Middle Ear Surgery Research Articles

Expensive today but cheaper tomorrow: lifetime costs of an active middle ear implant compared to alternative treatment options.

When choosing between different treatment options, implants often appear too costly. However, this perspective does not take future costs into account. This article evaluates lifetime costs for different surgical interventions to treat hearing loss. The analysis focused on three groups from the perspective of health insurers. Group 1 comprises patients who have only been implanted with a middle ear implant. Patients in Group 2 had already undergone middle ear surgery to improve hearing prior to the implantation of a middle ear implant. Group 3 consists of patients who were treated exclusively with hearing-improvement surgeries (no implant). The lifetime costs were calculated using the Monte Carlo simulation. The inputs were based on medical data from a maximum-care hospital and data from the German healthcare system. Based on an average observation period of 26.73years, the lifetime costs amounted to 28,325€ for group 1, 32,187€ for group 2 and 28,381€ for group 3. While the mean values between groups 1 and 3 appear comparable, group 1 has a significantly lower standard deviation (G1 vs. G3: 6120€ vs. 10,327€). Choosing a treatment option can be a complex medical decision and impose a substantial economic burden for the statutory health insurance. Hence, treatment decisions should be patient-centred at first but also including a shared-decision making on economic feasibility, whether proposed treatment alternatives are likely to be successful and economically reasonable.

Pain Control after Otologic Surgery: Do Nonopioid Analgesics Suffice?

Investigate whether nonopioid analgesics (NOA) provide adequate pain control after otologic surgery. Retrospective multicenter cohort. Two quaternary academic medical centers. Patients over 12 years old who underwent otologic surgery involving the middle ear and/or mastoid at two centers over a 5-month period. Patients were prescribed acetaminophen and ibuprofen postoperatively and instructed to contact the surgical team if pain control was inadequate, in which case an opioid medication was prescribed. Level of pain and medication use were assessed with a standardized questionnaire, 1 week after surgery. Postoperative pain levels during the first week after surgery (0-10); proportion of patients requiring opioid medication. Sixty-seven patients were included. Of these, 37% underwent tympanomastoidectomy, 27% cochlear implant, 19.5% postauricular tympanoplasty, 10.5% transcanal tympanoplasty, and 6% had a different surgery. The median of the average level of pain in the first 7 days was 5/10 (IQR 3-6). The median highest level of pain was 5 (IQR 4-8). The median current level of pain was 3 (IQR 1-5). Seven patients (10%) required breakthrough opioid pain medication. The remaining 90% utilized NOA only. One week after surgery, 60% were taking nonopioid analgesics only while the remaining 40% were not taking any pain medication at all. Although opioids were required infrequently, there were no significant differences in medication use between the two centers. NOA provide adequate pain control for most patients after middle ear and mastoid otologic surgery. Opioid analgesics do not routinely need to be prescribed.

Prospective study of the application of a 3D exoscope system (VITOM 3D) in ear surgery compared to conventional surgical microscopes: part I - analysis of objective parameters.

This prospective study compared the application of a 3D exoscope (VITOM 3D) with surgical microscopes (SM) in ear surgery. 62 patients were included (exoscope group (E+) n = 31; SM group (E-) n = 31). Procedures included cochlea implantation (nE + = 10, nE- = 10), reconstructive middle ear surgery due to chronic otitis media with (COMwC; nE + = 11, nE- = 11) and without cholesteatoma (COMsC; nE + = 10, nE- = 10). Objective (e.g. set-up time and wrap-up time, corrected cut-suture-time, pure operating time, adjustment time, time per adjustment procedure, learning curves) and subjective perioperative parameters were evaluated. This paper only addressed the analysis of the objective parameters. The pooled data showed that the mean time delay in the E + group was significantly higher compared to the E- group with regard to set-up time and wrap-up time, corrected cut-suture time, adjustment time and time per adjustment procedure. Time delay tended to be higher for pure operating time. In all subgroups of the E + group, the objective time parameters also showed at least a tendency to be prolonged on average compared to the corresponding subgroups in the E- group. The learning curve analysis showed that the E + group (corrected cut suture time for CI surgery, mean time per adjustment procedure across all subgroups) approached the times of the E- group during the course of the study. Based on the pooled data from the study arms, the exoscope tends to be inferior to the microscope for the objective time parameters evaluated when used in ear surgery. However, due to the small group sizes, no solid conclusions could be drawn regarding the individual surgical procedures. In addition, further studies with a longer observation period are needed to minimize the influence of the learning curve on the results.

