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To compare endoscopic epitympanic exploration with conventional canal wall up (cortical) mastoidectomy for mucosal chronic otitis media in terms of post-operative outcomes.
Seventy-six patients diagnosed with chronic otitis media (mucosal variety) were randomly assigned to two treatment groups: endoscopic epitympanic exploration and conventional canal wall up (cortical) mastoidectomy. The groups were compared in terms of: post-operative anatomical outcomes (graft uptake), middle-ear physiological outcomes (post-operative tympanometry), audiological outcomes (air–bone gap), surgical time, post-operative pain, vertigo, and long-term complications such as retraction pocket and re-perforation.
There was a statistically significant difference between the groups in terms of mean air–bone gap at 12 months, surgical time, and median post-operative pain measured at 6 hours (p < 0.05). No statistically significant differences were noted in terms of: graft uptake at 1, 3 and 6 months, mean air–bone gap at 3 and 6 months, tympanometry at 3, 6 and 12 months, vertigo at 1 week, or long-term complications.
Endoscopic epitympanic exploration resulted in significantly better long-term audiological outcomes, shorter operating time and less pain compared with conventional canal wall up (cortical) mastoidectomy.
Mastoid surgery is an aerosol-generating procedure that involves the use of a high-speed drill, which produces a mixture of water, bone, blood and tissue that may contain the viable coronavirus disease 2019 pathogen. This potentially puts the surgeon and other operating theatre personnel at risk of acquiring the severe acute respiratory syndrome coronavirus-2 from contact with droplets or aerosols. The use of an additional drape designed to limit the spread of droplets and aerosols has been described; such drapes include the ‘Southampton Tent’ and ‘OtoTent’.
To evaluate the use of a novel drape ‘tent’ that has advantages over established ‘tent’ designs in terms of having: (1) a CE marking; (2) no requirement for modification during assembly; and (3) no obstruction to the surgical visual field.
Results and conclusion
During mastoid surgery, the dispersion of macroscopic droplets and other particulate matter was confined within the novel drape ‘tent’. Use of this drape ‘tent’ had no adverse effects upon the surgeon's manual dexterity or efficiency, the view of the surgical field, or the sterility. Hence, our findings support its use during mastoid surgery in the coronavirus disease 2019 era.
Post-auricular mastoid fistula is a rare occurrence. It typically appears following repeated soft tissue injury, and is commonly caused by chronic suppurative otitis media and repeated surgical treatments. Management is challenging, with few reported successful surgical techniques, which often have limited applicability.
This paper presents the case of a 58-year-old male with a persistent right-sided post-auricular cutaneous mastoid fistula resulting from two previous mastoidectomies. Although the patient underwent two simple primary closures, the fistula recurred. This was successfully treated with a new technique utilising a sternocleidomastoid rotational and cervical-fascial advancement flap, which was completely healed at the one-year follow up without a recurrence of the fistula.
This novel technique provided definitive obliteration of a persistent cutaneous mastoid fistula. Utilising a double-layered flap and a facelift incision results in excellent functional and cosmetic outcomes.
Mastoidectomy is considered an aerosol-generating procedure. This study examined the effect of wearing personal protective equipment on the view achieved using the operating microscope.
ENT surgeons assessed the area of a calibrated target visible through an operating microscope whilst wearing a range of personal protective equipment, with prescription glasses when required. The distance between the surgeon's eye and the microscope was measured in each personal protective equipment condition.
Eleven surgeons participated. The distance from the eye to the microscope inversely correlated with the diameter and area visible (p < 0.001). The median area visible while wearing the filtering facepiece code 3 mask and full-face visor was 4 per cent (range, 4–16 per cent).
The full-face visor is incompatible with the operating microscope. Solutions offering adequate eye protection for aerosol-generating procedures that require the microscope, including mastoidectomy, are urgently needed. Low-profile safety goggles should have a working distance of less than 20 mm and be compatible with prescription lenses.
