Mastoid Surgery Research Articles

Additional Benefits of Facial Nerve Monitoring during Otologic Surgery.

This study assesses the role of facial nerve monitoring (FNM) for intraoperative decision making during otologic surgery and possible benefits beyond protecting facial nerve integrity. This prospective study examines intraoperative FNM data and structured interviews collected during 52 otologic procedures. Tertiary referral center. Subjects include adults and children undergoing middle ear or mastoid surgery. Data include intraoperative neuromonitoring activity and structured interviews conducted with the operating surgeon immediately following surgery. Facial nerve stimulation was used to confirm the position of the nerve in 42 of 52 surgical procedures. In 26.9% of cases, the patient became "light" and moved under anesthesia, which was predicted by neuromonitoring 71.4% of the time. Through structured interviews, the operating surgeons reported the following. (1) The facial nerve took an unexpected anatomic course in 7.8% of patients and was difficult to identify in 39.2%. (2) The nerve was at increased risk of injury in 66.7% of cases due to chronic disease or previous surgery. (3) Among these high-risk cases, the monitor helped reduce the risk of nerve damage 100% of the time. (4) Neuromonitoring allowed the surgeon to operate faster 86.5% of the time, and (5) FNM allowed the resident to perform more of the operation 68.9% of the time. No patients experienced postoperative facial weakness. Beyond potentially protecting facial nerve integrity, this study identified additional benefits of FNM, including warning of patient movement during anesthesia, confirming facial nerve anatomic location, reducing operative time, and enhancing resident surgical experience.

CI Surgery Cancellations due to COVID-19

CI Surgery Cancellations due to COVID-19

The Role of Obesity in Iatrogenic Encephaloceles of the Temporal Bone.

Acquired encephaloceles of the temporal bone may be traumatic, spontaneous, or from chronic ear disease or previous surgery. Iatrogenic encephaloceles arise in the setting of previous mastoidectomy and traditionally involve both bony dehiscence and dural injury. We aim to classify and analyze the pathogenesis, clinical presentation, and treatment options for patients with iatrogenic tegmen defects and encephaloceles of the temporal bone. Retrospective chart review. Single tertiary academic center. Subjects with iatrogenic tegmen defects and encephaloceles of the temporal bone were included. Patient demographics, history, symptoms, radiographic data, intraoperative findings, management, follow-up, and outcomes were recorded. Primary outcome measures included patient characteristics, time from primary otologic surgery to surgical repair, location of the defect, and management strategy including surgical approach, methods, and follow-up. Iatrogenic tegmen injuries or encephaloceles were identified in 18 patients and divided into intentional or unintentional. The latter group presented immediately, early, or late, as determined by intraoperative identification or from delayed symptoms. Eleven patients presented late with previously unrecognized encephaloceles. Compared with patients presenting with incidentally noted tegmen dehiscence during revision mastoidectomy, a significant proportion of patients with late encephaloceles had BMI ≥30 kg/m (p = 0.03). The majority of iatrogenic encephaloceles are unintentional, unrecognized, and may present many years after primary surgery. Similar to spontaneous encephaloceles of the temporal bone, obesity is associated with iatrogenic encephaloceles, although the rate of progression and timing is unclear. We recommend primary repair of any unintentional tegmen defect encountered during mastoid surgery, especially in obese patients.

Comparative evaluation of bupivacaine 0.25% with dexamethasone 2mg versus bupivacaine 0.25% alone in greater auricular nerve block for post-operative analgesia in mastoid surgery

Background: Pain severity after ear surgery is usually at its worst during the first few hours after surgery. The greater auricular nerve is the major sensory branch of the cervical plexus and is readily amenable to blockade as it lies superficially passing over the sternocleidomastoid muscle. Dexamethasone as an adjuvant is known to prolong analgesia Aims and Objectives To compare the efficacy of combination of bupivacaine 0.25% (9.5ml) with dexamethasone 2mg (0.5ml) versus bupivacaine 0.25% (9.5ml) with normal saline (0.5ml) in greater auricular nerve block for Duration of analgesia and Requirement of rescue analgesia postoperatively. Methodology: Prospective double blind randomized controlled trial .50 patients aged 18-65 years, ASA status I / II posted for mastoid surgery were randomly allocated into two groups. Both groups received routine general anaesthesia. Intra operatively, analgesia was maintained with boluses of IV fentanyl 25µg each if required. At the end of surgery, just before extubation the nerve was identified using anatomical landmarks and blocked blindly with the drugs chosen depending on the group. The patients were extubated after complete reversal of neuromuscular blockade. Results: Demographic data and type of surgery were similar in both the groups. There was a significant difference for duration of analgesia between the two groups (p<0.01). Conclusion: Dexamethasone as an adjuvant to bupivacaine in greater auricular nerve block significantly increases the duration of analgesia and reduces the need for rescue analgesics without any complications.

