Postoperative Air-bone Gap Research Articles

Comparison of endoscopic and microscopic methods in stapedotomy: a retrospective analysis.

The goal of the present study was to compare the audiologic results, complications, and advantages/disadvantages of endoscopic and microscopic stapedotomy. Patients who experienced stapedotomy surgery in the Ear Nose Throat Clinic (ENT) of Selcuk University Faculty of Medicine between September 2011 and January 2018 were included in the study. The data of all patients were analyzed and divided into two groups. Those who underwent endoscopic stapedotomy were included in group I, and patients who underwent microscopic stapedotomy formed group II. Surgical findings, complications, and operation times were compared for the two groups. Air and bone conduction thresholds were evaluated at the frequencies of 500, 1000, 2000, and 4000Hz pre- and postoperatively at 1, 3, and 6months, and the mean (± SD) air-bone gap value was recorded. While the mean pre- and postoperative air-bone gaps were 34.38 ± 7.47dB (23-53dB) and 9.69 ± 4.43dB (0-19dB), respectively, in group I, 34.32 ± 7.57dB (23-6dB) and 9.62 ± 4.25dB (2-23dB) were the respective means calculated in group II (p < 0.05). When the mean postoperative air-bone gap was compared, there was no statistically significant difference between the two groups (p = 0.774). The mean operative times for groups I and II were 57.22 ± 4.37min and 63.70 ± 7.34min, respectively (p < 0.001). The requirement for chorda tympani nerve manipulation and scutum curettage was significantly less in group I compared to group II (p = 0.003). Postoperative dysgeusia and postoperative pain were found to be higher in group II than group I, but they were not statistically significant (p > 0.05). Endoscopic stapedotomy displayed similar audiological results, shorter operation times, and similar complication rates, as well as being a less invasive surgery, compared to the microscopic approach.

Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition

Objectivesto compare hearing outcomes between endoscopic transcanal rebridging with bone cement and endoscopic transcanal incus interposition in patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type).MethodsThis retrospective study was performed on 83 ears of 83 consecutive patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). According to the extent of incus long process erosion and subsequent ossiculoplasty technique, patients were divided into 2 groups. Patients in group 1 had erosion involving up to two thirds of the length of the incus long process and underwent endoscopic transcanal rebridging with bone cement. Patients in group 2 had erosion involving more than two thirds of the length of the incus long process and underwent endoscopic transcanal incus interposition.ResultsHearing gain (mean ± standard deviation) was 21.39 ± 2.15 dB in group 1 and 19.71 ± 6.12 dB in group 2. A significantly greater hearing gain was achieved in bone cement group than in incus interposition group (P value < 0.001). Successful hearing outcome (post-operative air bone gap closure within 20 dB) was achieved in 81.6% and 71.1% of patients of group 1 and group 2 respectively.ConclusionEndoscopic transcanal rebridging with bone cement offers greater hearing gain than endoscopic transcanal incus interposition. The two techniques remain reliable and cost-effective techniques in management of patients with incus long process defects. The main limitation of this study was the short follow-up period. Further studies with relatively long-term follow-up are strongly recommended.

Quality of life after cholesteatoma surgery: comparison between surgical techniques.

SUMMARYObjectiveTo evaluate the long-term quality of life (QoL) in patients operated for cholesteatoma by canal wall-up tympanoplasty (CWUT) or canal wall-down tympanoplasty (CWDT) with mastoid obliteration.MethodsQoL was evaluated by the Chronic Otitis Media Questionnaire - 12 (COMQ-12). For each patient, the total score and three partial subscores, concerning disease activity, functional impairment and general impact on the patient’s life were calculated. These scores were correlated with the surgical technique, as well as anatomical and functional results.Results68 procedures were classified as CWUT and 78 as CWDT with obliteration. The mean follow-up was 65 months. Total and partial COMQ-12 scores did not show any significant difference between the two groups. Correlation analysis showed a significant direct association between the postoperative Air-Bone Gap (ABG) and both the COMQ-12 total score and functional subscore in the CWUT group.ConclusionsThis is the first study comparing CWUT and CWDT with obliteration with the COMQ-12, thus confirming the overlapping results in terms of QoL. These findings, together with the evidence of the significantly lower rates of recidivism, show that CWDT with obliteration should be considered as a good alternative to CWUT.