Mastoiditis is the most common intra-temporal complication of acute otitis media. Despite potentially lethal sequelae, optimal management remains poorly defined.
A retrospective case review was conducted of children diagnosed with mastoiditis at a tertiary referral centre, in North East England, between 2010 and 2017.
Fifty-one cases were identified, 49 without cholesteatoma. Median patient age was 42 months (2 months to 18 years) and median hospital stay was 4 days (range, 0–27 days). There was no incidence trend over time. Imaging was conducted in 15 out of 49 cases. Surgery was performed in 29 out of 49 cases, most commonly mastoidectomy with (9 out of 29) or without (9 out of 29) grommets. Complications included sigmoid sinus thrombosis (3 out of 49) and extradural abscess (2 out of 51), amongst others; no fatalities occurred.
A detailed contemporary description of paediatric mastoiditis presentation and management is presented. The findings broadly mirror those published by other UK centres, but suggest a higher rate of identified disease complications and surgical interventions.
This study sought to compare disease recidivism rates between canal wall up mastoidectomy and a canal wall down with obliteration technique.
Patients undergoing primary cholesteatoma surgery at our institution over a five-year period (2013–2017) using the aforementioned techniques were eligible for inclusion in the study. Rates of discharge and disease recidivism were analysed using chi-square statistics.
A total of 104 ears (98 patients) were included. The mean follow-up period was 30 months (range, 12–52 months). A canal wall down with mastoid obliteration technique was performed in 55 cases and a canal wall up approach was performed in 49 cases. Disease recidivism rates were 7.3 per cent and 16.3 per cent in the canal wall down with mastoid obliteration and canal wall up groups respectively (p = 0.02), whilst discharge rates were similar (7.3 per cent and 10.2 per cent respectively).
Our direct comparative data suggest that canal wall down mastoidectomy with obliteration is superior to a canal wall up technique in primary cholesteatoma surgery, providing a lower recidivism rate combined with a low post-operative ear discharge rate.
Retraction pocket theory is the most acceptable theory for cholesteatoma formation. Canal wall down mastoidectomy is widely performed for cholesteatoma removal. Post-operatively, each patient with canal wall down mastoidectomy has an exteriorised mastoid cavity, exteriorised attic, neo-tympanic membrane and shallow neo-middle ear.
This study aimed to clinically assess the status of the neo-tympanic membrane and the exteriorised attic following canal wall down mastoidectomy.
All post canal wall down mastoidectomy patients were recruited and otoendoscopy was performed to assess the neo-tympanic membrane. A clinical classification of the overall status of middle-ear aeration following canal wall down mastoidectomy was formulated.
Twenty-five ears were included in the study. Ninety-two per cent of cases showed some degree of neo-tympanic membrane retraction, ranging from mild to very severe.
After more than six months following canal wall down mastoidectomy, the degree of retracted neo-tympanic membranes and exteriorised attics was significant. Eustachian tube dysfunction leading to negative middle-ear aeration was present even after the canal wall down procedure. However, there was no development of cholesteatoma, despite persistent retraction.
This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically.
This study presents a case report and review of the literature.
A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms.
This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.
Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.
Results and conclusion
Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.
To examine the impact of temporal bone virtual reality surgical simulator use in the undergraduate otorhinolaryngology curriculum.
Medical students attended a workshop involving the use of a temporal bone virtual reality surgical simulator. Students completed a pre-workshop questionnaire on career interests. A post-workshop questionnaire evaluated the perceived usefulness and enjoyment of the virtual reality surgical simulator experience, and assessed changes in their interest in ENT.
Thirty-two fifth-year University of Auckland medical students were recruited. The majority of students (53.1 per cent) had already chosen their career path. The simulator experience was useful for: stimulating thoughts around career plans (71.9 per cent), providing hands-on experience (93.8 per cent) and teaching disease processes (93.8 per cent). After the workshop, 53.1 per cent of students were more interested in a career in ENT.