Ergonomic Transgression of the Corridor: A Sojourn of Microscopic to Endoscopic Middle Ear Surgery, the Learning Curve, Lessons Learned, and Reflections

Objective: For the last 20 years, transcanal endoscopic ear surgery has emerged as a viable, ergonomic, and powerful alternative surgical modality of choice replacing the conventional microscopic approach in many ways. This study compares the functional and anatomical outcomes of endoscopic tympanoplasty with microscopic tympanoplasty using full-thickness tragal cartilage as a graft of choice. Methodology: This observational, analytical, retrospective study was conducted in the department of Otolaryngology in a tertiary care hospital over two years. It included an analysis of medical records of 38 patients (above 10 years of age), who underwent conventional microscopic and transcanal endoscopic tympanoplasty (type I) for dry and small/medium size tympanic perforations. Morphological and functional outcomes were compared in both groups by noting the condition of graft and air-bone gap on follow-up. Result: There were 19 patients each in both groups. The mean pre-and post-operative ABG in each group was comparable and the difference was statistically significant in each group ( P< 0.05). Comparing the mean ABG change between both groups, there was a statistically significant difference noted (P<0.05). The success rate was found to be 89.5% (17 /19) in the endoscopic surgery group and 94.7% (18/19) in the microscopic surgery group. The difference in the anatomical success of both groups was not statistically significant. Conclusion: There was no statistically significant difference between both groups regarding graft take-up rates but functionally hearing outcomes were better in the MES group which was statistically significant. Bangladesh J Otorhinolaryngol 2024; 30(1): 5-14

A Comparative Study of Ossicular Reconstruction with TORP/PORP Versus Autologous Bone in Middle Ear Surgeries

A Comparative Study of Ossicular Reconstruction with TORP/PORP Versus Autologous Bone in Middle Ear Surgeries

Predictive Accuracy of Middle Ear Risk Index in Terms of Hearing Outcomes in Middle Ear Surgery

Abstract Introduction: Chronic otitis media (COM), affecting millions globally, remains a significant health concern despite antibiotic advancements. Evolving otological approaches focus on both dry ear attainment and hearing restoration. Grading systems such as middle ear risk index (MERI) can aid in stratifying disease severity and predicting surgical outcomes for effective patient management. Aims and Objectives: The study aimed to assess MERI scores in tympanomastoid surgery patients to categorize disease severity and evaluate its correlation with postoperative hearing improvement. Materials and Methods: A prospective study was conducted over 2 years on 50 patients of COM. Patients were categorized into three groups based on MERI scores developed by Becvarovski and Kartush. A preoperative audiometry was obtained. The type of middle ear surgery required for each patient was decided intraoperatively as per the findings. Patients were followed up for a 6-month period, and hearing improvement was assessed in terms of closure of air-bone gap in the postoperative audiogram. Statistical analysis was performed using SPSS v23 software for Windows, and P < 0.05 was considered statistically significant. Results: In our study, significant associations (P < 0.05) were observed between the “MERI category” and variables such as otorrhea, cholesteatoma, ossicular status, previous surgery, middle ear granulation/effusion, smoker, total MERI score, and surgery performed. MERI was found to be negatively associated with hearing improvement, the higher the score lesser the improvement in hearing, and vice versa. Conclusion: The incorporation of MERI scoring into the surgical evaluation of COM cases holds promise for improving patient care and treatment strategies.

Transcanal Endoscopic Management of Squamosal Type of Chronic Otitis Media.

