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Endoscopic ear surgery is a technique that is growing in popularity. It has potential advantages in the low-resource setting for teaching and training, for the relative ease of transporting and storing the surgical equipment and for telemedicine roles. There may also be advantages to the patient, with reduced post-operative pain, facilitating the ability to complete procedures as out-patients.
Our Ear Trainer has previously been validated for headlight and microscope otology skills, including foreign body removal and ventilation tube insertion, in both the high- and low-resource setting. This study aimed to assess the Ear Trainer for similar training and assessment of endoscopic ear surgery skills in the low-resource setting. The study was conducted in Uganda on ENT trainees.
Despite a lack of prior experience with endoscopes, with limited practice time most participants showed improvements in: efficiency of instrument movement, steadiness of the camera view obtained, overall global rating of the task and performance time (faster task performance).
These results indicate that the Ear Trainer is a useful tool in the training and assessment of endoscopic ear surgery skills.
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 compare post-operative audiometric outcomes for the two prevailing surgical approaches for isolated malleus and/or incus fixation: ossicular mobilisation with preservation of the ossicular chain, and disruption and reconstruction of the ossicular chain.
A search was conducted, in December 2016, of PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature articles written in English. Papers presenting original data regarding post-operative audiometric outcomes in patients who underwent surgical treatment for malleus and/or incus fixation with a mobile and intact stapes were included. A risk of bias assessment was performed on the 14 selected papers and a tier system was developed. Meta-analysis was accomplished by comparing pooled rates of surgical success by chi-square test and calculating odds ratios by logistical regression. Analysis was performed using Revman5 and R software.
Results and conclusion
Analysis of the literature revealed no differences in audiometric outcomes between ossicular chain mobilisation and ossicular chain reconstruction in patients with isolated malleus and/or incus fixation. A large, prospective study comparing both short- and long-term hearing results for ossicular chain mobilisation and ossicular chain reconstruction in this population may identify whether a difference in outcomes exists between the two approaches.
At the heart of surgical care needs to be the education and training of staff, particularly in the low-income and/or resource-poor setting. This is the primary means by which self-sufficiency and sustainability will ultimately be achieved. As such, training and education should be integrated into any surgical programme that is undertaken. Numerous resources are available to help provide such a goal, and an open approach to novel, inexpensive training methods is likely to be helpful in this type of setting.
The need for appropriately trained audiologists in low-income countries is well recognised and clearly goes beyond providing support for ear surgery. However, where ear surgery is being undertaken, it is vital to have audiology services established in order to correctly assess patients requiring surgery, and to be able to assess and manage outcomes of surgery. The training requirements of the two specialties are therefore intimately linked.
This article highlights various methods, resources and considerations, for both otolaryngology and audiology training, which should prove a useful resource to those undertaking and organising such education, and to those staff members receiving it.
Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.
A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.
A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.
The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.
Microscopic myringoplasty is the most frequently performed procedure for repairing tympanic membrane perforations. The endoscopic transcanal approach bypasses the narrow ear canal segment and provides a wider view.
An open-label randomised clinical trial was conducted on 56 patients with small anterior tympanic membrane perforations. Perforations were repaired with an endoscopic push-through technique (n = 28) or a microscopic underlay technique (n = 28). Follow up was conducted using endoscopic examination and pure tone audiometry three months’ post-operatively.
Graft success rate was 92.9 per cent in the endoscopic group versus 85.7 per cent in the microscopic group. The corresponding pre-operative mean air–bone gaps were 17.4 dB and 18.5 dB, improving to 6.1 dB and 9.3 dB post-operatively (p > 0.05). Mean air–bone gap closure was 11.4 dB in the endoscopic group and 9.2 dB in the microscopic group (p > 0.05). Mean operative time and estimated blood loss were 37.0 minutes and 29 ml in the endoscopic group, versus 107 minutes and 153 ml in the microscopic group (both p < 0.05).
The endoscopic push-through technique for anterior tympanic membrane perforations is as effective as microscopic underlay myringoplasty; furthermore, it is less invasive and takes less operative time.
Totally endoscopic ear surgery is a relatively new method for managing chronic ear disease. This study aimed to test the null hypothesis that open and endoscopic approaches have similar direct costs for the management of attic cholesteatoma, from an Australian private hospital setting.
A retrospective direct cost comparison of totally endoscopic ear surgery and traditional canal wall up mastoidectomy for the management of attic cholesteatoma in a private tertiary setting was undertaken. Indirect and future costs were excluded. A direct cost comparison of anaesthetic setup and resources, operative setup and resources, and surgical time was performed between the two techniques.
