A comparative study of endoscopic assisted versus conventional middle ear and mastoid surgery at a tertiary care teaching hospital

<p><strong>Background:</strong> Objectives were to compare outcomes, intra operative visualization and operative time duration in endoscopic assisted vs conventional middle ear and mastoid surgery.</p><p><strong>Methods: </strong>This prospective comparative study was conducted in 50 patients; among them 25 cases were of endoscope assisted middle ear surgery and 25 cases with conventional microscopic middle ear surgery. A 4 mm diameter, 18 cm long rigid, zero-degree endoscope and operating microscope was used. Primary outcomes include mean average pre and post operative air-bone (A-B) gap, hearing thresholds, intra operative visualization and duration of surgery.<strong></strong></p><p><strong>Results: </strong>Mean A-B gap closure for endoscopic assisted tympanoplasty was 12.76±6.00 dB, while it was 8.38±5.78 dB for non-endoscopic assisted tympanoplasty. The results were comparative. Mean intra-operative time duration for endoscopic assisted tympanoplasty was 70.23±4.17 min, while it was 77±9.80 min for non-endoscopic assisted tympanoplasty with statically significant difference between both groups (p=0.03). Graft uptake rate for endoscopic assisted tympanoplasty was 92.31% while it was 84.62% for non-endoscopic assisted tympanoplasty. Residual cholesteatoma remnant on endoscopy was found in 43.66% cases out of 12 mastoidectomy cases performed via endoscopic assistance.<strong></strong></p><p><strong>Conclusions: </strong>The endoscope can be successfully applied to ear surgery for most of the ear procedures with a reasonable success rate both in terms of perforation closure and hearing improvement and with minimal exposure. Wide-field zero, 30 or 70° endoscope sallow visualization of hidden anatomic spaces and working around corners i.e., epitympanum, hypotympanum and retro tympanum for safe removal of cholesteatoma.</p>

A STUDY OF DRILL INDUCED HEARING LOSS IN THE CONTRALATERAL EAR FOLLOWING MASTOID SURGERY.

Background: Mastoidectomy is the mainstay of COM treatment . Usage of the micro motor drill has an effect on the contralateral ear due to the noise induced by the drill and the sound-conducting characteristic of the intact skull. Aims And Objectives: 1. To identify the drill induced hearing loss in the contralateral ear, by transient evoked otoacoustic emissions following mastoidectomy. 2. To identify the relation between the type of burr tip used and the amount of hearing loss. Methodology: This study consisted of 63 patients that underwent mastoidectomy. A pre-operative PTA and TEOAE was done. PTA was repeated on POD-1 and POD-7. TEOAE was done on POD-1,3 and 7. Intraoperatively, the type of burr tip used and the individual drilling time for each type of drill bit was recorded. Results: 37 patients developed transient SNHL by POD-3. All patients recovered by POD-30. Higher frequencies of 3000 Hz and 4000 Hz were commonly affected. No change was detected on PTA. Conclusion: The drill is not only a source of noise but is also a strong vibration generator. These strong oscillations are transmitted into the cochlea. Thus surgeons should select appropriate burrs and drills to minimize the temporal bone vibrations.

Correlation between functional outcome and the SAMEO-ATO framework

Purpose To evaluate the recently proposed SAMEO-ATO framework for middle ear and mastoid surgery, by correlating it with the functional outcome in a large cohort of patients operated for middle ear and mastoid cholesteatoma in a tertiary referral center. Methods We retrospectively included all surgeries for middle ear and mastoid cholesteatoma undergone in our Department between January 2009 and December 2014, by excluding revision surgeries, congenital and petrous bone cholesteatoma. All surgeries were classified according to the SAMEO-ATO framework. The post-operative air bone gap (ABG) was calculated and chosen as benchmark parameter for the correlation analysis. Results 282 consecutive surgeries for middle ear and mastoid cholesteatoma were released in the study period on a total of 273 patients, with a mean age of 41.2 years. All patients were followed for an average period of 55.3 months. 54% of patients underwent M2c mastoidectomy (Canal Wall Down, CWD), while the remaining underwent Canal Wall Up (CWU) procedures, being M1b2a mastoidectomy the most common one (33%). Mean pre-operative and post-operative ABGs were 29.2 and 23.5 dB, with a significant improvement (p < 0.0001). ‘Mastoidectomy’ and ‘Ossicular reconstruction’ parameters of SAMEO-ATO showed significant association with postoperative ABG, with smaller residual gaps for the classes Mx and On, and worse hearing results for M3a and Ox. Conclusion Our results show the utility of SAMEO-ATO framework, and in particular of ‘M’ (Mastoidectomy) and ‘O’ (Ossicular reconstruction) parameters, in predicting the hearing outcome.