Endoscopic middle ear surgery can be utilized to visualize and excise retraction pockets without the need for extensive bone work and removal of lateral bone. To evaluate the role of endoscope in the management of squamosal type of chronic otitis media. A total of 25 adults subjects (male = 12, female = 13) in the age group of 18-55years suffering with chronic otitis media were operated by transcanal endoscopic approach. High resolution computed tomography of temporal bone was done to help identify the anatomy and underlying extent of disease. All patients were operated by transcanal endoscopic technique. The study concluded that the endoscope gives a better visualization of the middle ear and its hidden areas. The extensive bone work and associated cavity related problems can be avoided and normal anatomy can be preserved with the help of endoscopic ear surgery.

Correlation Study between Chronic Suppurative Otitis Media Severity and the Air Conduction Threshold of Its Contralateral Ear

Abstract Background: The more severe the middle ear inflammation with chronic suppurative otitis media (CSOM), the more likely its contralateral middle ear suffers from chronic otitis media. Paparella’s continuum theory describes otitis media as a continuous and dynamic inflammation that starts from eustachian tube blockage. This ongoing and prolonged inflammation may affect the contralateral ear (CLE), manifesting in bilateral chronic otitis media. Methods: A cross-sectional study on 42 medical records of CSOM patients hospitalized for middle ear surgery. In this research, we used the middle ear risk index (MERI) scoring to measure CSOM severity, which is estimated to affect air conduction (AC) threshold of the CLE by interfering with its middle ear impedance. The correlation between the MERI score of the CSOM ear and AC of the CLE was analyzed using the Pearson correlation test. Results: There was a strong positive correlation between the MERI score of CSOM with cholesteatoma and its CLE AC threshold (r = 0.610, P < 0.01), while the MERI score of CSOM without cholesteatoma had a weak positive correlation with its CLE AC (r = 0.384, P < 0.05). Conclusions: The higher MERI scores in either CSOM with cholesteatoma or without cholesteatoma were correlated to higher CLE AC threshold.

Patient satisfaction with endoscopic ear surgery technique: a comparative study with the postauricular incision microscopic technique

BackgroundEndoscopic ear surgery has numerous benefits, such as the capacity to obtain high-resolution pictures and visualize normally inaccessible locations such as the retrotympanum, sinus tympani, and facial recess. These areas are generally difficult to access with traditional microscopic techniques. Endoscopic ear surgery reduces operating time when performed by skilled surgeons, without the need for a postauricular incision wound.An essential aspect to consider when evaluating the effects of any procedure on individual satisfaction is the assessment of health-associated quality of life. It is a tool used for subjective assessment, which is regarded as a reliable measure of the satisfaction perceived—whether physically or mentally—resulting from a certain procedure.The goal of this study was to identify the benefits of middle ear surgery when done endoscopically compared to postauricular microscopic techniques in middle ear surgery. This was achieved by evaluating and comparing the level of satisfaction among patients who underwent either microscopic or endoscopic ear surgery.MethodsThe Chronic Ear Surgery Survey (CESS), a 13-point Likert scale survey designed specifically for assessing outcomes of surgery for chronic middle ear disease, was implemented to measure patient satisfaction. The survey comprises three subscales. We performed a retrospective study at the Otorhinolaryngology Department, Cairo University, Egypt. The study encompassed individuals who underwent surgery on the middle ear between March 2018 and September 2021.The patients were scheduled into two categories according to the technique of surgery (whether endoscopic or microscopic) in order to assess postoperative satisfaction using the Chronic Ear Surgery Survey (CESS).ResultsOur research findings demonstrated a statistically significant difference between the two categories in terms of the overall scores and all subscale scores of the Chronic Ear Surgery Survey (CESS), with patients who had middle ear surgery endoscopically (EES) showing better outcomes.ConclusionsIdentifying the elements that are strongly associated with subjective outcomes can assist surgeons in identifying patients who are more likely to have poorer satisfaction. This knowledge can be valuable in preoperative counseling. Endoscopic ear surgery (EES) seems to have a higher level of cosmetic acceptability, especially in terms of enhancing the socially related aspects of a patient's pleasure. This work thus supports the ongoing integration of endoscope utilization in otological surgical procedures.

