Day-case major ear surgery: is it viable?

INTRODUCTION: At present there is a strong emphasis on carrying out more elective day-case surgery. This paper presents a series of major ear cases performed on a day-case basis. METHOD: This is a retrospective review of outcome. Surgery was performed over 10 years at the Queen Elizabeth Queen Mother Hospital (part of the East Kent NHS Trust, UK). RESULTS: Over 10 years 253 major ear cases were performed. The unplanned admission rate for overnight stay was 2.8 per cent and the rate of short-period transfers to in-patient wards (for less than a six-hour stay) was 2 per cent. CONCLUSIONS: Our experience shows that major ear surgery, including mastoidectomy, is safe on a day-case basis in all age groups. With the advent of new anaesthetic agents recovery is faster, and modern anti-emetic cover for post-operative nausea and vomiting makes nearly all such major ear surgery feasible as day-case procedures.     

Earigate™ for softening ear wax: Is it safe when the eardrum is perforated?

Objective

To determine the safety of Earigate™ as an ear wax softening product.

Study Design

Prospective, controlled animal study.

Methods

Bilateral wide myringotomies were performed in eleven chinchillas. In each animal, Earigate™ was delivered to a randomly selected experimental ear canal as 2 puffs twice a day. Auditory brainstem response (ABR) was used to assess the hearing of the animals before, 3 days and 10 days following the local application of Earigate™. The ABR threshold shifts were compared for both experimental and control ears.

Results

The mean hearing threshold shifts in the experimental animals were comparable at all frequencies and at days 3 and 10. No statistically significant differences were observed in the mean threshold shifts for all of the frequencies evaluated, between the control and experimental ears.

Conclusions

The administration of Earigate™ to the middle ear of chinchillas did not cause any ototoxicity as assessed by ABR.     

Fully endoscopic laser stapedotomy: is it comparable with microscopic surgery?

Abstract

Background: Microscopic stapedotomy is very successful and has long history, but it still has some constraints. Thus, otoendoscopy is increasingly popular nowadays.

Aims/Objectives: The retrospective review study was to investigate the role of endoscopic laser stapedotomy in treating patients with otosclerosis.

Materials and methods: Seventeen patients who received endoscopic laser stapedotomy from April 2014 to July 2017 were enrolled and compared to 13 patients who had microscopic stapedotomy from February 2009 to March 2012. The anatomical structures, operative time, and postoperative hearing outcomes were assessed in two groups. Relation between external acoustic canal and operative time was also analyzed.

Results: Using an endoscope, the operative field was clear, with easily identified anatomy, without need to sacrifice bony structures. The operative time was significantly longer in the endoscopic group in 2014 and decreased in the following years. There was no significant difference of hearing improvements between the two groups. There was a weak correlation between the width of the external auditory canal and the operative time.

Conclusions and significance: Fully endoscopic stapes surgery is a feasible and safe surgical technique and results in satisfactory hearing outcomes. However, surgeons take longer to master the technique and to achieve shorter endoscopic operative times.     

Middle ear atelectasis: what causes it and how is it corrected?

Many options are available to manage a patient who has atelectatic ears. Establishing normal middle ear ventilation and aeration is the cornerstone to successful control of these ears. Often, medical management with nasal steroids and decongestants is all that is needed. If recurrent infections have weakened the tympanic membrane progressively, or the middle ear environment is so severe that medical management does not correct the problem, then surgical correction is often necessary. This article explores the pathogenesis of middle ear atelectasis and explains a classification system to help the clinician determine the best course of management.     

Particle repositioning manoeuvre in benign paroxysmal positional vertigo: is it really safe?

OBJECTIVE: A prospective study to determine the safety of the particle repositioning manoeuvre (PRM) by analyzing the various complications of the procedure. SETTINGS: Outpatient Department of Otorhinolaryngology, Nehru Hospital, Chandigarh, India. METHODS: Thirty patients with the classic findings of benign paroxysmal positional vertigo (BPPV) were included in the study. Clinical symptoms prior to the procedure were noted. Twenty-nine of them were subjected to PRM, and postprocedural instructions were given to all patients. Various side effects during and following the procedure were recorded. They were classified into early and late based on the period and into major and minor based on severity. All patients were reviewed after 3 days, 7 days, and 1 month. RESULTS: Of the 29 patients, 19 patients (65.52%) had heaviness in the head, with 11 each (37.93%) reporting nausea and imbalance and 9 (31.03%) reporting instability during the procedure. A major complication, asystole, was noted in one patient. The percentage of side effects remained more or less the same in the early phase following the procedure. Only 5 of 29 patients were entirely asymptomatic. Ninety percent were relieved of symptoms by the end of 7 days, with no major complication recorded. CONCLUSIONS: PRM is an easy, effective, and relatively safe procedure. The risk of major complications with PRM, such as arrhythmias and asystole, highlights the need to consider other management modalities for BPPV in certain medically unfit patients.     