Post-operative fever in children undergoing mastoidectomy due to complicated acute mastoiditis

Objectives: To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment. Study Design: A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019. Setting: Tertiary care university hospital. Participants: the study includes 33 patients, divided into two groups: 17 patients with subperiosteal abscess (SPA) alone - single complication group (SCG) and 16 patients with SPA and additional intracranial or intratemporal complications -multiple complications group (MCG). Main Outcome Measures: post-operative fever course and pattern (POF). Results :33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P=0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P=0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings. Conclusion: Following a cortical mastoidectomy for CAM, POF is not unusual in the first 6 days and seem to be benign condition. POF is more common, higher, and persistent for a longer duration in MCG compared with SCG. At POD 6, fever is expected to normalize in both groups, so if fever persists further evaluation should be considered.

Retrospective analysis of difficulties during mastoid surgeries in tertiary referral center in Nepal

<p class="abstract"><strong>Background:</strong> Complications can occur during and following mastoidectomy because of the variation in the temporal bone anatomy and surgical factors. The operating surgeon needs to be aware of potential difficulties and their clinical relevance to avoid the dread complication. This study aims to study various per-operative difficulties and complications encountered during mastoid surgery.</p><p class="abstract"><strong>Methods:</strong> A retrospective study was conducted, including 152 cases of chronic otitis media squamous type who underwent mastoidectomy from June 2017 to January 2019. Revision cases and cases with missing records on per-operative findings, early postoperative status, hearing assessment were excluded from the study. </p><p class="abstract"><strong>Results:</strong> Out of 152 cases, there were 80 males and 72 females with a mean of 27.5 years. Dural plate breach was recognized in 19 cases (12.5%) with iatrogenic injury in 16 cases. Breach of sinus plate and exposure of sigmoid sinus was noted in 11 cases (7.24%) and all were iatrogenic. Korner’s septum was noted in five cases (3.29%). The facial canal was dehiscence in 25 cases (16.4%) with the majority in the horizontal segment, but the sheath was intact in all cases. Immediate postoperative facial nerve palsy was seen in four cases (2.6%). Fistula in the lateral semi-circular canal was noted in two cases. Taste disturbance was noted in 13 cases. Local complications related to the surgical site was seen in 19 cases.</p><p class="abstract"><strong>Conclusions:</strong> The anatomic variations and surgical difficulty are common in mastoid surgery. The major complication rate is around 2-3% despite various mastoid variation and difficulties.</p>

National Trends in Opioid Prescriptions Following Outpatient Otologic Surgery, 2005-2017

Objective To describe opioid stewardship in ambulatory otologic surgery from 2005 to 2017. Study Design Descriptive study of US private insurance claims. Setting Nationwide deidentified private insurance claims database (Clinformatics DataMart; Optum). Methods A total of 17,431 adult opioid-naïve outpatients were included in the study. Patients were identified from CPT-4 codes ( Current Procedural Terminology, Fourth Edition) as having undergone middle ear or mastoid surgery. Multiple regression was used to determine sociodemographic and geographic predictors of postoperative morphine milligram equivalents (MMEs) prescribed, including procedure type, year of procedure, age, sex, education, income level, and geographic region of the United States. Results The mean prescribed perioperative dose over the examined period was 203.03 MMEs (95% CI, 200.27-205.79; 5-mg hydrocodone pill equivalents, 40.61). In multivariate analysis, patients undergoing mastoid surgery were prescribed more opioids than those undergoing middle ear surgery (mean difference, 39.89 MME [95% CI, 34.37-45.41], P < .01; 5-mg hydrocodone pill equivalents, 8.0). Men were prescribed higher doses than women (mean difference, 15.39 [95% CI, 9.87-20.90], P < .01; 5-mg hydrocodone pill equivalents, 3.1). Overall MMEs prescribed by year demonstrates a sharp drop in MMEs from 2015 to 2017. Conclusion While the amount of opioids prescribed perioperatively has declined in recent years, otologists should continue to be cognizant of potential overprescribing in light of previous studies of patients’ relatively low opioid intake.