Chronic Perforation Research Articles

Management of Already Inserted Ventilation Tubes During Pediatric Cochlear Implantation: To Remove or Leave the Tube?

Ventilation tube (VT) insertion is usually recommended before cochlear implantation (CI) in pediatric cochlear implant candidates with recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME). However, there is no consensus on whether the VT is beneficial even after CI, that is, whether the tube should be removed or left in place during CI. This study aimed to assess the effect of tube placement after CI, especially on the incidence of post-CI AOM, in pediatric cochlear implant recipients who had undergone VT insertion before CI because of recurrent AOM or chronic OME. A retrospective medical record review. A tertiary referral cochlear implant center. This study recruited 58 consecutive ears of children who underwent VT insertion followed by CI at age 7 years or younger between 2004 and 2021. Before October 2018, we removed the VT simultaneously with CI (removed group, 39 ears), while since then, the tube has remained in place during CI (retained group, 19 ears). Therapeutic. The primary outcome was the proportion of ears that developed AOM at post-CI 6 months in the removed and retained groups. The age at CI was significantly higher in the removed group than in the retained group (mean [standard deviation]: the removed group, 2.9 [1.2] yr; the retained group: 1.5 [0.8] yr; p < 0.001). The removed group showed a significantly higher proportion of ears with post-CI AOM (8 of 39 ears; 20.5%) than the retained group (none of 19 ears; 0%) 6 months after CI ( p = 0.044). The AOM-free proportion at post-CI 12 months was 76.9% in the removed group and 83.3% in the retained group, demonstrating no significant difference ( p = 0.49), probably because the VT was spontaneously extruded in the retained group at a median of 6.5 months after CI. Throughout the study period, 17 ears (13 from the removed group) were affected by post-CI AOM. Of these, three ears in the removed group and two in the retained group after spontaneous extrusion of the VT were hospitalized and treated with intravenous antibiotics for AOM that had failed to respond to oral antibiotic therapy. Only one ear in the removed group required an explanation of the infected implant. None suffered from chronic perforation of the tympanic membrane or secondary cholesteatoma after VT insertion or meningitis associated with post-CI AOM. Our results suggest that in CI for children who already have a VT because of a recurrent AOM or chronic OME, retaining the tube in position, rather than removing the tube, may decrease the incidence of AOM at least within 6 months after CI, during which most cochlear implant device infection was reported in the pediatric population.

The outcome of a single-stage endoscopic tympanoplasty with septoplasty using autologous septal cartilage graft in patients with mucosal chronic otitis media and deviated nasal septum

Background: Single-stage endoscopic tympanoplasty with septoplasty using autologous septal cartilage graft in patients with mucosal chronic otitis media and deviated nasal septum had resulted in successful repair of the tympanic membrane perforation and correction of the deviated nasal septum with improved eustachian tube dysfunction at the same time. Aims and Objectives: To study the structural and functional outcome of single-stage endoscopic Type 1 tympanoplasty using autologous septal cartilage graft after septoplasty in patients having mucosal chronic otitis media and deviated nasal septum. Material and Methods: We prospectively analysed 102 patients with chronic mucosal otitis media and central perforation of the tympanic membrane and deviated nasal septum with Eustachian tube dysfunction. The patients underwent endoscopic Type I tympanoplasty using an autologous septal cartilage graft with a thickness of approximately 0.5 mm that was harvested during endoscopic septoplasty. Morphological and functional results were recorded at 1, 6 and 12 month follow ups. Result: All patients were between years of age 31 to 40 years (31%). The average age of the study subject was 33.38 ± 12.63 years, with the male to female ratio of 1.31. Postoperatively the patients were looked for the acceptance of the cartilage graft and hearing gain. Of the total 102 patients, in 90 patients, eardrums perforations were closed satisfactorily, and 12 patients suffered from residual perforation (12%). On the functional front the mean pre-operative hearing loss of 40.98 ± 8.71 dB, improved significantly to 32 ± 9.06 dB postoperatively (P-value < 0.001). with a mean gain of 8.98 dB. Also, the mean pre-operative Air-Bone gap (27 ± 9.13 dB) was reduced postoperatively (13.82 ± 8.45 dB) (P-value < 0.001). Thus, improvement was noted to be 13.18 dB. Conclusion: Endoscopic cartilage tympanoplasty with autologous septal cartilage graft of the nose is a safe and effective way for Type I tympanoplasty with good structural and functional results and added benefits of reduced operating time, optimal graft uptake rate, minimal morbidity and pain and more importantly, ear surgery without a postauricular scar.