Totally endoscopic ear surgery has a mean direct cost reduction of AUD$2978.89 per operation from the hospital perspective, when compared to canal wall up mastoidectomy.
Totally endoscopic ear surgery is more cost-effective, from an Australian private hospital perspective, than canal wall up mastoidectomy for attic cholesteatoma.
Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the diagnosis and management of acute mastoiditis, resulting in considerable disparity in conservative and surgical management.
To review the current literature, proposing recommendations for the management of paediatric acute mastoiditis and appraising the treatment outcomes.
A systematic review was conducted using PubMed, Web of Science and Cochrane Library databases.
Twenty-one studies were included, with a total of 564 patients. Cure rates of medical treatment, conservative surgery and mastoidectomy were 95.9 per cent, 96.3 per cent and 89.1 per cent, respectively.
Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy may be an appropriate first-line management when treating acute mastoiditis.
Underwater endoscopic ear surgery does not require suction and so protects the inner ear from unexpected aeration that may damage its function in the treatment of labyrinthine fistula. A method of underwater endoscopic ear surgery is proposed for the treatment of superior canal dehiscence.
Underwater endoscopic ear surgery was performed for plugging of the superior semicircular canal through the transmastoid approach. Saline solution was infused into the mastoid cavity through an Endo-Scrub Lens Cleaning Sheath. The tip of the inserted endoscope was filled completely with saline water.
Using this underwater endoscopic view, the canal was clearly dissected to expose the semicircular canal membranous labyrinth and dehiscence area. No particular complication occurred during the surgical procedure.
The underwater endoscopic ear surgery technique for plugging in superior canal dehiscence secures an excellent visual field and protects the inner ear from unexpected aeration.
Medical and educational partnerships between high- and low-resourced countries provide opportunities to have a long-term meaningful impact on medical training and healthcare delivery.
An otolaryngology partnership between Komfo Anokye Teaching Hospital in Kumasi, Ghana, and the University of Michigan Department of Otolaryngology/Head and Neck Surgery has been undertaken to enhance healthcare delivery at both institutions.
A temporal bone dissection laboratory, with the equipment to perform dedicated otological surgery, and academic platforms for clinical and medical education and residency training have been established.
This article describes the details of this partnership in otological surgery and hearing health, with an emphasis on creating in-country surgical simulation, training on newly acquired medical equipment and planning regarding the formulation of objectified metrics to gauge progress going forward.
To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made.
A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results.
There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery.
There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.
Chronic suppurative otitis media is a neglected condition affecting up to 330 million people worldwide, with the burden of the disease in impoverished countries. The need for non-governmental organisations to hardwire training into their programmes has been highlighted. An ear surgery simulator appropriate for training in resource-poor settings was developed, and its effectiveness in facilitating the acquisition of headlight and microsurgical skills necessary to safely perform procedures via the ear canal was investigated.
Face validity was assessed via questionnaires. Six tasks were developed: a headlight foreign body removal task, and microscope tasks of foreign body removal, ventilation tube insertion, tympanomeatal flap raising, myringoplasty and middle-ear manipulation. Participants with varying ENT experience were video-recorded performing each task and scored by a blinded expert observer to assess construct validity.
Face validity results confirmed that our Ear Trainer was a realistic representation of the ear. Construct validity results showed a statistically significant trend, with experts performing the best and those with limited experience performing better than novices.
This study validates our Ear Trainer as a useful training tool for assessing headlight and microsurgical skills required to perform otological procedures.
Chronic otorrhoea after canal wall down mastoidectomy can be a clinical challenge. Basic principles for canal wall down surgery include establishing a large meatus. Several meatoplasty techniques have been reported. This paper describes this new indication for Todd's meatoplasty with surgical improvements.
Academic tertiary referral centre.
Modifications of transposition postauricular flap meatoplasty are reported. This technique was applied in a series of patients with chronic otorrhoea after a canal wall down mastoidectomy.
In general, a dry radical cavity was successfully created within six weeks and follow-up visits at the out-patient clinic were reduced. Only minor complications occurred, which are all reported.
The postauricular flap meatoplasty is a valuable tool in the management of chronic otorrhoea after an open cavity approach for cholesteatoma.
This paper presents our 10 years’ experience with Felix tympanoplasty. This surgical procedure is designed to repair large perforations of unhealthy tympanic membranes, providing good graft stability without blunting of the anterior tympanomeatal angle.