Outcome of bacterial culture from mastoid granulations: is it relevant in chronic ear disease?

OBJECTIVE: To detect the presence of bacteria in mastoid granulations and compare its prevalence in both types of chronic suppurative otitis media (CSOM). To find out if stage of disease activity, age, duration of disease, and aditus patency relate to obtaining positive cultures. STUDY DESIGN AND SETTING: A prospective, parallel group study done at a tertiary care referral centre. Mastoid granulations from 79 patients with CSOM undergoing mastoidectomy were processed for anaerobic and aerobic bacteria. RESULTS: Aerobes were isolated from 57.55 per cent of the tubotympanic and 74.4 per cent of atticoantral disease (p=0.18). Anaerobic cultures were positive in one case from each group. Monomicrobial growth was detected in 37.5 per cent of tubotympanic and 48.5 per cent of atticoantral disease. Polymicrobial growth occurred in 20 per cent and 25.6 per cent in the tubotympanic and atticoantral groups, respectively. The predominant aerobic isolate was coagulase negative Staphylococcus, followed by Pseudomonas aeruginosa, Staphylococcus aureus, non-fermenting Gram-negative bacteria, Enterobacter and Enterococcus, Proteus species, Citrobacter, non-pathogenic Neisseria, aerobic spore formers were grown only in atticoantral disease. A single isolate of Aspergillus was grown. Correlating the state of disease activity of the ears with positive mastoid granulation cultures, six out of the eight inactive ears were culture positive along with seven out of the nine active and 10 out of the 23 quiescent ears. Positive mastoid granulation cultures were obtained in 60 per cent of those with blocked aditus and 42.9 per cent with patent aditus. CONCLUSION AND SIGNIFICANCE: In this study, we found that mastoid granulations are not sterile but harbour polymicrobial pathogens. Positive cultures were obtained irrespective of stage of disease activity, age, duration of disease and aditus patency. The pattern of organisms cultured from safe and unsafe CSOM and also from ears in active, quiescent and inactive stages, were similar. These findings suggest that these organisms may be responsible for mastoid granulations. We also noted that positive cultures had no statistical correlation with aditus patency and duration of disease. We suggest further studies to evaluate the significance of asymptomatic mastoid granulations harbouring organisms and whether opening the mastoid antrum and achieving aditus patency, irrespective of the stage of disease activity, will help improve the long-term surgical outcome and also prevent recurrence of ear discharge.     

Electronystagmography: how helpful is it?

Two hundred and sixty patients tested with electronystagmography (ENG) for evaluation of complaints of disequilibrium were the representative sample for this study. As all new dizzy patients currently receive an ENG, the goal of this project was to determine how much an ENG adds to the diagnostic acumen, and which patients really needed an ENG in order to maximize efficiency and minimize patient cost. Results indicate the suspected diagnosis prior to ENG is assisted by its use only when the cause is thought to be central or is uncertain. The percentage of unknown causes of disequilibrium decreased from 34.2 to 13.8 per cent and the percentage of central causes increased from 13.1 to 23.1 per cent. Electronystagmography does not significantly aid in the diagnosis of peripheral lesions except as confirmation. Specific findings and recommendations are discussed.     

Sudden deafness: is it viral?

A number of theories have been proposed to explain the etiopathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL), including viral infection, vascular occlusion, breaks of labyrinthine membranes, immune-mediated mechanisms and abnormal cellular stress responses within the cochlea. In the present paper, we provide a critical review of the viral hypothesis of ISSHL. The evidence reviewed includes published reports of epidemiological and serological studies, clinical observations and results of antiviral therapy, morphological and histopathological studies, as well as results of animal experiments. The published evidence does not satisfy the majority of the Henle-Koch postulates for viral causation of an infectious disease. Possible explanations as to why these postulates remain unfulfilled are reviewed, and future studies that may provide more insight are described. We also discuss other mechanisms that have been postulated to explain ISSHL. Our review indicates that vascular occlusion, labyrinthine membrane breaks and immune-mediated mechanisms are unlikely to be common causes of ISSHL. Finally, we review our recently proposed theory that abnormal cellular stress responses within the cochlea may be responsible for ISSHL.     