Transtympanic soft tissue tympanoplasty can replace conventional techniques elevating tympanic membranes.

Most traditional tympanoplasties require elevating the tympanic membrane (TM). These techniques are rather complicated and success rates are not perfect. Therefore, the authors developed a novel technique, transtympanic soft tissue (TST) tympanoplasty, which does not require raising eardrums, and evaluated its surgical efficiency compared to perichondrium underlay (PU) tympanoplasty. A retrospective study was conducted in a single center. 152 cases who underwent TST tympanoplasty (n = 70) or PU tympanoplasty (n = 82) between 2011 and 2020 were included in the study. Perforation location, pure tone audiometry, complications, and closure rates were analyzed according to the size of the TM perforations: moderate perforation (25-40%, n = 100) and large perforation (≥ 40%, n = 52). For the moderate perforations, the closure rates of the TST (n = 45) and PU (n = 55) groups were 93.3% and 89.1%, respectively (p = 0.461), and even for the large perforations, the success rates were 88.0% in the TST group (n = 25) and 81.5% in the PU group (n = 27) (p = 0.515). The mean postoperative air-bone gap (ABG) values of the TST group for moderate and large perforations were 5.3 ± 5.8dB and 6.6 ± 5.7dB, respectively. There was no significant difference in postoperative ABG between the two surgical procedures (p > 0.05). The total operation time for TST tympanoplasty was significantly shorter than that for PU tympanoplasty (p = 0.002). TST tympanoplasty is considered a novel, simple technique to replace traditional tympanoplasty techniques involving raising eardrums, even for large-sized perforations.

Functional Results and Learning Curve of Endoscopic Ossiculoplasty

Background and Objectives Endoscopes are recently being used to manage various middle ear surgeries including ossiculoplasty. Here, we investigated hearing results of endoscopic ossiculoplasty and surgeon’ learning curve in gaining endoscopic ossiculoplasty proficiency. We compared the results with those of microscopic ossiculoplasty.Subjects and Method We analyzed 48 patients of ossiculoplasties performed from 2010 to 2020. Patients were divided into three groups: microscopic technique group (n=16); endoscopic early phase group (n=16); endoscopic late phase group (n=16). Operation time and hearing results including postoperative air-bone gap (ABG) and ABG closure were analyzed. Hearing outcomes were considered “successful” when the postoperative ABG was less than 20 dB and considered “excellent” when ABG was less than 10 dB. The learning curve of the outcomes were analyzed.Results Both operation time and postoperative ABG showed decreasing tendency, but only operation time showed statistical significance. The ratio of successful and excellent operations improved, but did not show statistical significance. Improvement in learning curve was not statistically significant presumably due to the lack of patient numbers.Conclusion Surgeon’s proficiency of endoscopic ossiculoplasty was correlated with the improved clinical outcomes, and proficiently conducted endoscopic ossiculoplasty could be used as a surgical technique comparable to microscopic ossiculoplasty.

Total ossicular chain reconstruction using a titanium prosthesis: functional results.

To evaluate the efficacy and safety of a titanium total prosthesis (TORP) in ossicular chain reconstruction. Retrospective analysis of 113 cases of total ossicular chain reconstruction performed by a single surgeon between 2006 and 2018. Follow-up lasted until January 2020. Participants were patients with chronic otitis media, cholesteatoma, or ossicular chain disruption. Mean preoperative air-bone gap (± standard deviation) was 32.74dB (± 11.62). Mean postoperative air-bone gap was 21.68 (± 11.29). Mean air-bone gap improvement was 11.06dB (± 14.99) (p < 0.001). 57 cases had a post-operative air-bone gap smaller than or equal to 20dB (50.44%). In four cases, prosthesis dislocation was observed (12.39%). Mean prosthesis length in this group was 5.29mm (± 0.86) versus 4.36mm (± 1.02) in cases without prosthesis dislocation (p = 0.002). Total ossicular reconstruction using a titanium prosthesis yields favorable functional results, also during prolonged follow-up. Prosthesis length was significantly longer in cases with prosthesis dislocation.