From January 2001 to December 2011, 64 Felix tympanoplasties were performed, conducted as the only surgical procedure. This paper describes the surgical technique and analyses the functional results.
Graft take was achieved in 61 ears (95.31 per cent). There was air–bone gap improvement in 84.6 per cent of cases.
Felix tympanoplasty was effective in repairing unhealthy tympanic membranes with large perforations; the avoidance of blunting at the anterior tympanomeatal angle achieved good functional results.
The use of endoscopic techniques is becoming more widespread in otological and neuro-otological surgery. One such procedure, endoscopic tympanoplasty, is used in chronic otitis media treatment. This study aimed to analyse the results of endoscopic transcanal cartilage tympanoplasty.
Data of tubotympanic chronic otitis media patients who underwent transcanal endoscopic type I cartilage tympanoplasty between June 2012 and May 2013 were analysed. The main outcome measures were graft success and hearing improvement.
Graft success rates were 94.3 per cent and 92.5 per cent at post-operative months one and six, respectively. Post-operative air–bone gap values were significantly improved over pre-operative values (p < 0.01).
Transcanal endoscopic type I cartilage tympanoplasty is a minimally invasive, effective and reliable surgical treatment option for chronic otitis media.
To develop an autologous total ossicular replacement prosthesis with sustainable hearing results.
The ears of 40 patients, who had chronic otitis media with absent suprastructure of the stapes and long process of the incus, were repaired using the autologous total ossicular replacement technique. Post-operative results were evaluated after 6 and 12 months on the basis of average pure tone air conduction and average air–bone gap measured at 0.5, 1, 2 and 3 kHz.
Successful rehabilitation of pure tone average to 30 dB or less was achieved in 75 per cent of patients, and air–bone gap to 20 dB or less was attained in 82.5 per cent of patients. Overall mean improvement in air–bone gap was 23.9 ± 8.5 dB (p < 0.001). Mean improvements in air–bone gap were significantly greater (p < 0.05) in the tympanoplasty only group (27.3 ± 6.6 dB) and the intact canal wall tympanoplasty group (25.9 ± 6.3 dB) than in the canal wall down tympanoplasty group (16.3 ± 8.9 dB).
This paper describes an autologous total ossicular replacement prosthesis that is biocompatible, stable, magnetic resonance imaging compatible and, above all, results in sustainable hearing improvement.
To document the use of transmastoid labyrinthectomy in the treatment of disabling vertigo after unilateral cochlear implantation.
A 58-year-old man with severe-to-profound bilateral sensorineural hearing loss secondary to chronic otitis media underwent cochlear implantation in his right ear with a Pulsar Med-El device. The surgery was uneventful and the electrode was positioned correctly. He had episodic vertigo three months after implant surgery, and medical treatment and aggressive vestibular rehabilitation did not relieve the vertigo attacks.
Right transmastoid labyrinthectomy was performed one year after cochlear implantation. The patient's symptoms were immediately relieved, and cochlear implant function was not adversely affected at follow up after three years.
Transmastoid labyrinthectomy seems to be an effective, safe method for ablating the vestibular end organ after unilateral cochlear implantation.
Chronic suppurative otitis media is a major cause of long-standing hearing impairment in many Sub-Saharan African countries.
Attempts were made to optimise the pre-treatment process before mobile ear surgery for chronic suppurative otitis media in Wolisso, a semi-urban community in the Oromia region, and in Attat, a rural community in the Gurage region, both in the south-west of Ethiopia, between 2008 and 2010. This included special training for ENT nurses, and the use of a strict scheduling regime and improved topical treatment.
Results and conclusion:
This strategy allowed effective middle-ear surgery to be carried out using simple means and with a mobile ear surgery team, the latter of which is only transiently but regularly on site.
There is currently a lack of robust evidence on the best form of packing for otological surgery. We describe the use of the absorbable gelatin sponge, a packing material that does not require removal and has the benefit of being considerably cheaper compared to other common forms of ear packing.
A comparison was made of the financial cost of several forms of packing for common otological procedures. In addition, a retrospective audit of complications was undertaken of all patients in whom the absorbable gelatin sponge was used over the past three years.
The absorbable gelatin sponge was shown to be cheaper to purchase per unit and also more economical to use. It has been the exclusive form of packing used in 519 procedures over the past three years at the William Harvey Hospital in Ashford (UK), with very few complications noted at the follow-up review.
We strongly advocate using the absorbable gelatin sponge, a packing material that is kinder to the patient, has similar efficacy to other forms of packing and is also much cheaper to use compared to other common forms of packing.