Diagnosis of Middle Ear Diseases Based on Convolutional Neural Network

An otoscope is traditionally used to examine the eardrum and ear canal. A diagnosis of otitis media (OM) relies on the experience of clinicians. If an examiner lacks experience, the examination may be difficult and time-consuming. This paper presents an ear disease classification method using middle ear images based on a convolutional neural network (CNN). Especially the segmentation and classification networks are used to classify an otoscopic image into six classes: normal, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM), congenital cholesteatoma (CC) and traumatic perforations (TMPs). The Mask R-CNN is utilized for the segmentation network to extract the region of interest (ROI) from otoscopic images. The extracted ROIs are used as guiding features for the classification. The classification is based on transfer learning with an ensemble of two CNN classifiers: EfficientNetB0 and Inception-V3. The proposed model was trained with a 5-fold cross-validation technique. The proposed method was evaluated and achieved a classification accuracy of 97.29%.

Role of topical antibiotic ointment in the lateral graft following underlay myringoplasty: a prospective randomised study

ObjectiveThe objective of this study was to compare the graft outcome and postoperative infection of with and without the use of antibiotic ointment following myringoplasty for the treatment of chronic perforations.Study DesignRandomized controlled trial.Material and Methods135 chronic perforations were prospectively randomized to use of antibiotic ointment group (UAO, n = 68) or no use of antibiotic ointment group (NAO, n = 67) following myringoplasty. The graft outcomes and postoperative infection were compared among two groups at 6 months.ResultsAt postoperative 6 months, the graft infection rate was 4.4% in the UAO group and 10.4% in the NAO group, the difference was not significant (P = 0.312).The graft success rates were 92.6% in the UAO group and 91.0% in the NAO group, the difference was not significant (P = 0.979). In the UAO group, 3 patients with purulence ear discharge resulted in a residual perforation although they received ofloxacin ear drops and intravenous antibiotic therapy treatment. In the NAO group, 6 patients with purulence ear discharge resulted in a residual perforation, only one, with mild purulence discharge was successfully treated and closed. In addition, no significant between-group differences were observed pre- (P = 0.746) or post- (P = 0.521) operative air bone gap (ABG) values or mean ABG gain (P = 0.745). However, granular myringitis with minimal moistness but without infection has been noted in 3 (4.4%) patients in the UAO group and in 5 (7.5%) in the NAO group, the difference was not significant (P = 0.699).ConclusionsUse and non-use of antibiotic ointments for lateral packing of graft are both comparable methods following myringoplasty for postoperative infection and graft outcomes.

Validation of the OPEN-CLEAN Chronic Total Occlusion Percutaneous Coronary Intervention Perforation Score in a Multicenter Registry

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p=0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p=0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p=0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI.

Radiation therapy for the treatment of macroscopic canine anal gland tumors - a retrospective study