Analgesic Characteristics of Ultrasound-guided Great Auricular Nerve Block in Middle Ear Surgery: A Prospective Randomized Controlled Preliminary Trial

PurposeTo explore the analgesic characteristics of ultrasound-guided great auricular nerve (GAN) block to further improve pain management. DesignSingle-center, prospective, randomized, controlled, and double-blind preliminary clinical trial. MethodsThirty-seven patients who underwent middle ear surgery were included in this study: 15 in the GAN block group (the large ear nerve block [NB] group) and 22 in the traditional anesthesia group (control [CON] group). After induction of anesthesia, the NB group was given an ultrasound-guided GAN block (0.25 % Ropivacaine 2 mL), while the CON group was exempt from the GAN block. The patient’s basic information, perioperative information, the region, and numeric rating scale of postoperative pain (at 1 hour, 6 hours, 12 hours, and 24 hours), and adverse reactions were recorded. Repeated measurement analysis, t test, and Fisher exact probability method were used for statistical analysis. FindingsCompared with the CON group, the numeric rating scale in the NB group was lower after surgery (1 hour: 1.18 ± 0.35 vs 0.27 ± 0.20, P = .023; 6 hours: 1.82 ± 0.37 vs 1.13 ± 0.39, P = .203; 12 hours: 1.05 ± 0.19 vs 0.20 ± 0.10, P < .001; 24 hours: 0.55 ± 0.17 vs 0.13 ± 0.09, P = .029). In the NB group, the region of pain was merely concentrated in the ear canal. In the CON group, the pain extended to areas outside the ear canal, such as tragus and mastoid (at 12 hours, P = .006). There was no significant difference in the risk of postoperative adverse reactions between the two groups. ConclusionsUltrasound-guided GAN block can relieve patients’ pain after middle ear surgery, especially in the area outside the ear canal.

Risk of hearing loss in the opposite ear after tympanomastoidectomy.

The definitive treatment for chronic suppurative otitis media is surgery. Surgical technique and procedure varies according to individual case findings and pathology and may require mastoidectomies in which the canal wall is preserved or lowered to eradicate disease from mastoid air cells. Surgical treatment of chronic middle ear disease carries a risk of damage to the inner ear. The aim of this study was to investigate whether the noise produced by the tour system following chronic ear surgery causes sensorineural hearing loss, a condition for which not many studies have been published in the literature. The study consisted of a total of 49 patients with type I, type II and type III canal wall preservation and 62 patients with tympanoplasty with canal wall preservation and lowering. Bone and air thresholds were compared before and after middle ear surgery. Changes in bone and air thresholds were compared according to the type of tympanoplasty. In the ICW-I, ICW-II and ICW-III tympanoplasties, and in the ICW and CWD tympanoplasties, the preoperative and postoperative values of the opposite ear hearing measurements were performed, and did not differ according to the type of surgery. There is no correlation drilling duration and hearing for the opposite ear. The prevention of postoperative sensorineural hearing loss depends on multiple factors, and assessing the magnitude of hearing loss in relation to these factors is important in determining the success of the surgery.

Outcomes at 6 months after isolated or non-isolated surgery for temporal bone cerebrospinal fluid leak in adults: A STROBE analysis

AimThe main aim of this study was to evaluate 6-month closure success in surgery for isolated or non-isolated temporal bone osteomeningeal breach (OMB). Secondary objectives were to analyze complications of closure and correlations between success and breach, treatment and patient data. Material and methodThis was a single-center retrospective observational study of patients who underwent surgery for temporal bone OMB via a middle cranial fossa or transmastoid approach in a French university teaching hospital between 2007 and 2022, with follow-up of at least 6months. Patients with superior semicircular canal dehiscence were excluded. Study data comprised gender, age, body mass index, OMB etiology, mode of discovery, audiometric and radiological data, surgical technique, length of hospital stay and postoperative complications. The primary endpoint was absence of a cerebrospinal fluid leak on MRI at 6months. Fisher's exact test or Chi2 test were used for qualitative data and Student t-test for quantitative data. ResultsThe closure success rate was 87%: 81% (3 recurrences) in the middle cranial fossa group of 16 patients and 93% in the transmastoid group of 14 patients. Postoperative audiometry showed significant improvement (P=0.0016) for air conduction in the middle cranial fossa group. Five patients (17%) operated on via the middle cranial fossa approach and 1 (7%) operated on via the transmastoid approach had postoperative complications. OMB was in the tegmen mastoideum in 8 patients (29%), tegmen tympani in 7 (25%), tegmen antri in 4 (14%), tegmina antri and tympani in 3 (11%), antri and mastoideum in 1 (8%) and in the whole tegmen in 5 (18%). Eleven OMBs were lateral to the superior semicircular canal, 13 medial and 4 on either side. ConclusionThe transmastoid approach is indicated in case of associated middle-ear procedures, patients aged over 75years or OMB lateral to the superior semicircular canal. The middle cranial fossa approach is reserved for OMB located medial to the superior semicircular canal patients under 75years of age without associated ossicular procedures. For patients with OMB medial to the superior semicircular canal who require middle-ear surgery, a combined approach can be used.

