Effectiveness Of Surgical Management Research Articles

The effect of surgical management in mitigating fragility fracture risk among individuals with primary hyperparathyroidism

BackgroundPrimary hyperparathyroidism predominately affects women who are postmenopausal and causes complications, including fragility fractures. Its treatment is parathyroidectomy, which is associated with low complication and >95% cure rates. Considering fractures are associated with premature death, we aimed to determine whether the surgical management of individuals with biochemical diagnosis of primary hyperparathyroidism was associated with a reduction in fracture risk. MethodsIn this population-based cohort study, we used administrative health databases to identify adults ≥18 year old who were biochemically diagnosed with primary hyperparathyroidism between 2007 and 2016 in Ontario. Patients were included if their calcium was ≥2.6 mmol/L (≥10.42 mg/dL) with a concurrent parathyroid hormone of ≥2.2 pmol/L (≥20.75 pg/mL). We followed patients and compared the incidence of fractures between those with and without parathyroidectomy. To control for potential confounding, we used inverse probability of treatment weighting to estimate the average treatment effect in the treated. Fine-Gray competing risk regression models were used to determine the association between surgery and time to fracture. ResultsIn a cohort of 28,059 with a biochemical diagnosis of primary hyperparathyroidism, the mean age (standard deviation) was 65 years (14.2 years), and 75% (n = 21,139) were female. Only 12.6% (n = 3,523) underwent parathyroidectomy. Weighted fracture cumulative incidence at 12 years postdiagnosis was 10.17% (n = 182) in surgical patients and 14.04% (n = 2,004) in nonsurgical patients. Parathyroidectomy prevented 1 fracture for every 26 surgeries performed (weighted risk difference, 3.87%, 95% confidence interval, 0.96%–6.62%) and reduced the hazard of fracture by 22% (weighted hazard ratio, 0.78; 95% confidence interval, 0.64–0.95). ConclusionIn a large, publicly funded health system, parathyroidectomy significantly reduced the short- and long-term risk of fragility fractures in patients with primary hyperparathyroidism.

The Diagnosis and Treatment of Caesarean Scar Defect: Progress and Controversies

Objective: A caesarean scar defect (CSD), a niche in the uterus, is an emerging long-term complication after caesarean section (CS). With rising rates of CS, the risk of post-caesarean iatrogenic complications has increased, although many women may be diagnosed incidentally while asymptomatic. We present a review of the diagnosis and treatment of CSD. Mechanism: We describe the current state of treatment of CSD in terms of diagnosis and the different treatment options. Findings in Brief: The diagnosis can be confirmed by transvaginal sonography, hysteroscopy and other imaging examinations. At present, therapy is dependent on the presence of symptoms, the size of the CSD, and secondary infertility. Non-invasive management includes oral contraceptives and the levonorgestrel-releasing intrauterine system (LNG-IUS), which can improve the clinical symptoms of prolonged menstrual periods to some certain extent. Currently, the principal therapy is surgery, and micro-invasive surgical management includes transvaginal, hysteroscopic and laparoscopic procedures. However, there is no unified surgical selection standard, and the selection of surgical methods and the effect of surgical management are also controversial and need to be further studied. Conclusions: The aim of this review is to summarize and compare the selection of diagnostic and therapeutic methods and the differences in the curative effects of these therapeutic methods for CSD.