Correlation of Pre-operative Temporal Bone CT Scan Findings with Intraoperative Findings in Chronic Otitis Media: Squamous Type.

To correlate the pre-operative Temporal Bone High Resolution Computer Tomography (HRCT) Scan findings with intraoperative findings in Chronic Otitis Media-Squamous type. This prospective, correlative, observational study was done at Department of Otorhinolaryngology and Head and Neck Surgery, Tribhuvan University Teaching Hospital, Kathmandu. 156 patients underwent mastoid surgery under General Anaesthesia from October 2017 to November 2018. Ethical committee approval taken from the institutional review committee. Informed consent regarding the study was taken prior to surgery. The peroperative findings were correlated with preoperative HRCT findings. Cohen's kappa coefficient (k-value) was used to estimate the degree of correlation. Statistical analysis was done using SPSS version 25. Total 156 patients between 8 and 70years of age were enrolled in the study. Presence of cholesteatoma/granulation on HRCT scan was found with 100% sensitivity with k-value of 0.569 denoting fair agreement. Regarding ossicular status, malleus showed maximum k-value of 0.525 with sensitivity of 81.3% followed by stapes and incus with k-value of 0.308 and 0.380 and sensitivity of 68.3% and 70.2% respectively. Sinus plate status showed perfect radiosurgical agreement with k-value of 1.0 and sensitivity and specificity of 100%. Bony facial canal demonstrated slight agreement with k-value of 0.506 and sensitivity of 45.8%. Dural plate status showed fair agreement with k-value of 0.503 and sensitivity of 38.9%. For Lateral Semicircular Canal (LSCC) erosion, we found very good agreement with k-value of 0.893 with sensitivity of 90.9%. Preoperative HRCT scan temporal bone correlates well for the detection of disease presence and shows good radiosurgical agreement for sinus plate erosion, LSCC erosion but fair agreement for dural plate erosion and malleus erosion. Plain HRCT scan with 3-D reconstruction is a poor predictor of bony facial canal, incus and stapes erosion.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. Retrospective case review. Academic tertiary center. Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. Transmastoid or MCF CSF leak repair. Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ± 12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

Changes in Lung Function Parameters after Total Intravenous Anaesthesia and Balanced Anaesthesia with Desflurane: A Prospective Randomised Study.

ObjectiveFollowing anaesthesia, there is a decrease in pulmonary function. Unlike volatile anaesthetics, propofol decreases the upper airway tone, and total intravenous anaesthesia (TIVA) with propofol may decrease coughing on emergence. Coughing may reduce postoperative atelectasis. Thus, TIVA may lead to greater decreases in lung function postoperatively as compared to balanced anaesthesia with desflurane.MethodsSixty patients of either sex, aged 18–60 years and American Society of Anaesthesiologists (ASA) status I/II, who were to undergo mastoid surgery, were randomly allocated to Group B and Group T. Anaesthesia was maintained with desflurane, nitrous oxide and oxygen in Group B, and with TIVA in Group T. Pulmonary function tests (PFT) were done preoperatively, and 1, 3 and 24 hours postoperatively.ResultsDemographic data and preoperative PFT were comparable in both groups. One hour after surgery, there was a greater decrease in FEV1 and peak expiratory flow rate (PEFR) in Group T (p=0.044 and 0.042, respectively). Three hours postoperatively, the decrease in MEFR and PEFR was again greater in Group T (p=0.005 and 0.008, respectively), while the MEFR recovered to preoperative values in Group B. By 24 hours, the forced vital capacity (FVC), MEFR and PEFR recovered to preoperative values in Group T, while FVC remained reduced in Group B (p=0.006).ConclusionBoth anaesthetic techniques cause a postoperative impairment in the lung function, but while TIVA causes a greater reduction in PFT in the early postoperative period, recovery is also earlier. On the other hand, balanced anaesthesia with desflurane was associated with a greater reduction in PFT at 24 hours.

Management of invasive intralabyrinthine cholesteatoma: Can one realistically preserve hearing when disease is medial to the otic capsule?