Comparison of Surgical Outcomes Between Ossicle-Cartilage Composite Graft and Synthetic Ossicular Prosthesis for Ossicular Reconstruction.

To propose a modified technique of ossiculoplasty using an ossicle-cartilage composite graft (OCCG) and compare its hearing outcome and protrusion rate with those of a synthetic prosthesis. Autologous tragal or homologous septal cartilage was combined with an ossicle to create an umbrella shape OCCG. A total of 302 ossiculoplasty surgeries performed in a single university hospital between 1997 and 2006 were retrospectively reviewed based on the prosthesis type-OCCG or polymaleinate ionomeric prosthesis (IONOS®). Data includes demographic profiles, audiometric outcomes, intraoperative findings, and post-operative complications and was categorized by the follow-up periods. Ossicle-cartilage composite graft was used for 175 patients and IONOS® for 127 patients. The mean post-operative air-bone gap (ABG) of the OCCG group was 22.36dB, which was better than the IONOS® group of 25.08dB (P = .015). The successful ABG closure rate of less than 20dB was also higher in the OCCG group compared to the IONOS® group (38.3% vs 26.8%, P = .036). The ABG between the pre- and post-operative conditions exhibited a significant difference between the 2 groups (P = .006). In the data divided into 3 groups according to the follow-up period, the OCCG group showed a better outcome in the long-term follow-up with 0 cases of protrusion during the follow-up period in the OCCG group compared to 8 cases of the IONOS® group (P = .018). Ossiculoplasty with OCCG exhibited satisfactory audiometric outcomes and low complication rates. Ossicle-cartilage composite graft can be a good option with sufficient informed consent and preliminary screening of transmitted diseases.

A retrospective analysis of hearing after cholesteatoma surgery: the bony obliteration tympanoplasty versus canal wall up and canal wall down without mastoid obliteration

ObjectiveTo evaluate and compare the hearing outcome after the bony obliteration tympanoplasty (BOT), canal wall up (CWU) without mastoid obliteration and canal wall down (CWD) without mastoid obliteration in a large patient cohort. As the aeration of the middle ear is associated with hearing outcome, we hypothesized that the post-operative hearing after the BOT may be better compared to CWU and CWD without obliteration.MethodsThis is a retrospective cohort study on all adult patients who underwent the BOT, CWU without obliteration or CWD without obliteration for primary or revision cholesteatoma between January 2003 and March 2019 with audiological follow-up at our institution. Pre-operative, short-term post-operative and long-term post-operative hearing tests were analyzed and potential factors influencing post-operative hearing were assessed.Results626 ears were included. We found no significant differences between the short-term and long-term post-operative audiometry. The pre-operative air–bone gap (ABG) was the factor with the largest effect size on change in air–bone gap (ABG) between pre- and post-operative. When stratifying for this factor along with the type of ossicular chain reconstruction to account for differences at baseline, no significant differences in post-operative ABG were found between BOT and non-obliteration CWU and CWD.ConclusionIn this large retrospective cohort study, we found no significant differences in post-operative ABG between the BOT and the non-obliteration CWU and CWD. A solid comparison of hearing between groups remains very challenging as hearing outcome seems to be dependent on many different factors. Hearing outcome seems to be no additional argument to choose for BOT over non-obliteration surgery.