Abstract TP295: Stroke Prevention Surgery > Quality of Life and Cognitive Ability to Drive Are Maintained After Surgical Repair of Unruptured Intracranial Aneurysm

Background: Studies have questioned the effectiveness of surgery for the management of unruptured intracranial aneurysm (uIA). Few studies have examined the ability to drive and quality of life (QOL) after surgery for uIA. Objective: This study examined the effectiveness of surgical management of uIA by measuring patients’ perceived quality of life and their cognitive abilities related to driving. Methods: Between January 2011 and January 2016 patients with a uIA were assessed using the Quality Metric Short Form 36 (SF36) and the off-road driver screening instrument DriveSafeDriveAware. Reassessments were conducted at the 6-week post-operative follow-up for surgical patients and at 12-month follow-up for surgical and conservatively managed patients. Results: 175 patients enrolled in the study, of which 112(66%) had surgical management of their aneurysm. For the surgical cases who completed all assessments (N=74), there was a trend for the DriveSafe pre-operative mean score of 108 (SD 10.7) to be lower than the 6-week and 12-month post-operative mean scores (111 SD 9.7 and 112 SD 10.2 respectively)(p=0.05). There were no significant changes in DriveAware scores at any epoch or between patient groups nor in the MCS in the surgical group.. There was a significant decline in PCS scores at 6 weeks post-operatively which recovered at 12 months (52 SD 8.1, 46 SD 6.8 and 52 SD 7.1 respectively)( p <0.01). There was no significant difference in 12-month mRS scores between the surgical cases who completed with cases who did not complete all assessments. Conclusion: Surgery for uIA did not affect cognitive abilities for driving at 6 weeks or 12 months after surgery. There was a decline in the QOL in the first months after surgery, however QOL returned to pre-surgical status 12 months after surgery. If the risk of seizures is low and there are no post-operative complications, returning to driving can be recommended.

Disparity in access to bariatric surgery among African-American men.

Despite improvements in safety and effectiveness in surgical management of extreme obesity, men and racial minorities are less likely to receive metabolic and bariatric surgery (MBS) compared to other patient groups. This study examines the racial and gender disparities in access to MBS to understand the mechanism that drives these problems and to propose strategies for closing the disparity gap. Using 2013-2014 National Health and Nutrition Examination Survey data, we estimated the proportion of individuals, by race and gender, who were eligible for MBS based on Body Mass Index (BMI) and comorbidity profile. We analyzed the 2015 MBS Accreditation and Quality Improvement Program Participant Use Data File to examine differences in patient characteristics, comorbidities, and postsurgical outcomes among African-American (AA) and White men. Predictors of poor outcomes were identified using unconditional logistic regression models. AA men represented 11% of eligible patients but only 2.4% of actual MBS patients. Compared to White men, AA men were younger, had higher BMI, were more likely to have a history of hypertension, renal insufficiency, required dialysis, and had American Society of Anesthesiologists class 4 or 5 (all P values < 0.01). After surgery, AA men were more likely to suffer from postoperative complications (adjusted odds ratio (aOR) 1.25, 95% confidence interval (CI) 1.02-1.52) and stayed in the hospital for more than 4days (aOR 1.51, 95% CI 1.26-1.82) compared to White men. Despite being eligible for MBS based on both BMI and obesity-related comorbidities, AA men are significantly less likely to undergo MBS. Those AA men who receive surgery are significantly younger than White men but also experience greater comorbidities compared to White men and all women. Further longitudinal studies into patient-, system-, and provider-level barriers are necessary to understand and address these disparities.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis.

Background:The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).Methods:This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.Results:Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.Conclusions:Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Surgical management associates independently with improved survival among de novo stage IV breast cancer patients without liver or brain metastasis.