To report our long-term results in surgical management of invasive intralabyrinthine cholesteatoma. The study is a case series in a tertiary referral center. Retrospective chart review of all mastoid operations performed for chronic ear disease between 1994 and 2019 at University Health Network, Toronto. The type of surgery, intraoperative findings, hearing outcome, recurrence of disease and the need for revision surgery were evaluated. 10 cases of extensive petrous bone cholesteatoma medial to the otic capsule were identified in 616 mastoid surgeries. All but one patient with extensive petrous bone cholesteatoma who underwent an exteriorizing procedure to preserve cochlear function failed the first surgery. A second procedure was needed in all cases due to complications which included facial palsy, recurrent cholesteatoma or internal auditory canal (IAC) abscess. Hearing was not preserved in any patient. In contrast, 57 ears with cholesteatomatous labyrinthine fistula lateral to the otic capsule had matrix exteriorized and had very good long-term results. We were rarely able to preserve hearing in massive petrous bone cholesteatoma. There should be no hesitation to remove the otic capsule to exteriorize diseases even under circumstances where residual cochlear and vestibular function is present if required to provide a safe ear.

Preparing the surgical area for non-shaved ear surgery: a clinical assessment.

To review the clinical experience for non-shaved middle ear/mastoid surgery and evaluate the proper method of preparing the postauricular surgical field. This retrospective study reviewed medical records of cases where the non-shaved surgical procedure was carried out for middle ear/mastoid diseases. In all cases, middle ear and mastoid surgery was performed by one otologic surgeon without hair shaving to treat chronic perforation of tympanic membrane, as well as chronic suppurative otitis media, with or without mastoiditis during two years. The prevalence of surgical site infection (SSI) and bacterial culture of the surgical field was assessed just before the skin incision. In this review of 106 cases, the SSI rate was 1.6% for the non-shaved ear surgery. Bacterial colonisation was found on the prepared surgical field in 8.5% of cases and these bacteria was different from true pathogens. SSI of the skin incision occurred in two cases, although no bacterial colonisation of the non-shaved surgical field was found. The surgical exposure of postauricular area was enough to do tympanoplasty or tympanomastoidectomy, even though in cases where a hairline was close to postauricular sulcus. This study showed that when preparing the non-shaved ear surgery, the surgeons should not have to worry about skin contamination by hair. We suggest that the non-shaved ear surgery would appear to be preferable for the postauricular approach.

Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery

Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery

An operative barrier system for skull base and mastoid surgery: creating a safe operative theatre in the era of COVID-19

Within Neurotology, special draping systems have been devised for mastoid surgery recognizing that drilling of middle ear mucosa is an aerosol generating medical procedure (AGMP) which can place surgical teams at risk of COVID-19 infection. We provide a thorough description of a barrier system utilized in our practice, along with work completed by our group to better quantify its effectiveness. Utilization of a barrier system can provide near complete bone dust and droplet containment within the surgical field and prevent contamination of other healthcare workers. As this is an early system, further adaptations and national collaborations are required to ultimately arrive at a system that seamlessly integrates into the surgical suite. While these barrier systems are new, they are timely as we face a pandemic, and can play a crucial role in safely resuming surgery.

Mastoid surgery during coronavirus disease 2019 pandemic: Focusing on mitigation measures

Mastoid surgery is an aerosol-generating procedure and is considered as high-risk procedure during this pandemic of coronavirus disease. It should, however, be performed in certain life-threatening conditions. Otorhinolaryngologists should be well versed with the measures to protect ourselves from acquiring the coronavirus. We, therefore, report a case of mastoidectomy performed during this pandemic for an intracranial complication of chronic otitis media, focusing on the mitigation measures.

Evaluation of Taste Disturbance in Pre and Post Mastoid Surgery Patients

Background: Mastoid surgery is one of the commonest surgeries in Otolaryngology &amp; Head &amp; Neck department. Surgeons are less aware of preserving chorda tympani nerve (CT). Injury to the chord tympani nerve is common in middle ear surgery as the course of CT runs between ossicles and close to tympanic membrane. It makes the surgeon difficult to preserve it during the surgery. The study was done to observe frequency of taste disturbances (TD) in all patients undergoing mastoid surgery and to correlate between intra operative status of CT and type of intra operative status of CT injury with postoperative taste disturbances.&#x0D; Methods: A prospective analytical study was conducted in patients who underwent mastoid surgery. The intra operative status of CT was studied, different forms of injury to the nerve were noticed and its impact on taste disturbances was assessed subjectively with questionnaire. The patients with taste disturbances were followed till twelve weeks.&#x0D; Result: None of the patients had taste disturbances prior to surgery. Out of 65 patients, only 15 patients became symptomatic in second postoperative day and the taste disturbances were in the form of altered taste (26.66%), dry mouth (26.66%) and numbness (46.66%). Symptoms like altered taste and numbness were present till the eighth week of surgery and disappeared by the twelfth week except one patient in whom numbness persisted till twelfth week. The symptoms did not correlate with the intra operative status of CT. The symptoms disappeared with duration of operation and it was significant.&#x0D; Conclusion: None of the patients voluntarily complained regarding taste disturbances until they were specifically asked. Only 15 patients had taste disturbances; 7 had numbness, 4 dryness of mouth and 4altered taste. The taste disturbances did not correlate with the type of intra operative status of CT. CT was not identified in 9 patients and only 3 (33.3%) became symptomatic and CT was cut with micro scissors in 26 patients but only 4 (15.38%) patients were symptomatic.