Audioogical Outcome of Stapedotomy for Primary Otosclerosis

Introduction: To find out the audiometric outcome after stapedotomy patients with clinical diagnosis of otosclerosis. Methods: This prospective observational study was performed in a total of 142 patients diagnosed with primary Otosclerosis, who underwent Stapedotomy at the Department of ENT &amp; Head-Neck Surgery, Combined Military Hospital, Dhaka between January 2013 to January 2018. All patients were evaluated as per the candidacy criteria for stapedotomy and selected patients underwent surgery during the study period and were followed up for a period of 12 months in the Otology clinic. Pre-operative and Post-operative audiometric evaluation were done using conventional pure tone audiometry with standard calibrations. Post-operative audiometry was performed at 03 month, 06 month and 12 month. Results: Overall, the frequency specific pre-operative mean average Air-Bone gap was 51.6 dB at 500Hz, 35.7 dB at 1000 Hz, 40.5 dB at 2000 Hz, 38.9 dB at 4000 Hz and the frequency specific postoperative mean average Air- Bone Gap closure was achieved by 28.1 dB at 500Hz, 30.3 dB at 1000 Hz, 12.5 dB at 2000 Hz, 10.8 dB at 4000 Hz, by the time of 1 years of follow up. The difference was statistically significant (p&lt;0.05) between pre-operative Air-Bone gap and post operative Air-Bone gap. After the surgery 88.7% tinnitus patients reported improvement and 11.3 % noted no change in tinnitus. Postoperative sensorineural hearing loss (SNHL) was seen in 1.4 %, failure rate was found 3.8% and 1.4% patients developed post-operative persistent vertigo. Conclusion: Most of the audiometric Results reveal excellent hearing improvement after stapedectomy surgery and worsened bone conduction (postoperative threshold shifts) for primary otosclerosis. It is safe and successful procedure providing long-term hearing expansion in primary otosclerosis with minimum failure rate. J Bangladesh Coll Phys Surg 2022; 40: 116-120

Audiological characteristics and effect of endoscopic surgery for simple congenital malformation of ossicular chain

ObjectiveTo analyze the audiological characteristics and surgical results in patients undergoing surgery for simple congenital ossicular chain malformation, and the effect of endoscopic surgery. MethodsA retrospective review was performed on 86 patients who underwent surgery for the congenital malformation of the ossicular chain. Clinical characteristics and audiometric data were analyzed. Fifty-eight patients had detailed postoperative data, and the preoperative and postoperative audiometric results were compared. The subjects were further divided into endoscopic and microscopic groups, and their surgical effects were examined. ResultsThe preoperative audiometry results in the low-frequency group were worse than those in the high-frequency group (P < 0.05). A postoperative air-bone gap closure to 20 dB or less was achieved in 73.33% of the 60 ears of patients postoperatively. The postoperative air conduction and air-bone gap were significantly better than the preoperative ones (P < 0.05), and the improvement effect was the best in class III patients (P < 0.05). Postoperative hearing had no significant differences between the endoscopic and microscopic groups. However, endoscopic surgery also was more advantageous in terms of operating time (P < 0.05). ConclusionsPreoperative pure tone audiometric results showed moderate or moderate–severe hearing loss, especially in the low-frequency area. The reconstruction of the auditory ossicle chain can achieve satisfactory results, especially in class III patients. Endoscopic and microscopic surgery in the treatment of simple congenital ossicular chain malformations can effectively improve postoperative hearing.

A comparative study of changes in audiological characteristics when using endoscopic and microscopic stapes surgery in patients with otosclerosis.