Addition of Dexmedetomidine to Propofol Anesthesia for Middle-Ear Surgeries: A Prospective Randomized Double-Blind Study.

Background Middle-ear surgery commonly performed under a microscope requires a bloodless field provided by hypotensive anesthesia. Our objective wasto study the effects of dexmedetomidine on propofol consumption and intraoperative hemodynamic stability. Methods One hundred adults undergoing elective middle-ear surgery were randomized into two groups. The propofol+dexmedetomidine group (Group PD) received a loading dose of dexmedetomidine 1μg/kg in 10ml normal saline over 10min followed by infusion of the same at 0.5μg/kg/h. Propofol-only group (Group P) received 10ml normal saline over 10min followed by an infusion of the same. General anesthesia was induced with intravenous morphine, propofol, and vecuronium, and maintained with propofol, oxygen, and N2O. During microscope use, we aimed to maintain mean arterial pressure (MAP) within 60-69mmHg. Results There was no significant difference in the mean (SD) consumption of propofol [Group P 8.6 (2.1)mg/kg/h vs Group PD 8.1 (1.5)mg/kg/h, P=0.172]. The induction dose of propofol was significantly less in Group PD [1.8 (0.3) vs 2 (0.4)mg/kg, P<0.001]. Except for the baseline value, the heart rate was significantly lower in Group PD, P<0.001. The time duration during which MAP was within 60-69mmHg was higher in Group P [37.5 (36.8) vs 30.9 (38.3)min] though the difference was not statistically significant. The recovery was delayed in Group PD [25.4 (8.6) vs 17.6 (4.9)min, P<0.001]. Group PD had a significantly better operative field, P=0.0003. Conclusion The addition of dexmedetomidine did not reduce propofol consumption but reduced the induction dose of propofol. Propofol and dexmedetomidine combination provided comparable mean arterial pressure and better operative field but caused delayed recovery.

Masseteric-facial anastomosis and hypoglossal-facial anastomosis after lateral skull base and middle ear surgery.

Lateral skull base (LSB) and middle ear pathologies often involve the facial nerve (FN), and their treatment may require FN sacrifice. Cases with unidentifiable proximal stump or intact FN with complete FN palsy, necessitate FN anastomosis with another motor nerve in order to restore innervation to the mimicking musculature. The results of hypoglossal-to-facial nerve anastomosis (HFA) and masseteric-facial nerve anastomosis in patients with facial paralysis after middle ear and LSB surgeries, are presented and compared. Adult patients with total definitive facial paralysis after middle ear or LSB surgery undergoing facial nerve reanimation through hypoglossal or masseteric transfer anastomosis were enrolled. The facial nerve function was graded according to the House Brackmann grading system (HB). The facial function results at 3months, 6months, 12months, 18months and at the last follow up (more than 18months) are compared. 153 cases of LSB and middle ear surgery presented postoperative facial palsy and underwent facial nerve reanimation surgery with HF in 85 patients (55.5%) and MF in 68 patients (44.5%). The duration of the FN palsy before reconstructive surgery was inversely associated to better FN results, in particular with having a grade III HB (p = 0.003). Both techniques had significantly lower HB scores when an interval between palsy onset and reanimation surgery was 6months or less (MF p = 0.0401; HF p = 0.0022). Patients who underwent a MF presented significant improvement of the FN function at 3months from surgery (p = 0.0078). At the last follow-up, 63.6% recovered to a grade III HB and 22.7% to a grade IV. On the other hand, the first significant results obtained in the HF group were at 6months from surgery (p < 0.0001). 67.8% of patients had a grade III HB after a HF at the last follow-up, 28.8% a grade IV. FN grading at 6months from surgery was significantly lower in the MF group compared to the HF (p = 0.0351). The two techniques had statistically similar results at later follow-up evaluations. MF was associated to initial superior results, presenting significant facial recovery at 3months, and significantly better functional outcomes at 6months from surgery compared to HF. Although later results were not significantly different in this study, earlier results have an important role in order to limit the duration of risk of corneal exposure.