e12106 Background: To examine the independent effect of surgical management of the primary tumor and axillary lymph node on survival in patients with de novo Stage IV breast cancer (BC) Methods: 113 patients with de novo stage BC between 2010 to 2013 were followed up to Oct. 1, 2016. Multivariable Cox proportional hazard models were constructed to assess the effect of mastectomy (MAS) and axillary lymph node dissection (ALND) on overall survival (OS) after univariate analyses and K-M curves. Non-treatment covariates included age, BMI, menopause, Stage T, Stage N, ER, PR, HER2, Ki67&gt;14% status, and metastasis sites (lung, liver, bone, brain and others). Chemotherapy, hormonal, target treatement and radiotherapy before the disease progression were others. Results: Mean age 52 (24 - 84) years old, metastasis site by bone 53% (60), lung 32% (36), liver 32% (36), brain 2% (2), and other 23% (23). Median survival 21.4 months. All 42% (48) surgical patients had simultaneous MAS and ALND. Younger (mean 49 vs. 54) and fewer post-menopause (42% vs. 62%) were significantly noticed in surgical patients with median survival 37.8 vs. 14.2 months of others. Multivariable analysis showed OS favorable HRs 0.53 (95% CI 0.24 - 1.17, p=0.12) of surgery and HR 0.48 (0.22 - 1.04, p=0.06) of hormonal drug, and significant HR 0.10, (0.02 - 0.52, p&lt;0.01) of target therapy, insignificant effects of chemotherapy HR 0.60(0.26 - 1.42, p=0.25) and radiotherapy HR 0.70 (0.33 - 1.50, p =0.36). Unfavorable metastasis sites were identified as brain and liver at multivariable model for subgroup analysis. K-M curves estimated median survival 29.3 vs. 14.4 months (favorable vs. unfavorable patients). Both univariate and multivariate analyses showed the significant effect of surgery in favorable subgroup (N=76) with HR 0.30 (0.16 - 0.56, p &lt;0.01) and 0.33 (0.11 - 0.98, p=0.05) on OS, respectively. In unfavorable subgroup (N=37), the results were insignificant effect of surgery on OS with HR 0.75 (0.37 - 1.55, p=0.54) and 1.60 (0.33 - 7.81, p=0.56). Conclusions: Surgical management associated independently with improved survival among de novo stage IV BC patients without liver or brain metastasis.

Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis.

The purpose of this study was to assess the effectiveness of arthroscopic and open surgical techniques on the treatment of shoulder multidirectional instability. Literature searches were conducted using the databases MEDLINE, Embase, ClinicalTrials.gov, the Cochrane Library, and the Cochrane Central Register of Controlled Trials. Original articles on the surgical management of multidirectional instability were retrieved against selection criteria. Data were extracted and divided into three groups by surgical technique. Proportion and mean meta-analyses were performed for comparison. The available evidence was from 35 level IV and 1 level II studies. The recurrent instability rate was 9.9 % (95 % CI 7.3-12.9 %) in open capsular shift (OCS) group and 6.0 % (95 % CI 3.7-8.9 %) in arthroscopic capsular plication (ACP) group, between which no difference was observed. However, thermal capsular shrinkage (TCS) group resulted in a recurrent instability rate of 23.9 % (95 % CI 16.6-32.2 %), significantly higher than the above two groups. OCS and ACP groups revealed low reoperation rates of approximately 5.2 % (95 % CI 2.7-8.5 %) and 4.8 % (95 % CI 2.3-8.0 %), respectively, which are lower than that in TCS group of 16.9 % (95 % CI 12.4-21.8 %). OCS caused more loss of external rotation than ACP, losing 7.0 (95 % CI 3.3-10.6) degrees versus 2 (95 % CI 0.9-2.4) degrees, respectively. ACP and OCS techniques have similar primary outcomes, but the former causes less post-operative stiffness. It is suggestible to avoid TCS in the treatment of MDI. Level IV.