BackgroundEndoscopic stapes surgery (ESS) is widely used to treat patients with otosclerosis, and accumulating evidence demonstrates that endoscopic stapedotomy is feasible and has similar, and often even better, audiological outcomes compared with microscopic stapedotomy. There is a lack of studies on comparisons of ESS and the audiological outcomes of ESS and microscopic stapes surgery (MSS). Therefore, in the present study, we investigated these to figure out if ESS could be a reasonable alternative treatment for otosclerosis patients.MethodsThis was a cohort study of 65 patients with otosclerosis who underwent ESS (n=30) or MSS (n=35) between 2017 and 2021, whose diagnoses were mainly based on a history of progressive conductive or mixed deafness over 25 dB in the range of 0.25–4 kHz. Preoperative and postoperative audiological evaluation, including air-conduction (AC), bone-conduction (BC) and air-bone gap (ABG), was carried out using pure-tone audiometry and performed within 4 weeks before surgery and from 1–14 months after surgery.ResultsThirty ESS and 35 MSS patients were included. There were no significant differences in preoperative and postoperative pure-tone average AC (AC-PTA), BC-PTA, and ABG-PTA between the 2 groups. Postoperative ABG ≤10 dB was found in 8 ESS patients (60%) and 15 MSS patients (43%) (P=0.168). AC and ABG changes in the low-frequency (LF) and mid-frequency (MF) ranges were greater than those in the high-frequency (HF) range for both groups (P<0.05). Although auditory changes between the 2 groups were similar, MSS appeared to have a better BC-PTA compared with ESS (P=0.049). Shifts in ABG and BC were linearly related to preoperative ABG and BC in both groups, and shifts in AC were linearly related to preoperative AC in the ESS group (P<0.05).ConclusionsESS had a similar audiological outcome compared with MSS, and LF and MF hearing improved to a greater degree than HF hearing in both groups in our study. Based on the linear regression analysis in our study, preoperative ABG-PTA was proved to be the most efficient surgical indicator for both types of stapes surgery for patients with otosclerosis.

Retrograde mastoidectomy with canal wall reconstruction versus intact canal wall tympanomastoidectomy for cholesteatoma with minimal mastoid extension.

Appropriate reconstruction of the canal wall or maintenance of the middle ear pressure in cholesteatoma may help in preventing recurrence. Retrograde mastoidectomy with canal wall reconstruction (RMR) can overcome the challenge of a wider canal wall defect or temporal bone immaturity, which possibly increases the recurrence risk. This study compared the outcomes of RMR and intact canal wall tympanomastoidectomy (ICW) for cholesteatomas with minimal mastoid extension and quantitatively evaluate the relationship between anatomical features and recurrence. This single-center retrospective cohort study included patients who had undergone primary ICW or RMR for pars flaccida cholesteatoma with minimal mastoid extension from 2009 to 2019. The main outcome measures were anatomical measurements of the shortest distance between the cranial fossa and the upper canal wall (SCU), attic volume, and bony defect area of the canal wall (BDC) on computed tomography; recidivism; and postoperative air-bone gap (ABG). There were no significant differences in the preoperative anatomical factors, recidivism incidence, and postoperative ABG between the RMR (n = 20) and ICW (n = 60) groups. However, the median BDC was significantly greater in the RMR group (58.3 vs. 37.0 mm2). There was no significant difference in the SCU and attic volume between patients with and without recurrence. Selection of RMR or ICW may not affect recidivism and hearing outcomes in cholesteatoma with minimal mastoid extension. Bony defect size and attic narrowness were not associated with recurrence. Considering wider visualization and one-staged operation, RMR can be more adaptable than ICW for cholesteatoma with minimal mastoid extension.

Special Considerations for Tympanoplasty Type I in the Oncological Pediatric Population: A Case-Control Study.