Tuberculous otitis media –series of 10 cases

BackgroundTuberculosis (TB) of the middle ear cleft (MEC) is a rare extra-pulmonary manifestation. Signs and symptoms of tuberculous otitis media are indistinguishable from that of non-tuberculous otitis media making early diagnosis difficult. ObjectivesTo study the clinical presentations, complications and effective diagnostic modalities in tuberculosis of middle ear cleft. MethodsWe retrospectively studied 10 patients diagnosed with chronic otitis media, unresponsive to 2 months conventional treatment. Pure tone audiogram, High resolution computed tomography (HRCT) of temporal bone, and AFB staining of ear discharge were done. All patients underwent mastoid surgery. AFB staining and histopathological examination of granulation tissue removed from the middle ear and mastoid were also done. ResultsClinical findings were mastoid swelling, facial palsy and post-aural fistula 3,4 & 2 patients respectively. All patients had persistent ear discharge and three had vertigo. Hearing loss was of moderate conductive type in five, sensorineural type in three and mixed type in two. HRCT of temporal bone revealed soft tissue density in MEC in 9 and evidence of bone destruction in 6 cases. Diagnosis of TB was confirmed either by (a) demonstration of AFB in ear discharge (4 patients)/tissue removed during surgery (4 patients) or (b) by demonstration of tuberculous granulomas with necrosis on histopathological examination of tissue from MEC (8 patients). ConclusionTuberculosis should be suspected in all cases of chronic otitis media unresponsive to conventional treatment particularly in endemic areas. Histopathological examination and AFB staining of tissue removed during mastoid surgery are reliable diagnostic methods.

Cholesteatoma Versus Granulations: Changing Incidence Trends and Association with Age and Complications.

CSOM is a common disease in lower socio-economic set-ups. Its incidence has decreased over time due to improved hygiene status increased use of antibiotics. It can be associated with cholesteatoma or granulation tissue as far as unsafe ears are considered. Cholesteatoma is defined as a well demarcated noncancerous cystic lesion derived from an abnormal growth of keratinising squamous epithelium in the temporal bone, commonly characterised as skin in the wrong place. Granulations are defined as the inflammatory response of middle ear mucosa to toxic insults. Overtime the incidence of granulations has increased. This study aims to observe the incidence trends of cholesteatoma in comparison to granulation tissue as intraoperative finding in CSOM patients and the association of these two with the age of the patient and associated complications if present. All the patients admitted to E.N.T ward of M.D.M. Hospital, Jodhpur, Rajasthan, India undergoing mastoid exploration surgery between the time period of 1year from September 2017 to August 2018 were observed and their clinical findings along with patients data including age and sex were recorded and studied in regard with incidence of cholesteatoma, granulation tissue or both simultaneously along with associated complications. Majority of the patients who required mastoid exploration surgery had the presence of granulation tissue as intraoperative finding (55.07%). The incidence of cholesteatoma and both cholesteatoma and granulations together was (21.73%) and (23.18%) respectively. Complication percentage was highest with that of cholesteatoma patients (44.45%). Most of the patients presented in the 3rd-4th decade of their lives (63.77%) and the incidence was low amongst the children (30.43%) and the elderly (5.8%). The complication rate was higher in children (55.56%). Granulation tissue showed an increased incidence trend as compared with cholesteatoma; although complication rate was higher in the latter. Incidence as a function of age was maximum in the middle ages but the complication rate was more amongst the children.

From Mid 16th Century French Court to End 18th Century Danish Court: The Fatal Power of the Mammillary Process.