Virtual reality may be a fun and engaging way of teaching ENT. Furthermore, it could help guide student career planning.
To review the microbiology of open tympanomastoid cavities in patients who underwent revision surgery due to chronic instability.
This paper describes a retrospective chart review of surgical revision cases of chronically unstable open mastoid cavities. Patient records from 2000 to 2010 were reviewed for the type of organism cultured, antimicrobial resistance and the presence of cholesteatoma.
In total, 121 revision surgical procedures were performed on 101 patients. Seventy-nine procedures involved culture specimen processing, 37 of which were positive. The most commonly cultured organism was Staphylococcus aureus, which was more than twice as common as any other pathogen. The presence of cholesteatoma had no impact on the likelihood of a positive culture or polymicrobial culture. Antimicrobial-resistant pathogens were uncommon.
A positive culture was not an overwhelmingly common characteristic of unstable tympanomastoid cavities. Furthermore, antimicrobial resistance did not appear to play an essential role in leading patients towards revision open mastoid surgery.
The key to avoiding damage to the horizontal facial nerve in middle-ear surgery is to formally identify the nerve in the early stages of the procedure.
In the non-infected ear this can be achieved relatively easily by identifying the oval window niche. However, in the infected ear with cholesteatoma, the safest landmark to use is the processus cochleariformis, which can be identified by three different methods.
In an infected ear that is full of granulation tissue and/or cholesteatoma, the horizontal facial nerve can be reliably identified by locating the processus cochleariformis using the three methods described. This avoids damage to the nerve and important structures around it.
To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage.
The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage.
Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae.
Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.
We report a case of bilateral acute mastoiditis and subperiosteal abscesses successfully managed with simultaneous surgery.
A case report and literature review are presented.
A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve. Computed tomography confirmed bilateral mastoid abscesses with destruction of the mastoid cortex. Bilateral drainage of the subperiosteal abscesses and bilateral cortical mastoidectomies were carried out. Post-operatively, he recovered well, and free field audiometry showed a normal hearing threshold of 20 dB across all test frequencies.
This is only the second reported case of bilateral mastoiditis and subperiosteal abscesses. This case illustrates the use of bilateral cortical mastoidectomy in the successful management of this condition following failed antibiotic therapy, and highlights important management considerations.
To review outcomes following paediatric cholesteatoma surgery performed between 1999 and 2009 in a tertiary paediatric ENT unit.
Retrospective case note review.
A total of 137 mastoid procedures were recorded. Fifty-four per cent of children were observed to have disease involving the entire middle-ear cleft and mastoid complex. The revision rate was 25 per cent. Time to recurrence was one to three years in 17 patients, three to six years in five patients, and six to nine years in three cases. Eight of 25 revision cases demonstrated spontaneous improvement in air conduction thresholds following primary surgery. A high facial ridge and inadequate meatoplasty correlated highly with disease recurrence.
Children tend to present with aggressive disease. Disease extent and ossicular chain involvement are associated with a higher risk of recurrent disease. Spontaneous improvement in hearing thresholds following cholesteatoma surgery should alert the clinician to recurrent disease.
(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).
Materials and methods:
All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.
Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.
Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.
To determine the immediate and long-term taste effects of chorda tympani nerve sacrifice in patients undergoing open cavity mastoidectomy.
Design, setting and participants:
A retrospective, questionnaire survey of patients receiving follow up and aural toilet following open cavity mastoidectomy, over a four-month period. The questionnaire assessed taste disturbance, both immediately post-operative and current. Available surgical records were reviewed for chorda tympani references.
Of 57 patients, six had undergone surgery to both ears. Of those who could recall (37/57), 24.3 per cent were aware of taste disturbance immediately after surgery, while 8.7 per cent reported current disturbance (median post-operative interval, 28.5 years; range, one month to 67 years). No bilateral surgery patients were aware of taste disturbance.