IntroductionAlthough cutting-edges antineoplastic therapies increase survival in children with malignancies, the optimal surgical strategy to address associated comorbidities such as chronic tympanic membrane perforation is still poorly documented. The aim of this study is to evaluate the outcomes of type I tympanoplasty in pediatric cancer survivors who received chemo and/or radiotherapy to the skull and to identify potential associated risk factors.MethodsThis case-control study included medical records review of oncologic patients (age <21) treated at the same Academic medical oncologic center between March 2015 and July 2021 and referred for conductive hearing loss and chronic tympanic membrane perforation. Patients and middle ear status-related variables were analyzed, and outcomes were compared with matched peers without any history of malignancies.ResultsA total of seven pediatric cancer survivors and seven paired children without any history of malignancies were included in this report. The mean age at tympanoplasty type I surgery was 10.2 years (range = 4.3–19.9; median = 7.9 years) for the pediatric cancer survivors' group and 10.1 years (range = 5.5–19.2; median = 7.9 years) in the control group. Three pediatric cancer patients had received chemotherapy alone, one patient had radiotherapy to the skull base, and three patients had received chemoradiotherapy. On average, surgery was performed 3.9 years after chemo and/or radiotherapy termination, except for 1 patient for whom the tympanoplasty was performed during chemotherapy treatment. A retroauricular approach was used for one of the pediatric cancer patients, a transcanal approach was performed in one other and five patients benefited from an otoendoscopic approach. Tragal perichondrium with cartilage was used in most of the pediatric cancer survivor cases (four out seven cases) while xenograft (Biodesign) and Temporalis fascia without cartilage graft were used in five out of the seven control cases. Rate of tympanic membrane perforation recurrence was similar between groups (28.6%). Mean functional gain for air conduction Pure Tone Average (AC PTA) was 2.6 and 7.7 dB HL for the oncologic and control group, respectively. Mean postoperative air-bone gap (ABG) was 10.7 dB HL [median = 8.7; inter-quartile range (IQR) = 13.8] for the oncologic cohort and 10.1 dB HL (median = 10.7; IQR = 9.6) for the control group.DiscussionChemo- and chemoradiotherapy to the skull are associated with damages to the inner and middle ear structures with secondary eustachian tube dysfunction and chronic middle ear effusion. Although healing abilities and immunological defenses are compromised as part of the expected effects of antineoplastic therapies, type I tympanoplasty can be safe and effective in this population. While different approaches may be considered, otoendoscopy showed excellent results with less morbidity in this vulnerable population.

Using the external auditory canal skin graft of the healthy side to treat unilateral congenital aural atresia: preliminary results of clinical research

Objective: To investigate whether the contralateral normal external auditory canal (EAC) skin graft can maintain the ear canal health after EAC reconstruction in unilateral congenital aural atresia (CAA) cases. Methods: A Zelen design randomized controlled study was used to collect unilateral CAA patients for EAC reconstruction prospectively (clinical trial registration number: ChiCTR2000032103). The patients were randomly divided into the control group and the trial group. The trial group used the contralateral normal EAC skin graft group (transplant part of the contralateral normal EAC skin to repair the atresia side for unilateral CAA patients), the control group all used scalp blade thick skin. We observed the EAC health and hearing results of the two groups after EAC reconstruction. Results: A total of 13 cases were enrolled from July 2020 to August 2021. There were eight patients in the trial group, including six males and two females, with an average age of 22.3 years (14-36 years). There were two patients with CAA on the left and six patients on the right. The average follow-up time was 8.8 months (4-14 months). There were five patients in the control group, all cases were male with an average age of 16.2 years (12-20 years). There were four patients with CAA on the left and one patient on the right. The average follow-up time was 7.0 months (2-14 months). In the trial group, eight cases of reconstructed EAC epithelium were healthy, one patient had cicatricial stenosis of EAC opening and lateralization of the tympanic membrane. The other patient had cicatricial stenosis of reconstructed EAC, this case also had scar hyperplasia of the contralateral EAC opening but recovered after soft packing and triamcinolone acetonide injection treatment. The healthy side EAC of the rest trial group had no scarring stenosis or local bone hyperplasia during long-term follow-up. In the control group, one patient was lost to follow-up and the other four patients had dry ears of reconstructed EAC, but easily to form crusts and needed to be cleaned repeatedly, one patient had lateralization of the tympanic membrane, the EAC epithelium was not healthy for long-term follow-up. The incidence of complications related to EAC reconstruction was lower than previous studies (χ²=5.55, P=0.018), and the average postoperative Air-Bone Gap increased (18.8±10.0)dB. Conclusion: By optimizing the EAC reconstruction technology, the health of the reconstructed EAC is improved compared with the previous study. After active intervention and treatment, there should be no scarring stenosis or local bone hyperplasia on the contralateral side EAC.