Canine anal gland tumors are locally invasive and early metastasize to the loco-regional pelvic lymph nodes. Radiation therapy is a good method for loco-regional tumor control, especially in inoperable tumors. Since the organs in the pelvic area are sensitive to both acute and late radiation damage (chronic diarrhea, bleeding, strictures or intestinal perforations) and such damage mainly depends on the fraction size, we examined the radiation protocol used in this study with a reduced number of fractions (hypofractionated) regarding effectiveness and side effects. This retrospective study describes 13 dogs with macroscopic anal gland carcinoma that were irradiated with imaging-guided, intensity-modulated radiation therapy with a hypofractionated curative protocol of 12 × 3,8 Gy. Gross pathology was either in the region of the anal gland and/or in the sublumbar lymph nodes. Ten of the 13 dogs had advanced tumor diseases (stage 3a or 3b). The acute radiation reactions were mild to moderate and had been reported for some of the dogs in a previous study. The mean study time was 572 days (range 105-1292 days). Disease progression was observed or suspected in 7/13 dogs during the study period: local or loco-regional progression occurred in 3 dogs (23 %) and distant metastases in 4 dogs (31 %). Median progression-free survival was 480 days (95 %CI, 223-908), median survival was 597 days (95 %CI, 401-908). One year after treatment, 76,9 % (95 %CI, 53,5-100) of the dogs were still alive. The likelihood of tumor progression was lower with increasing age, otherwise none of the examined tumor or patient factors showed a prognostic influence on progression or survival time. No clinically relevant late side effects were observed apart from slight alopecia, pigmentation changes or dry, scaly skin, Medium to long-term tumor control can be expected in dogs with macroscopic anal gland tumors treated with a moderately hypofractionated radiation therapy protocol (12 × 3,8 Gy). During long-term monitoring no serious side effects or side effects requiring treatment were observed.

Immunoglobulin G4-related disease in the sigmoid colon in patient with severe colonic fibrosis and obstruction: A case report

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition characterized by abundant IgG4 positive plasma cells and fibrosis in the affected tissues. It affects most parts of the body; however, there are not many reports on IgG4-RD involving the colon. A 50-year-old man complaining of intermittent fever for more than two years was referred to our hospital. Based on various investigations before surgery, we diagnosed him with chronic perforation of the sigmoid colon caused by inflammatory change or tumor. IgG blood tests before the operation suggested IgG4-RD, and postoperative pathology confirmed this prediction. We present a patient with IgG4-RD with colon involvement, which is an uncommon site. This report will expand the understanding of IgG4-RD in unknown tissues.

Risk factors and outcomes in acute perforated gallbladder: A retrospective cohort study

BackgroundAcute gallbladder perforation is a rare complication of biliary diseases with an estimated incidence of 2% of all gallbladder diseases. It carries a higher risk of morbidity and mortality. This study examines the risk factors and outcome of patients admitted with acute and subacute gallbladder perforation (AGBP) to a tertiary hospital in the Eastern Province of Saudi Arabia. MethodsA retrospective study was performed including all patients with biliary diseases who were operated on from Jan. 2016 until Dec. 2020. The patients were divided: the first group included patients with AGBP and the second group included patients with other biliary diagnoses. We excluded patients with chronic perforation, traumatic or malignant perforation. ResultsA total of 587 patients were eligible for this study. The incidence of AGBP was 2.7% and its morbidity was 6.3% with no mortality reported. AGBP was significantly associated with male gender, older age, in patients with two or more associated comorbidities; diabetes mellitus, hypertension and dyslipidemia. Ultrasonography was not diagnostic while AGBP was confirmed by computed tomography in 42.9%. AGBP was associated with a significant higher risk of conversion to open cholecystectomy and partial or subtotal cholecystectomy. The multivariate linear regression analysis revealed that the length of hospital stays increased by 70% in patients with AGBP. ConclusionAcute perforated gallbladder is predominant in elderly male patients with multiple comorbidities, especially diabetes mellitus, hypertension, and dyslipidemia. CT has a higher sensitivity to detect or suspect AGBP. Laparoscopic cholecystectomy is a safe management approach.