Surgical management of post carotid artery stenting restenosis

To discuss the feasibility, safety and effectiveness of surgical management of post carotid artery stenting (CAS) restenosis, mainly focusing on the surgical options and indications. This study represented retrospective analysis of 3 kinds of surgical managements of 21 patients with symptomatic post CAS restenosis from April 2012 to April 2014. Patch carotid endarterectomy (pCEA), Eversion carotid endarterectomy (eCEA) or carotid excision and graft interposition (CEGI) was selected to remove the stent and reconstruct the blood flow, based on the preoperative imaging results and intraoperative adhesion degree. Use of carotid shunt, blood loss, operative time, carotid artery cross-clamp time and other data were recorded. Patients were followed for improvement of symptoms, complications and restenosis. Eleven, 4 and 6 patients received pCEA, eCEA or CEGI respectively. All the stents were successfully removed. Shunts were deployed in 14 cases. The mean bleeding was (152.6 ± 38.0) ml, the mean operation time was (100.7 ± 34.8) min and the mean carotid artery clamping time was (29.1 ± 4.6) min. In the early postoperative period, there were no infection, strokes, cranial nerve injury, myocardial infarction or mortalities. One patient developed neck hematoma, while 2 patients had the symptoms of hyperperfusion such as headache, irritability and multi-lingual but no intracranial hemorrhage happened according to the brain CT scan, who all fully recovered within 3 days. Within a median follow-up of (13.2 ± 4.3) months, no strokes, myocardial infarctions or recurrent restenosis (> 50%) on duplex ultrasound imaging or CTA was discovered except for 1 patient who died of lung cancer. Surgical management to remove the stent and reconstruct the blood flow, which offered new options in the treatment of post CAS restenosis, with its initially confirmed simplicity, feasibility, safety and validity.

Ressonância da fala após tratamento cirúrgico da insuficiência velofaríngea secundária à cirurgia ortognática

OBJETIVO:investigar o efeito da cirurgia corretiva da insuficiência velofaríngea sobre a ressonância da fala de indivíduos nascidos com fissura palatina que passaram a apresentar hipernasalidade, após a cirurgia ortognática.MÉTODOS:foram analisados os resultados da ressonância de 23 pacientes com fissura labiopalatina corrigida cirurgicamente que apresentavam ressonância oronasal equilibrada antes da cirurgia ortognática e foram submetidos à correção cirúrgica da insuficiência velofaríngea, devido ao aparecimento de hipernasalidade após a cirurgia ortognática. Os pacientes foram submetidos à avaliação perceptivo-auditiva da fala para classificação da hipernasalidade, em três situações: 3 dias antes e 5 meses, em média, após a cirurgia ortognática e, 13 meses, em média, após a cirurgia corretiva da insuficiência velofaríngea. A hipernasalidade foi classificada utilizando-se escala de 4 pontos: 1=ausência de hipernasalidade; 2=hipernasalidade leve; 3=moderada e 4=grave. Os escores de hipernasalidade nas três situações estudadas foram comparados por meio do teste de Friedman, com nível de significância de 5% e, posteriormente, pelo teste de Tukey para comparações múltiplas.RESULTADOS:do total de 23 pacientes, houve eliminação do sintoma de fala após a correção da insuficiência velofaríngea em 83% (19/23), sendo os escores médios de nasalidade antes da cirurgia ortognática=1, após a cirurgia ortognática=3 e após a correção da insuficiência velofaríngea=1. Houve diferença estatisticamente significante entre as três situações estudadas (p&lt;0,001).CONCLUSÃO:a cirurgia corretiva da insuficiência velofaríngea foi um tratamento efetivo na grande maioria dos casos que apresentaram hipernasalidade secundária à cirurgia ortognática, com retorno à condição de normalidade.

Clinical observation of one-stage resection of left colon cancer with acute obstruction

Objective To explore the effect of surgical management of left colon cancer with acute obstruction. Methods A retrospective analysis was made on the clinical data of 85 cases with acute obstructive colorectal carcinoma treated by one-stage resection. Among the 85 cases, there were 48 cases of left colon obstruction(treatment group), and the control group included 37 cases of right colon cancer. To compare the occurrence of postoperative complications. Results 20 cases had postoperative complication in the treatment group, among which,2 cases had anastomosis fistula,4 cases of pulmonary infection,5 cases of abdominal abscess,6 cases of incision infection and 3 cases of intestinal adhesion. In control group, there were 15 cases had complication, among which,1 case had anastomosis fistula,3 cases of pulmonary infection,3 cases of abdominal abscess,5 cases of incision infection and 3 cases of intestinal adhesion. There was no significant difference in incidence rate of complication between two groups(P> 0.05). Conclusion One stage resection in the treatment of left colon cancer with acute obstruction is safe and feasible. Key words: Colonic neoplasms; Intestinal Obstruction; Anastomosis, Surgical

Comparison operative and conservative management for primary patellar dislocation: an up-to-date meta-analysis.