Sellar reconstruction: is it necessary?

BACKGROUND: Sellar reconstruction is practiced routinely during the transsphenoidal approach to pituitary tumor resection. This practice exposes the patient to risks of donor site complications and may interfere with measuring postoperative tumor reduction. We propose that it is not a necessary component of transsphenoidal pituitary surgery in the absence of intraoperative cerebrospinal fluid (CSF) leak. METHODS: A retrospective chart review of 45 cases of minimally invasive pituitary surgery were reviewed. Twenty-eight cases were identified with no sellar reconstruction being performed. Age, sex, revision surgery, postoperative CSF leak, days with lumbar drain, meningitis, ophthalmoplegia, visual acuity loss, postoperative epistaxis, diabetes insipidus, development of empty sella syndrome, and length of stay were investigated in these cases. RESULTS: Twenty-three cases were the primary procedure and five cases were revision surgery. Complication rates were low and compared favorably with those reported in the literature. Five cases of transient diabetes insipidus occurred. There was one postoperative CSF leak that required 4 days with a lumbar drain. No cases of empty sella syndrome developed. There were no cases of meningitis. The average length of stay was 2.9 days. CONCLUSION: Sellar reconstruction during transsphenoidal approach to pituitary tumor resection is not required for patients without evidence of an intraoperative CSF leak. This practice exposes the patient to the risks of donor site complications without reducing the rate of postoperative complications.     

Computed tomography in suppurative ear disease: does it influence management?

The value of high resolution computerized tomography (CT) prior to routine mastoid surgery for cholesteatoma remains controversial. Doubts about sensitivity and specificity, in detecting the extent of underlying pathology and in predicting asymptomatic complications, prevent widespread adoption. This retrospective study looks at the influence of pre-operative scanning on the surgical management of chronic suppurative otitis media over an 18-month period. The radiological findings determined the choice of surgical approach, but contributed less to the decision to operate and the prediction of potential hazards. CT is of most value when the otologist can be flexible in surgical technique, tailoring it to imaging findings.     

Polyflex stent: is it radiopaque enough?

We report a case of tracheal stenosis in which a migrated Polyflex (Rusch AG, Germany) stent entered the right main bronchus but could not be identified on the chest radiograph. The stent was identified at bronchoscopy and removed under general anaesthesia. Polyflex stents are radiopaque but may not always show up on radiograph. We recommend reliance on clinical symptoms rather than imaging to diagnose migration. If stent migration is suspected then imaging should include thoracic inlet films that incorporate a lateral view.     

Coblation tonsillectomy: is it inherently bloody?

The aim of the study was to compare a single surgeon’s post-tonsillectomy haemorrhage rates using cold steel dissection and coblation tonsillectomy techniques. Retrospective study on patients, who underwent tonsillectomy at West Wales General Hospital (WWGH) performed by a single surgeon from 2006 to 2010 employing both cold steel and coblation tonsillectomies. Data were analysed using Mann–Whitney and Chi-squared tests. The nominated surgeon performed 239 tonsillectomies at WWGH from 2006 to 2010. 119 patients underwent cold steel dissection and 120 had coblation tonsillectomy. There was no demographic difference between the two groups. There was no statistically significant difference in the length of hospital stay between the two groups (median 1 day in each group). 6/119 (5.0%) patients in the cold steel group, and 7/120 (5.8%) in the coblation group had post-operative bleeding (p = 1.00). The return to theatre rate for cold steel dissection was 1/119 (0.84%) and for coblation surgery was 1/120 (0.83%) (p = 1.00). Among the first 60 cases of coblation tonsillectomies, 4 patients (6.6%) had post-operative haemorrhage and the latter 60 cases had 3 patients (5%). There was no evidence of a difference in the overall post-operative bleeding between those who had cold steel dissection and coblation tonsillectomies. These data suggest that higher post-operative haemorrhage is not inherent to coblation tonsillectomy.