Case study of a hydrostatic pressure-induced traumatic chronic tympanic membrane perforation with purulent otorrhea and spontaneous closure

&lt;p&gt;Tympanic membrane (TM) perforations are ruptures of the membrane separating the middle and outer ear which heal spontaneously in 78.7-94% of cases. However, with large perforations and infection, the spontaneous closure rate diminishes.Chronic TM perforations are thought to rarely close spontaneously and are often treated with a myringoplasty which has a variable success rate, potential risks, and a significant recovery period during which patient activity is notably limited. Significant controversy exists over the indication for surgical intervention in the case of grade 3, chronic TM perforation with a history of infection. The aim of this case study is to provide insight into the typical progression and potential spontaneous resolution of such cases. Moreover, there is a lack of publicly available reference images outlining the progress of TM perforation healing, so detailed time-stamped photos are included. The investigators imaged, at regular intervals, a 23-year-old male’s mid-anterior chronic grade 3 TM perforation who presented with an outer and middle ear infection with purulent otorrhea. The result indicates that chronic grade 3 TM perforations with a history of infection still have potential to spontaneously close. Given the risks and inconvenience of a myringoplasty, further consideration should be taken before recommending this procedure in these cases.&lt;/p&gt;

Surgical Management of Cholecystitis with Chronic Perforation and Liver Abscess Associated with Choledocholithiasis

Calculous cholelithiasis represents about 90% of acute cholecystitis. The high incidence of the disease demonstrates the importance of knowing its clinical manifestations such as pain in the right hypochondrium, anorexia, nausea, vomiting and jaundice, in addition to its serious complications such as liver abscess and intrahepatic perforation. In the case described, we report a 72-year-old male patient who had asthenia about two months ago in association with anorexia and weight loss, with choledocholithiasis as a complication with gallbladder perforation and liver abscess. The study will present the pathogenesis of these complications and will correlate to the importance of a fast and effective care.

To Study the Outcome of Paper Patch Myringoplasty in Patients with Tympanic Membrane Perforations

Background: The aims of our study were to evaluate the outcome of paper patch grafting in tympanic membrane (TM)&#x0D; Methods: This is a retrospective study of 50 patients that underwent paper patch myringoplasty in an outpatient setting.&#x0D; Results: The long-term success rate of paper patch grafting for TM perforation was 78.00% in this study&#x0D; Conclusion: Paper patch grafting can also be considered before formal surgical myringoplasty in the case of small, dry, chronic TM perforations.&#x0D; Keywords: Myringoplasty, TM, Paper patching.

Modified inlay butterfly cartilage myringoplasty: An outpatient minimally invasive procedure for closure of central perforation-graft success rate and hearing outcome

ObjectiveThe objective of this was to evaluate anatomical and hearing results of modified inlay butterfly perichondrium-cartilage myringoplasty for repairing central perforation in an office setting. Material and methodsWe performed a prospective study in 81 patients with chronic central perforations who underwent modified inlay butterfly perichondrium-cartilage myringoplasty in an office setting. The graft success rate, hearing outcome, and complications were evaluated at postoperative 3, 6 and 24 months. Results81 patients with 81chronic perforations were included in this study. The graft success rate was 100.0% (81/81) at postoperative 3 months. At postoperative 24 months, 16 patients lost follow-up, the graft success rate was 98.5% (64/65). The mean preoperative ABG was 23.0 ± 2.6 dB, while the mean postoperative ABG postoperatively 12 months was 11.4 ± 3.1 dB; the difference between these values was significant (P < .05). No graft-related complications (e.g., graft lateralization, graft medialization, graft keratin pearl, middle ear cholesteatoma) were encountered during the follow-up period. In addition, excess perichondrium lateral to the superficial layer of TM remnant became necrotic and crust at postoperative 2–3 months. However, graft keratin pearl and intra-tympanic cholesteatoma/epithelial inclusion cyst weren't found in any patients at postoperative 24 months. Granular myringitis with minimal moistness but without infection has been noted in 6 patients. ConclusionsModified inlay butterfly perichondrium-cartilage myringoplasty is a viable and less invasive option for closure of central perforations in an office setting because this technique does not require tympanomeatal flap elevation and general anesthesia.

Successful repair of chronic esophageal perforation due to hardware migration with buttressing free gracilis flap: a case report

Successful repair of chronic esophageal perforation due to hardware migration with buttressing free gracilis flap: a case report

Comparison ofendoscopic over-underlay technique with and without packing forrepairing chronic perforation.