The aim of this review was to compare the clinical outcomes between operative and conservative management for primary patella dislocation (PPD). PubMed Medline, EMBASE, Google scholar, and the Cochrane Library were systematically searched for randomized controlled trials that compared operative technique versus conservative technique for PPD. The results of eligible studies were independently extracted and analyzed according to the following: patient's satisfaction, Kujala score, Tegner score, and redislocation rate. Random-effect and fixed-effect models were adopted to calculate the weight mean difference and the odds ratio for continuous and dichotomous variables with 95 % confidence interval. Seven studies met the inclusion criteria, resulting in 402 (216 surgery and 186 conservation) patients available for the present study. A meta-analysis showed no significant differences between the two treatment groups in terms of patient's satisfaction and Kujala score. However, significant differences in Tegner score (P < 0.00001) and redislocation rate (P = 0.002) were observed in favor of surgical treatment. In the subgroup analysis, surgical intervention achieved higher (P = 0.002) Kujala score in short term (<5 years), while conservation gained advantage (P = 0.003) in long term (>5 years). There was no significant difference in dislocation rate in long term. Surgical treatment might provide better clinical results in short term. More persuasive evidence is still needed to proof the effect of surgical management in long time.

A clinical analysis of 40 cases with congenital fibrosis of extraocular muscles

To analyse the clinical manifestations and the effects of surgical management on Congenital fibrosis of extraocular muscles (CFEOM). Forty cases with CFEOM were retrospectively summarized. The follows were recorded and analysed, including sex, surgical age, visual acuity, refractive condition, phenotype, the diopter, the complications of eye and other position of the body, familial history, surgical methods. In the 60 eyes having refractive record, 7 eyes were simple hyperopia (11.67%), 2 eyes were simple myopia (3.33%); 51 eyes is astigmatism (85.00%); Amblyopia were 94.64%. 29 cases were CFEOM1 (72.5%); 10 cases were CFEOM 3 (25.0%); 1 case was CFEOM 2 (2.5%).10 cases had familial history (25%). The methods of surgery include recession, hang-back or tenotomy of the rectus muscles. If forced duction of the antagonist was negative, we can considered strengthening it. The clinical manifestations can be improved in 62 eyes After surgery. CFEOM is one of rare CCDDs, the astigmatism of refractive errors was among 51 eyes (85%), the incidence of amblyopia and CFEOM1 were high. The strabismic angles can be decreased in most patients through surgery.

A clinical analysis of sixty-seven cases with Duane's retraction syndrome

To analyze the clinical manifestations and the methods and effects of surgical management on Duane's Retraction Syndrome (DRS). 67 cases with DRS were summarized retrospectively. The data were recorded and analysed, including sex, age, type, clinical features, surgical methods and the results. 63 cases had only monocular involvement. The number of Type I DRS was 47 cases (35 cases with esotropia, 12 cases with exotropia). 8 cases were Type II DRS with exotropia and 12 cases were Type III DRS (11 of them with exotropia). In 37 cases with upshoot and/or downshoot phenomenon, 31 of them were associated with exotropia. Ipsilateral medial rectus or lateral rectus recession, or bilateral medial rectus recession, improved the head compensation position, narrow palpebral fissure and globe retraction, with improvement or elimination of the deviation. After the operation, 60 cases (90%) showed horizontal tropia less than 10 prism diopters. Upshoot and/or downshoot were improved in all of the 37 cases after recessing medial or/and lateral recti, or simultaneously weakening of the inferior oblique muscle. Weakening medial and/or lateral recti can improve the clinical manifestations of DRS. Upshoot and downshoot are more common in eyes with exotropia. Lateral rectus recession is the main treatment method for relieving upshoot and downshoot in DRS with exotropia. We infer that the upshoot and downshoot phenomenon mainly related to the "bridle" effect. Recession of both horizontal recti can improve the serious clinical manifestations.