ASSESSMENT OF HEARING OUTCOME IN ENDOSCOPIC TYMPANOPLASTY BY UNDERLAY TECHNIQUE

AIM: To study the hearing outcome of “Endoscopic Tympanoplasty” by underlay technique. METHODS: This study includes 30 patients presenting with Chronic Suppurative Otitis MediaTubotympanic type. Preoperative assessment includes complete clinical history, thorough ENT examination, X-ray mastoids, Pure Tone Audiogram and routine investigations. Informed and written consent was obtained from all the patients. All the patients were subjected to endoscopic transcanal tympanoplasty by underlay technique using temporalis fascia. Patients were regularly followed up for a period of 3 months and at the end of 3 months pure tone audiogram was done to assess hearing. RESULTS: In our study of 30 patients postoperatively, 80% of the patients had successful graft uptake. In our study, postoperative air-bone gap closure was in the range of 0-10 dB in 55% of patients, 11-20 dB in 20% of patients, 21-30 dB in 5% of patients and 31-40 dB in 20% of patients. CONCLUSION: Transcanal Endoscopic Tympanoplasty is a minimally invasive surgical approach as the endoscope usage provides good exposure of tympanic membrane and improves the visualisation of middle ear structures without canaloplasty

An Exposition on Endoscopic Broad Palisade Cartilage Tympanoplasty: Procedural Illustrations and Connotations in Context of Audiological and Morphological Outcomes.

The objective of this study was to evaluate graft take up rate and hearing improvement in type I and type III endoscopic tympanoplasty using broad palisade cartilage graft and to compare the results with other studies who have used single piece cartilage as graft. This retrospective observational descriptive study was done in a tertiary care hospital. This study included 64 cases, who met the inclusion criteria, which were operated over 2years and were followed for 3years. The results were evaluated using graft uptake rates and hearing improvement comparing the preoperative and postoperative air conduction threshold (ACT) and air bone gap closure (ABG). The graft take rate was 92.1% and 87.5% at the end of 1year and 3years respectively. The preoperative and post-operative air conduction threshold were 35 ± 6.0dB HL and 17.5 ± 2.7dB HL in type I tympanoplasty respectively (p value <0.0001) while in type III tympanoplasty, preoperative and post-operative air conduction threshold (ACT) were 43.3 ± 8.6dB HL and 23.1 ± 4.2dB HL respectively (p value <0.0001). The preoperative and postoperative air bone gap (ABG) were 29.0 ± 5.6dB HL and 14.4 ± 4.20dB HL in type I tympanoplasty respectively (p value <0.0001). In type III preoperative and post-operative air bone gap were 36. 1 ± 7.5dB HL and 16.4 ± 3.3dB HL respectively (p value < 0.0001). Endoscopic broad palisade cartilage tympanoplasty has similar outcomes in morphological and audio logical perspectives as single piece cartilage tympanoplasty. Further studies with long term follow up period are required to corroborate the result of this study.

The Emerging Surgical Concepts and Principles of Attic and Postero-Superior Wall Reconstruction by Auricular Cartilage and Free Fibro-Periosteal Tissue in Middle Ear Surgery. An Exposition on Surgical Experiences, Observations and Mistakes.