This study was performed to compare the efficacy of the endoscopic modified cartilage over-underlay technique with and without packing for repairing chronic tympanic membrane (TM) perforations. A total of 70 cases of chronic TM perforation were randomly allocated to endoscopic modified cartilage over-underlay myringoplasty groups with (n = 35) and without (n = 35) packing. The graft success rate and hearing outcomes were compared between the two groups. In addition, neovascularization scores were subjectively obtained. At 12months postoperatively, the difference in graft success rate between the packing and no-packing groups was not significant (94.3% vs. 100.0%, P = 0.473). In addition, there were no significant differences between the two groups in the pre- or postoperative air-bone gap (ABG) (15.18 ± 2.73 vs. 15.07 ± 4.02, P = 0.623 and 8.63 ± 3.03 vs. 8.52 ± 4.50, P = 0.591) or mean ABG gain (6.56 ± 3.23 vs. 6.54 ± 2.83, P = 0.751). However, the average operating times were 43.6 ± 7.1 and 32.7 ± 2.1min in the packing and no-packing groups, respectively (P < 0.001). Surgical and hearing outcomes were comparable between patients with chronic TM perforation treated using the endoscopic modified over-underlay technique with and without packing. However, without packing, the procedure was less invasive and had a shorter operating time.

‘Invasive’ Gallbladder Fundus Mass Masquerading as Cancer

Background: Gallbladder perforation (GBP) is an uncommon but serious complication of cholecystitis with mortality rates between 12-16%. In 1934, Niemeier described three classifications; chronic perforation with fistula communication, subacute perforation with walled off abscess, and acute perforation into the free peritoneal cavity. Almost 90 years later, GBP remains poorly understood with varying clinical pictures. In this case report of GBP, the overlapping clinical and radiological picture with Gallbadder Cancer (GBC) presented a diagnostic dilemma for radiologists and surgeons. Case: A 77-year-old woman was admitted to The Canberra Hospital, Australia, reporting a 4-month history of weight loss, fatigue, diarrhoea, anorexia, abdominal pain and a firm mass in the right upper quadrant. CT scan demonstrated a mass arising from the gallbladder fundus with invasion into the right sided rectus abdominis and adjacent edge of segment 4b of the liver suggesting malignancy. Surgical resection of the presumed T3 GBC was performed, and surprisingly the histopathology report revealed a gallbladder perforation on a background of acute on chronic cholecystitis, chronic fibrosis at the abscess sites and no evidence malignancy. Conclusion: This rare case illustrates that GBP can have an insidious presentation and with striking clinical and radiological features of malignancy. As gallbladder perforations are uncommon, there is a lack of large studies evaluating clinical and radiological characteristics, especially in the chronic setting. This case exemplifies how complex the evaluation of such patients is for clinicians, and the care needed to confirm diagnosis, especially in an era of evolving neoadjuvant treatment options for GBC.

Endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers

ObjectiveThe objective of this study was to evaluate the graft outcome and complications of endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers. Study designProspective case series. Materials and methods56 patients with chronic large perforations more than 50% of the TM who underwent endoscopic perichondrium-cartilage button technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 3, 6 and 12 months. ResultsOf the 56 ears, 3 (5.4%) patients lost follow-up, 53 (94.6%) patients were finally included in this study. The mean operation time was 37.2 ± 5.4 min. The retrograde tympanomeatal flap elevation was performed in 16 (30.2%) patients.The graft success rate was 96.2% (51/53) at postoperative 3 months and 94.3% (50/53) at postoperative 12 months. The mean preoperative ABG was 25.0 ± 3.7 dB, while the mean postoperative ABG postoperatively 6 months was 12.8 ± 3.1 dB; the difference between these values was significant. No graft-related complications (e.g., graft lateralization, significant blunting, and graft medialization) were encountered during the follow-up period. However, graft keratin pearl was noticed in 5.7% (3/53) patients, which occurred in the handle of malleus in 2 and antero-inferior margin in one. All the graft pearls were endoscopically removed in the outpatient setting. ConclusionsEndoscopic perichondrium-cartilage button technique can be achieved in every teenager patient with chronic large perforation without cholesteatoma, and, is a safe and efficient procedure.