Analysis of the effect of surgical management on vitreomacular traction syndrome

To evaluate the efficacy of vitreous surgery for the patients with vitreomacular traction syndrome. The 16 consecutive patients (16 eyes) who underwent vitrectomy for vitreomacular traction syndrome during July 1998 and January 2002 were retrospectively analyzed. Vitreomacular traction was released successfully after vitrectomy, a better visual acuity was obtained in 10 eyes, the number of patients whose visual acuity was below 0.1 was increased from 6 to 8. In 5 cases with the visual acuity was 0.02 or worse before surgery, however their visual acuity was improved in some degree. Complications of vitreous surgery included iatrogenic macular hole (2 eyes), postoperative cataract in (1 eye), partial-thickness macular hole (1 eye), and macular pucker (1 eye), both of last two complications was demonstrated three months later. Pars plana vitrectomy can relieve macular traction, improve visual acuity and prevent a further decease of visual acuity.

Management of pain after brachial plexus injury: a parallel study

Abstract Introduction: The study was carried out to find out the effects of surgical management on pain after brachial plexus injury. Method: A prospective with control trial was performed in 279 patients (236 males and 43 females) who had isolated total root avulsion for brachial plexus injury accompanied by pain. The patients were allocated into 5 groups according to the time between the injury and the first visit: within 2 months in group 1 (66 patients), 2 to 4 months in group 2 (80 patients), 4 to 8 months in group 3 (51 patients) and more than 8 months in group 4 (60 patients). The patients in group 5 (22 patients) all came to us within 2 months, but did not accept any kind of surgical management. So these patients received only conservative treatment and were defined as the control group. Total root avulsion was confirmed by physical examination, electrodiagnosis and cervical myelogram in all patients. Furthermore, surgical exploration was performed in all patients of groups 1, 2, 3 and 4. Neurotiz...

Retrospective review of 208 patients with leiomyosarcoma of the uterus: prognostic indicators, surgical management, and adjuvant therapy☆

Objective We evaluated the predictive value of several proposed prognostic indicators and the effect of surgical management and adjuvant therapy on clinical outcome associated with leiomyosarcoma (LMS) of the uterus. Methods A medical record search of patients treated at Mayo Clinic from 1976 through 1999 was performed using the International Classification of Diseases, Ninth Revision codes for LMS and malignant neoplasm of the uterus. Study inclusion criteria included confirmation of the diagnosis of LMS of the uterus by a pathologist at our institution. Survival curves were generated using the Kaplan–Meier method. Multivariate analysis was performed using the Cox proportional hazards model. A case-control investigation was also performed. Results A total of 208 patients met study requirements. The median follow-up for survivors was 7.7 years. Multivariate analysis showed that high grade, advanced stage, and oophorectomy were associated with significantly worse disease-specific survival. Case-control investigations suggested that ovarian preservation does not adversely affect survival and that adjuvant pelvic radiation therapy does not significantly improve survival. An LMS risk-assessment index that was generated is highly predictive of survival. Conclusions Tumor grade and stage (using modified criteria for endometrial cancer) appear to be valid prognostic indicators for LMS of the uterus. Ovarian preservation may be considered in premenopausal patients with early-stage leiomyosarcoma of the uterus. Additionally, adjuvant therapy does not appear to significantly affect survival. Finally, our highly predictive LMS risk-assessment index may be useful for counseling patients.

Somatosensory and brainstem auditory evoked potential in congenital craniovertebral anomaly; effect of surgical management.

