaining factors surveyed did not differ significantly between groups. A review of the literature yielded two studies suggesting that swimming may have a beneficial effect on eustachian tube function and may indirectly decrease the occurrence of otitis media. Based on these findings, the authors conclude that there appears to be no basis to the commonly held belief that swimming may induce or exacerbate otitis media. In fact, the converse may be true.

American Neurotology Society's Fall Meeting

At the American Neurotology Society's fall meeting, held in New Orleans, La, on September 16, 1995, the following topics were discussed.<b>Iatrogenic Facial Nerve Palsy.</b>Jack Kartush, MD, Farmington Hills, Mich, opened the session by discussing "Errors in Medicine." He reminded the group that the American Neurotology Society has<b>no official policy on iatrogenic facial palsy.</b>He discussed the fact that bad outcomes are not always the results of negligence or incompetence. He added that examining bad outcomes in an honest fashion is important. <b>Clough Shelton, MD</b>, Salt Lake City, Utah, examined<b>predisposing factors in iatrogenic facial palsy.</b>He noted that the incidence of iatrogenic facial palsy after chronic ear surgery has been reported to be as high as 1% after primary surgery and 4% to 10% after revision surgery. In his study, the most common site of injury is just proximal to the second genu in the lower tympanic segment.

慢性中耳炎手術症例における迷路ろう孔の検討

Twenty cases of labyrinthine fistula have been reviewed. From 1988 to 1993, surgery was performed on 384 ears with chronic otitis media, and 20 of these cases had a labyrinthine fistula (incidence 5.2%). All twenty cases had a lateral semicircular canal fistula and one case had an additional superior semicircular canal fistula. There was no relationship between the size of the labyrinthine fistula and the incidence of vertigo or fistula symptoms. Also there was no relationship between the size of the labyrinthine fistula and preoperative bone conduction thresholds. All twenty cases were characterized by chronic otitis media with cholesteatoma, and the matrix of the cholesteatoma was completely removed in all patients with the exception one case where the cholesteatoma was enormous. Preoperative bone conduction hearing was preserved after removal of the cholesteatoma matrix in all cases except the latter.These results suggest that lesions over the lateral semicircular canal fistula should be completely removed, at best with care, when they are discovered during chronic ear surgery. This policy rarely causes lateral semicircular canal fistula bone conduction hearing to become worse.

Obliteration of the Mastoid with Hydroxyapatite During Chronic Ear Surgery

Obliteration of the Mastoid with Hydroxyapatite During Chronic Ear Surgery

Use of Endoscopes for Chronic Ear Surgery in Children

To determine whether an endoscopic second-look examination of the mastoid and middle ear could replace an open second-look mastoidectomy. Patients were examined endoscopically. The findings were compared with a standard open mastoidectomy procedure during the same operation. The mastoid can be inspected through a small postauricular incision and the middle ear can be inspected through a myringotomy incision or tympanomeatal flap. Ten patients aged 6 to 16 years. Endoscopic findings correlated exactly with open mastoidectomy findings in all cases. In light of this study an open second-look mastoidectomy may be avoided if minimal or no recurrent cholesteatoma is found during the endoscopic exploration. The use of the ridged endoscope has added another dimension to the standard microsurgical techniques used in pediatric otology. The indications, techniques, and findings of otoendoscopy in the management of chronic otitis media in children will be presented.

Chronic ear surgery

Educational objectives: To recognize the indications for surgery for chronic otitis media and to know the techniques necessary for the management of chronic otitis media.

Middle ear air injection after chronic ear surgery

In the early period after chronic ear surgery, the reasons for conductive hearing loss may be difficult to determine. Patients who cannot autoinflate the middle ear after 3 weeks, or who have a negative Rinne test result with the 512 Hz tuning fork, are treated with a transtympanic injection of 0.5 cc of air with a 27-gauge needle and tuberculin syringe. This represents 20% of patients who had chronic ear surgery. Results show that hearing may be immediately improved, the sensation of pressure in the ear may be reduced, and fluid may be cleared from the middle ear. Other benefits may include the release of adhesions. The surgeon is better able to assess the thickness of the graft, and the status of the ossicular chain reconstruction can be determined. There have been no complications of middle ear infection or failure of the micropuncture site to heal. In our practice, middle ear air injection is a routine procedure in patients with inadequate eustachian tube function after chronic ear surgery. This report describes the results of 100 patients over 14 years who received middle ear air injections after chronic ear surgery compared with a control group of 100 patients who did not meet the criteria for requiring air injection. Hearing was immediately improved in 74% of patients as determined by Rinne testing. Audiograms were performed in 25 of these patients, documenting a mean improvement in pure-tone average of 16 dB. The long-term hearing results in patients undergoing air injection, who by definition had evidence of poor eustachian tube function, are similar to the results in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic ear surgery and reconstruction

Chronic ear surgery and reconstruction