Pediatric tympanoplasty: A paradigm shift?

Introduction and objectivesPediatric tympanoplasty is still a matter of controversy. Many factors have been associated with the surgical outcome of tympanoplasty in children, including age, size and location of the perforation, surgical technique and Eustachian tube dysfunction. The optimal approach and timing of this surgery remains controversial.This study aims to evaluate the outcomes of pediatric tympanoplasty and analyze factors that may influence the success of this surgery. Materials and methodsA retrospective review was conducted which included children from 5 to 15 years old that underwent tympanoplasty with or without ossiculoplasty for chronic tympanic perforation in a tertiary care university hospital over a 6-year period. Patients were divided in two age groups (5 to ≤10 years old and >10 to 15 years old). Children with cholesteatoma or that underwent simultaneous mastoidectomy were excluded. Results83 cases were included. Average age was 10.7±2.1 years and mean follow-up time was 9 months. Of the cases, 21.7% were revision surgeries. Successful closure of the tympanic membrane perforation was achieved in 76.9% of primary surgeries and 55.6% of revision surgeries. Most of the patients improved their conductive hearing-deficit. No statistical difference in graft failure was noted regarding age, presence of craniofacial dysmorphism and surgical approach. The use of simple graft (temporal muscle fascia or tragus perichondrium) was significantly superior in primary surgery (p<0.05). We also found a significant difference between the location of the perforation and revision surgery, with anterior perforations showing a higher risk (p<0.05). ConclusionsPediatric tympanoplasty is effective in repairing chronic tympanic perforations. In our study, accepted predictors of surgical outcome such as age and surgical approach were not associated with graft failure.

Chronic tympanic membrane perforation: Histopathological evidence of the experimental model

ObjectivesThis study aims to compare the effectiveness of three different models of chronic tympanic membrane perforations. MaterialsThe experimental study included 18 male chinchillas, divided into 3 equal groups. Group 1 perforations were performed with infolding technique myringotomy. Laser myringotomy was performed for perforation creation in Group 2. Group 3 perforations were performed with infolding myringotomy combined with ventilation tube insertion. At the end of the follow-up period, which lasts 8 weeks, all tympanic membranes with patent perforations were examined histologically. ResultsAlthough, the mean perforation patency in Group 2 was significantly higher than in Group 1 (5 vs. 2.4 weeks, p < 0.01), both of them failed in creation of chronic perforation according to time parameters. Group 3 demonstrated the longest mean perforation patency among investigated models (8 weeks). In Group 3, histological examination of perforations, which were considered to be chronic, revealed, that stratified squamous epithelium continued from the lateral surface around the perforation edge to join with the medial mucosal layer of TM. ConclusionOur findings demonstrated that the combination of infolding technique and ventilation tube insertion seems to be a potential candidate for an effective animal model of tympanic membrane perforation. Further large-scale studies are required to verify our promising results.