Two Royal events marked the history of the mastoid process between the 16th and 18th centuries. The first was the death of François II, King of France, following a complication of a chronic running left ear at the age of 16 years, and the second the death of Justus von Berger, Court physician of Christian VII, King of Denmark, after a trepanation of the mastoid process to heal his right-sided deafness at the age of 68 years. The aim of this study is to analyze these two events again with only original references and to replace them in their historical context. Historical review of original literature dealing with the subject. These two Royal events marked the history of the mastoid process, but they were unlikely to have been avoided during their specific era. Medical knowledge was insufficient to avoid these fatal outcomes. Because of their societal impact, they were known of and largely discussed, notably in the medical world, leading to the eventual modification of medical practice during that time. François II's death had no medical impact but von Berger's death practically stopped, for more than a half century, the development of mastoid surgery.

Evaluation of Type III Tympanoplasty Using Cartilage Ossiculoplasty in Cholesteatoma Ear Surgery.

This prospective observational study evaluates the role of tympanoplasty type III in cholesteatoma ear disease during same sitting with mastoid surgery using cartilage ossiculoplasty. Forty patients of chronic suppurative otitis media-cholesteatoma disease were recruited in the study. All the patients had extensive cholesteatoma and underwent canal wall down mastoid surgery. Tympanoplasty type III, that is, stapes columella, minor columella, or major columella, was done in each case along with mastoid surgery depending upon the remnant ossicular status. Conchal cartilage graft was used for ossiculoplasty along with temporalis fascia graft. Hearing and graft uptake results were evaluated at the end of 6 months postoperatively. Of the 40 cases, 3 cases failed tympanoplasty. In the remaining 37 cases, a statistically significant hearing improvement (air-bone gap of 33 dB) was observed postoperatively. Seven cases underwent stapes columella, 13 cases underwent minor columella, and 17 cases underwent major columella tympanoplasty type III. Although a hearing improvement was recorded in all these subgroups, a statistically significant hearing gain was present only in tympanoplasty type III minor columella cases thereby underlying the importance of intact stapes. However, it is difficult to discern the type of tympanoplasty type III that the patient would undergo prior to the ear surgery.

Usefulness of High Resolution Computed Tomography scans in depicting the status of the middle ear structures

Background: Prior to surgery it is very important that the surgeon is fully aware, and he should have the clear picture as to the extent of the disease and the nature of the disease to give satisfactory surgical outcomes for the patient. HRCT (High resolution computed tomography) is one such guiding tool for the surgeon. The objective was to study usefulness of HRCT scan in attico-antral disease in depicting the status of the middle ear structures.Methods: A total of 30 patients were studied. HRCT temporal bone was performed by using SIEMENS EMOTION 16 slice CT machine in axial plane and coronal images were reformatted. Findings of HRCT temporal bone were recorded. Findings of mastoid exploration surgery were recorded. Report of HRCT of temporal bone was correlated with surgical findings and tabulated using percentages.Results: Surgery showed cholesteatoma in 26 (86.6%) patients. Epitympanum was involved in 29 (96.6%) patients in HRCT and 30 (100%) patients at surgery. Extension beyond middle ear cleft was seen in 4 (13.3%) patients in HRCT and 5 (16.6%) patients at surgery. Tympanic segment of facial canal was the most commonly involved, showing erosion in 10 (33.3%) patients in HRCT and 12 (40%) patients at surgery. Lateral SCC was the most commonly involved in bony labyrinth seen in 4 (13.3%) patients in both HRCT and surgery. Erosion of dural plate was seen in 6 (20%) patients in HRCT whereas 9 (30%) patients showed dural plate erosion at surgery.Conclusions: HRCT of temporal bone plays a promising role in pre-operative assessment of cholesteatoma as it depicts the extent of the disease and integrity of most of the middle ear structures.

Application of bone-plastic materials for mastoidoplasty

The aim of this study is comparative assessment of of different bone-plastic materials for mastoidoplasty. The study included 30 patients who underwent 'canal wall down' mastoid surgery with mastoidoplasty. The following criteria were used for comparing: 1) simplicity of modeling of the material 2) the wound healing process 3) osteointegration - the process of formation of 'new bone' tissue (CT of temporal bones 6 and 12 months after oreretion). It was confirmed that the main groups of bone-plastic material (bioglass, composite materials and β-tricalcium phosphate) is suitable for mastoidoplasty after 'canal wall down' mastoid surgery.

Korner's septum: An uncommon clinical entity

A case of mastoid surgery in which Korner's septum was identified is presented. Identification of this structure is important to make sure complete exenteration of the air cells of mastoid and thus reduce the tendency of recurrent mastoid disease.