Taste Disorders After Middle Ear Surgery: Chorda Tympani Nerve Injury and Quality of Life.

To evaluate taste disorders after middle ear surgery, their modifying factors especially chorda tympani nerve injury or underlying otologic disease. We investigated consequences of taste disorders on quality of life. Prospective cohort study. Monocentric study in tertiary care center. A total of 214 patients who underwent middle ear surgery were included. Data regarding taste disorders were collected by questionnaires over a 1-year follow-up period. Taste disorders were reported in 42.7% at 10 days, in 23.3% at 4 months, and in 9.2% 1 year postoperatively. When the chorda tympani nerve was initially healthy, taste disorders were more frequent after its transection throughout the follow-up period. When it was involved in a cholesteatoma or inflammatory process, postoperative taste disorders were more frequent after nerve stretching. Postoperative discomfort in daily life was rated on the Likert scale at 3.5 out of 10. Dietary modifications were reported by 25.8% of patients, and mood alterations by 15% of patients. Taste disorders are frequent after middle ear surgery although they mostly improve in the first months. When the CTN is healthy, cutting it leads to more taste disorders than stretching it, thus advocating its preservation to prevent these symptoms. However, in cases of pathological CTN, cutting this nerve, which is sometimes necessary to control the disease, is less likely to cause taste disorders than stretching it. These taste disorders are a source of discomfort and may present risks of dietary modifications and emotional impact.

The prevalence of facial canal dehiscence: first cross-sectional study in Iraq

BackgroundThe facial nerve is considered a crucial structure and is vulnerable to injury during middle ear and mastoid surgery. The facial canal could be dehiscent in certain populations; therefore, identifying it and avoiding injury to the nerve is an important step during otological surgeries. In this study, we assessed the rate of facial canal dehiscence (FCD) among patients undergoing surgery due to the presence of chronic suppurative otitis media (CSOM).MethodsA cross-sectional study was performed between June 2019 and May 2023. We included 102 patients (aged 8–70 years), admitted for primary tympanomastoid exploration due to the presence of CSOM with and without cholesteatoma at Azadi Teaching Hospital in Duhok/Iraq. Cases with a history of trauma or craniofacial abnormalities were excluded from the study. Also, none of the selected patients complained of facial nerve disorders.ResultsAmong the 102 patients who were admitted, 11.76% (n = 12) had FCD; they were between the ages of 11 and 58 (average: 30.9) years (18.8% ≤ 18 years vs. 10.5% > 18 years, p = 0.396). The dehiscence was more common in males than females (14.3% vs. 10.0%, p = 0.545) and was also more common on the left side than the right side (13.8% vs. 9.1%, p = 0.547). Of those with the dehiscent facial nerve, 83% (n = 10) had the dehiscence on the tympanic segment. The dehiscence was statistically more common in patients with cholesteatoma than those without (25.9% vs. 6.7%, p = 0.014).ConclusionDehiscence in the facial nerve can be encountered in patients with CSOM, particularly those with cholesteatoma. In such patients, the dehiscence is most commonly found on the tympanic segment of the facial nerve, so care should be taken during surgery for such cases to avoid injury of the nerve.