THE DEADLY PACE

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myocardial perforation remains as a rare but important complication of pacemaker insertion. Perforation can occur acutely within 24 h after implantation, sub-acutely between 24 h to one month after implantation and chronically occurring more than one month after implantation. (Sidhu). Acute perforations are well described at medical literature, but chronic perforations are much less common and can be difficult to diagnose (Ahmed). This is the case of atypical presentation of a chronic right ventricular perforation caused by RV ICD lead presenting with tamponade and left sided compression atelectasis. CASE PRESENTATION: A 73-year-old Male with PMHx of A-Fib, CHF class II, A-HTN, NIDDM, RA, PUD, TAA, S/P ICD placement 3 months before presentation, that comes to the ED with pleuritic chest pain, dizziness, SOB and fatigue of 3 months of evolution. Patient states that the symptoms slowly worsened over the last 3 days. At physical examination was found with BP 90/40, HR 105 bpm, RR 21rpm Sat 95% in acute distress, using accessory muscles with muffled heart sounds and + JVD. COVID-19 Ag was negative. EKG shows sinus tachycardia and low voltage on precordial leads. A bedside echocardiogram shows large pericardial effusion with tamponade physiology, ventricular perforation and emergent pericardiocentesis was performed. A total of 515 ml of bloody pericardial fluid was removed and patient vital signs improves. Chest CT scan later confirmed the presence of pericardial fluid accumulation and left sided compression atelectasis. The ICD lead was removed and relocated at the ventricular septum to avoid ventricular perforation in the future. DISCUSSION: In rare circumstances when a large effusion develops over time, it may cause compression atelectasis of the surrounding bronchi and lung (Amin). Compression atelectasis caused by ventricular perforation are better described in cases of acute or subacute ventricular perforation at the medical literature. The most common presentation of chronic perforation is SOB and hypoxemia. This patient presentation after 3 months of ICD placement, with sudden onset cardiac tamponade and no hypoxemia is an atypical presentation of chronic ventricular perforation. The rapid fluid accumulation over time in the pericardium, is what causes that this space stretches to accommodate the excess fluid, that later cause a compression atelectasis of the surrounding bronchi and lung (Amin). CONCLUSIONS: This patient atypical presentation of ventricular perforation wasn't described before in the literature. Is very important not to assume that any perforation may the sequelae of a recent intervention and can present acutely like in this life-threatening clinical scenario. As clinicians we need to keep in mind that ventricular perforation may present with large effusion causing compression atelectasis, with or without tamponade physiology. REFERENCE #1: Sidhu B, Rajani R, Rinaldi C. Chronic Ventricular lead perforation: Expect the Unexpected. Clin Case Rep. 2019, 7: 455-468 REFERENCE #2: Ahmed A, Shokr M, Lieberman R. Subacute right ventricular perforation by pacemaker lead causing left sided hemothorax and epicardial hematoma. Case Reports in Cardiology. 2017: 1-5 REFERENCE #3: Amin H, Gyawali B, Chaudhuri D. A large pericardial effusion culminating in left lung collapse. Cureus. 2019, 11: e5287 DISCLOSURES: No relevant relationships by Jesse Aleman, source=Web Response No relevant relationships by Francisco Caraballo, source=Web Response No relevant relationships by Greisha Gonzalez Santiago, source=Web Response

Endoscopic modified perichondrium-cartilage sandwich graft for repairing chronic subtotal and total perforations

ObjectiveThe objective of this study was evaluate the short-and long-term graft outcome and complications of endoscopic modified perichondrium-cartilage sandwich graft for repairing chronic subtotal and total perforations. Study designProspective case series. Materials and methods135 patients with chronic subtotal and total perforations who underwent endoscopic modified perichondrium-cartilage sandwich graft technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 6 and 24 months. Results124 patients were finally included in this study. The graft success rate was 96.3% in subtotal perforation and 97.7% in total perforation (P = 0.874), with an overall success rate of 96.8% at postoperative 6 months. The graft success rate was 95.8% (68/71) in subtotal perforation and 94.9% (37/39) in total perforation (P = 0.795), with an overall success rate of 95.5% (105/110) at postoperative 24 months. The mean ABG improved from 28.0 ± 5.3 dB preoperatively to 14.9 ± 4.8 dB postoperatively 12 months (P < 0.05) for subtotal perforations; from 33.4 ± 7.4 dB preoperatively to 16.1 ± 2.4 dB postoperatively 12 months (P < 0.05) for total perforations. No graft-related complications (e.g., graft lateralization, significant blunting, graft medialization) were encountered during the follow-up period. Of the 110 patients, temporal bone CT revealed well pneumatization of the middle ear and mastoid region. However, graft keratin pearl was noticed in 1.8% (2/110) patients. ConclusionsEndoscopic modified perichondrium-cartilage sandwich graft for repairing subtotal and total perforations had excellent short and long-term graft success rate with less time-consuming and minimal complications.