Clinical features and evoked potential recordings were analysed in 32 patients with congenital atlantoaxial dislocation before and after surgery. Seven patients (group 1) had atlantoaxial dislocation, while 22 patients had associated basilar invagination (group 2). In both groups, pyramidal tract signs, posterior column signs, wasting of the upper limbs, and abnormality of somatosensory evoked potentials (SSEP) were similar. Conversely, lower cranial nerve involvement and abnormal brainstem auditory evoked potentials (BAEP) were significantly more in patients with basilar invagination (p less than 0.05). All seven patients in group 1 and 17 patients in group 2 were operated upon. Clinical and electrophysiological deterioration were significant in patients with basilar invagination (group 2), following posterior fixation compared with group 1. Among the patients in group 2, who clinically deteriorated following posterior fixation, seven had transoral excision of odontoid and six of them improved both clinically and electrophysiologically. Two patients in group 2 had odontoid excision before posterior fixation, and in both the evoked potentials improved postoperatively. In group 1 the patient's BAEP remained unaffected following posterior fixation, however, in group 2, eight patients over 53% showed improvement in brainstem function following posterior fixation. This study shows the value of evoked potentials in congenital atlantoaxial dislocation, and rationalizes the surgical procedure in these patients. In patients with basilar invagination, odontoid excision is the preferred first stage procedure.

Chronic secretory otitis media: effects of surgical management : Gates, G.A., Cooper Jr. J.C., Avery C.A. and Prihoda T.J.Ann. Otol. Rhinol. Laryngol. (1989) 98/1 PART II SUPPL. 138 (2–32)

Chronic secretory otitis media: effects of surgical management : Gates, G.A., Cooper Jr. J.C., Avery C.A. and Prihoda T.J.Ann. Otol. Rhinol. Laryngol. (1989) 98/1 PART II SUPPL. 138 (2–32)

Chronic Secretory Otitis Media: Effects of Surgical Management

To study the effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion, we randomly assigned 578 4- to 8-year-old children to receive one of the following: bilateral myringotomy and no additional treatment (group 1), tympanostomy tubes (group 2), adenoidectomy and myringotomy (group 3), or adenoidectomy and tympanostomy tubes (group 4). The 491 who accepted surgical treatment were evaluated at 6-week intervals for up to 2 years. Treatment effect was assessed by four main outcomes: time with effusion, time with hearing loss, time to first recurrence of effusion, and number of surgical re-treatments. For the groups (in order), the mean percent of time with any effusion in either ear was 49, 35, 30, 26 (p less than .0001); the mean percent of time with hearing thresholds 20 dB or greater was 19, 10, 8, and 7 (p less than .0001) in the better ear; and 38, 30, 22 and 22 in the worse ear (p less than .0001); the median number of days to first recurrence was 54, 222, 92, and 240 (p less than .0001); and the number of surgical re-treatments was 66, 36, 17, and 17 (p less than .0001). The most notable adverse sequela, purulent otorrhea, occurred in 22%, 29%, 11%, and 24% of the patients assigned to groups 1 through 4, respectively (p less than .001). In severely affected children who have chronic otitis media with effusion resistant to medical therapy, adenoidectomy is an effective treatment. Adenoidectomy plus bilateral myringotomy lowered posttreatment morbidity more than tympanostomy tubes alone and to the same degree as did adenoidectomy and tympanostomy tubes. Adenoidectomy appears to modify the underlying pathophysiology of chronic otitis media with effusion. This effect is independent of the preoperative size of the adenoid. Tympanostomy tube drainage and ventilation of the middle ear provide adequate palliation so long as the tubes remain in place and functioning. We recommend that adenoidectomy be considered in the initial surgical management of 4- to 8-year-old children with hearing loss due to chronic secretory otitis media that is refractory to medical management and, further, that the size of the adenoid not be used as a criterion for adenoidectomy. Concomitant bilateral myringotomy with suction aspiration of the middle ear contents also should be done, with or without placement of tympanostomy tubes at the discretion of the surgeon.