Anti-inflammatory response to 1,8-Cineol and associated microbial communities in Otitis media patients

Chronic Otitis Media (COM) is defined as long term inflammation and colonization with pathogenic bacteria due to a defect or retraction of the tympanic membrane. Surgical interventions are often augmented by antibiotic resistance development and therefore, off-label treatment using the natural drug 1,8-Cineol was carried out. All COM patients underwent antibiotic therapy and middle ear surgery and developed antibiotic resistances. Microbiological investigations from the auditory canal and stool samples were performed in correlation with the clinical course. Therapy of COM patients with 1,8-Cineol revealed a clear reduction of inflammatory microbes P. aeruginosa and Proteus mirabilis in ear samples as well as intestinal Prevotella copri, which was associated with an improved clinical outcome in certain individuals. The present off-label study revealed manifold anti-inflammatory effects of the natural monoterpene 1,8-Cineol in Otitis media patients. A better understanding of the underlying mechanisms will improve the current treatment options and possible forms of application of this natural drug.

Ergonomics of Various Modalities for Ear Surgery.

Evaluate ergonomic differences of various modalities for performing middle ear surgery. Observational study. Two academic tertiary care centers. Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score. Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]). Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

Comparative Study of the Preemptive Dexmedetomidine Versus Ondansetron Effect in Post-Operative Nausea and Vomiting after Middle Ear Surgery

Background: Nausea and vomiting after operation has high prevalence and cause adverse effect. The aim of this study was to compare the effect of dexmedetomidine with ondansetron in prevention of post-operative nausea and vomiting (PONV) after middle ear surgery under general anesthesia.and saliva gas in traumatic patients under mechanical ventilation. Methods: This in this double-blinded clinical trial study, one hundred and sixty-two patients undergoing middle ear surgery under general anesthesia were randomly divided into three groups of 55 each: ondansetron (O), dexmedetomidine (D) and control (C). Group O received 0.1 mg/kg of ondansetron, Group D received 1 μg/kg/min of dexmedetomidine and Group C received 10 cc of normal saline 15 to 20 minutes before surgical incision. After that, the patients were examined in post-anesthesia care unit (PACU) and up to 24 hours after the operation in terms of PONV and other study variables. Results: The severity of nausea after operation based on VAS (visual analog scale) was significantly different between Group O (2.2±0.7) and Group D (3.9± 0.7) and Group C (5.15±1.3) (P= 0.04). The incidence of vomiting in the first 24h postoperatively was 14.8% in Group O, 46.3% in Group D and 88.8% in Group C (P= 0.003). Conclusion: Our study showed that ondansetron was better than dexmedetomidine for prevention of PONV after middle ear surgery.

Otitis media/interna and encephalitozoonosis are the most common causes of head tilt in pet rabbits in the UK: 73 cases (2009‒2020).

There are limited studies that identify diseases associated with head tilt in pet rabbits. This was an observational, retrospective, single-centre study of rabbits with head tilt presented between 2009 and 2020. Descriptive statistics were performed for all cases, whereas univariate and multivariate analyses were only performed for the 36 cases with a final diagnosis. Seventy-three rabbits met the inclusion criteria. The final diagnoses included Encephalitozoon cuniculi meningoencephalomyelitis (EC) (15/36; 41.7%), otitis media/interna (OMI) (8/36; 22.2%) and concurrent EC and OMI (13/38; 36.1%). Subacute-to-chronic onset was more common in rabbits with OMI than in those with EC (p = 0.018). Previous middle ear surgery (p = 0.046) and a diagnosis of otitis externa (p = 0.004) significantly increased the risk of OMI. Meloxicam was associated with improvement of clinical signs(p = 0.007). Upright ears (p = 0.013), recumbency (p = 0.037) and impaired mentation (p = 0.001) were associated with a higher risk of death/euthanasia. The proportions of residual head tilt (66.7%) and relapse of vestibular signs (42.1%) were high. This was a retrospective study with cases varying in their investigation and conclusive final diagnoses. OMI and EC were the most common aetiologies of head tilt in pet rabbits in the UK. Meloxicam might be associated with a favourable outcome in affected rabbits. Paired EC serology and a CT scan of the head should be the baseline investigation for head tilt in rabbits.