In middle ear surgeries, addressing the pathologies (cholesteatoma, retractions or tympanosclerosis) in attic or postero-superior area, are associated with difficulties like reconstruction of attic and postero-superior canal wall after clearing the disease. There are various graft materials available for such attic reconstruction in intact canal -wall surgeries. We describe our experience of attic and postero-superior canal wall reconstruction in combined approach tympanoplasty (CAT) using free auricular cartilage and free fibro-periosteal tissue and to present our results in anatomical and functional perspectives. This retrospective observational study was conducted in a tertiary care center which comprised 25 cases of combined approach tympanoplasty (with attic wall reconstruction) which were operated for attic cholesteatoma, tympanosclerosis or adhesive otitis media from January 2017 to December 2019 in our otolaryngology department. Outcomes were evaluated in audiological and morphological dimensions and paired "t" test (significant p value <0.05) was used to analyse the audiological data. A total of 25 cases (22 primary and 3 revision cases) were included in the study. Defect in attic and posterosuperior canal wall was caused by pathology (disease itself) in 2 cases, surgically created (intraoperatively to clear the disease) in 11 cases and both by pathology and surgically in 12 cases. 22 cases had successful graft uptake, with a morphological success rate of 88%, whereas graft failure was encountered in 3 cases. Complications observed were post-operative otorrhea (2 cases), recurrence (3 cases), no hearing improvement despite intact graft (1 case) and worsening of hearing post operatively in 1 case. Pre-operative ACT (Air conduction threshold) was 45.96 ± 12.47dB and the post-operative ACT was 38.61 ± 9.76dB (p value = 0.0246). Pre-operative ABG (Air-bone gap) was reduced from 30.58 ± 11.06dB to the post-operative ABG of 21.89 ± 6.24dB (p value = 0.0013). Reconstruction of postero-superior canal wall and attic defects in CAT using auricular cartilage and fibro-periosteal tissue (over mastoid cortex) is a novel method and associated with satisfactory morphological and audiological results. It is also effective in preventing postoperative retractions.

Efficacy and safety of balloon dilation of eustachian tube in children: Systematic review and meta-analysis

ObjectivesEustachian tube dysfunction is a common condition that may lead to otitis media with effusion, hearing loss and developmental delays in children. We sought to determine the efficacy and safety of balloon dilation of the eustachian tube (BDET) in the pediatric population. Data sourcesOriginal studies of BDET in a pediatric population were identified in PubMed, Embase, Web of Science, Cochrane, Clinicaltrials.gov and CINAHL. MethodsOutcomes of efficacy included audiometric findings and adverse events were summarized for each study. ResultsSeven articles were included involving 408 children with a mean age of 9.9 years old (95%CI 8.8, 11.1) and a mean follow up of 19.2 months (95%CI 15, 23). Type B tympanograms decreased after BDET from 64.2% (95%CI 53.3, 73.8) to 16.1% (95%CI 8.5, 28.4). Air-bone gap (ABG) decreased after BDET from a mean of 25.3 dB (95%CI 18.9, 31.6) to 10.2 dB (95%CI 8.9, 11.5). The pooled estimate of adverse events after BDET was 5.1% (95%CI 3.2, 8.1), the majority being self-limited epistaxis with no major adverse events reported. Three studies compared BDET to ventilation tube insertion; analysis of post-operative ABG showed a greater decrease in the BDET group (mean difference −6.4 dB; 95%CI -9.8, −3.1; p = 0.002). ConclusionAlthough there are no prospective randomized control trials, BDET ± tympanostomy tube placement may produce outcomes that are comparable to tympanostomy tube placement in the treatment of otitis media with effusion in the pediatric population. Most children undergoing the procedure are those with recalcitrant disease. The procedure is safe with the most common complication being epistaxis.

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

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

Can the unmodified incus be used for a simpler, more cost-effective functional ossicular chain reconstruction? A retrospective clinical study.

To evaluate patients' hearing outcomes after ossicular chain reconstruction using unmodified autologous incus. A single-centred, retrospective study of patients who underwent incus interposition between June 2010 and October 2017 was conducted at a Dutch secondary referral centre. This paper describes a chart review of patients who presented with erosion of the long process of the incus due to atelectasis or cholesteatoma who were treated with an unmodified incus interposition. The main outcome measures were: post-operative air-bone gap and level of air-bone gap closure. Thirty-three ears of 32 patients were included. Follow-up duration ranged from six weeks to seven years. A mean post-operative air-bone gap under 25 dB was considered successful; this was achieved in 25 patients (76 per cent), 20 (91 per cent) in the partial ossicular reconstruction prosthesis group and 5 (45 per cent) in the total ossicular reconstruction prosthesis group. This difference was statistically significant (p = 0.007). Successful preservation and improvement of hearing was observed in most patients. As expected, the closure rate in the partial ossicular reconstruction prosthesis group was better. Longer follow-up studies with larger case numbers are needed to assess whether further reconstruction techniques are necessary.