Mastoidectomy consent procedure emphasises the risk of hearing loss and facial nerve injury, yet in open cavity surgery chorda tympani division is almost inevitable. Reassuringly, most post-operative taste disturbance resolves, and most patients are not aware of long-term disturbance. However, a small percentage suffer ongoing taste disturbance; this could be significant for professional chefs and wine-tasters. The risk of taste disturbance should be addressed in the consent procedure.
To analyse patients with cholesteatoma undergoing canal wall down mastoidectomy together with ossicular reconstruction with a titanium prosthesis, in order to identify factors associated with hearing outcomes.
Retrospective review of 97 cases undergoing single-stage surgical management.
All patients underwent canal wall down mastoidectomy. Kurz titanium ossicular prostheses were used for ossicular chain reconstruction. Pre-operative and post-operative air conduction and bone conduction hearing thresholds were obtained at 500, 1000, 2000 and 3000 Hz.
The mean pure tone average improved from 46.02 ± 14.54 dB pre-operatively to 29.32 ± 14.64 dB post-operatively, for both total and partial ossicular replacement prosthesis groups combined. The mean air–bone gap improved from 30.38 ± 11.12 dB pre-operatively to 15.62 ± 9.65 dB post-operatively, for both groups combined.
Reconstruction with a titanium prosthesis offers good functional results when performed during canal wall down surgery for advanced cholesteatoma, as a single-stage procedure.
To describe our technique of endaural meatoplasty for mastoid surgery, and to publish an online video demonstration.
After the endaural incision, a skin incision is accurately marked over the anterior conchal bowl, identified by pushing the anti-helix anteriorly. This should meet the line of the endaural incision superiorly and extend inferiorly to the lower anterior edge of the conchal cartilage. After performing the incision, a segment of conchal cartilage is removed. The soft tissue meatoplasty is facilitated by resecting a triangular segment of skin and underlying soft tissue medial to the conchal incision (on which it is based). The free edges are closed with absorbable sutures after the (attico)mastoidectomy.
We have used this method on 64 patients over the past two years. Satisfactory functional and cosmetic outcomes were achieved in all.
Our technique is simple, easy to learn, quick and effective in helping to achieve our goal of a dry mastoid cavity with an adequate meatoplasty.
To evaluate the treatment of intracranial abscess of otogenic origin, and to study the outcome measures of single stage treatment of the otogenic focus and drainage of intracranial abscess via a transmastoid approach.
Retrospective case review.
Dr Balabhai Nanavati Hospital and Medical Research Centre, Mumbai, India, an academic tertiary referral centre, and Shri H Bhagwati Municipal General Hospital, Mumbai, India, an academic secondary referral centre.
Seventy-three patients with intracranial abscess secondary to otogenic pathology, confirmed by computed tomographic scanning.
Single stage treatment of the ear pathology and drainage of intracranial abscess via a transmastoid approach, performed by the senior author (KPM).
Of the 73 patients, 12 were lost to follow up and were excluded from the study. Outcomes for the remaining 61 patients were known, and these patients were followed up for at least two years. Adults were more commonly affected by otogenic intracranial abscess than children, with a male preponderance. Otogenic intracranial abscess was associated with both cholesteatomatous (41 per cent) and non-cholesteatomatous ears (59 per cent). All cases were treated with transmastoid drainage of the intracranial abscess and canal wall up or down tympanomastoidectomy, depending on the ear pathology. Two cases developed post-operative cerebrospinal fluid leakage (3 per cent), and another two cases developed meningitis (3 per cent). Five patients had recurrent abscess; two of these patients (3 per cent) died but were included in the study. Three patients had residual abscess, improved with additional management.
In this series, the low morbidity and mortality rate, combined with a shorter hospital stay, suggest that single stage, transmastoid drainage of intracranial abscess and concurrent treatment of the otogenic pathology is an effective treatment for otogenic intracranial abscess.