The Current Limitations and Future Direction of Instrument Design for Totally Endoscopic Ear Surgery: a Needs Analysis Survey.

OBJECTIVE: This study aimed to identify limitations and challenges associated with existing instruments and techniques used in totally endoscopic ear surgery (TEES). BACKGROUND: Otologic instruments, traditionally developed for two-handed surgery with operating microscopes, are not necessarily optimized for the TEES environment. Better understanding of technical challenges and the limitations of current instrumentation may allow advances in instrument design for TEES surgery. METHODS: This cross-sectional study employed a mixed-methods nine-question survey that was distributed internationally to surgeons with an interest in TEES. Respondents were asked to classify their TEES experience and instrumentation used, rate their need for better instrumentation to address six TEES-related challenges using visual analog scales, and comment on how to modify or develop new instrumentation. RESULTS: With 51 respondents, we quantified a need for better instruments to address the following 6 potential TEES challenges ordered from greatest to least need: 1) reaching structures visualized by the endoscope, 2) dissection and removal of cholesteatoma, 3) cutting and/or removing bone, 4) bleeding control, 5) keeping the endoscope lens clean, 6) moving and positioning a graft into the intended place. The majority of surgeons perceive a need for improved instrumentation to address each challenge. Challenges 1) and 2) were associated with significantly greater need than the others (p < 0.05, Wilcoxon method for nonparametric pairwise comparisons). CONCLUSION: In addition to highlighting and quantifying some of the common TEES challenges, these findings provide valuable insight into the design requirements for developing improved surgical instrumentation and techniques.

Intraoperative Bleeding and the Risk of Residual Cholesteatoma: A Multivariate Analysis.

OBJECTIVE: Residual cholesteatoma most frequently occurs where visualization and surgical access are restricted by anatomic constraints. Other factors that compromise surgical field visualization might also increase rates of residual cholesteatoma. We evaluated whether impaired surgical field clarity from bleeding increases rates of residual cholesteatoma. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care hospital. PATIENTS: Consecutive series of children having intact canal wall surgery for cholesteatoma. INTERVENTIONS: Impact of bleeding on surgical field clarity was assessed intraoperatively on a six-point scale. MAIN OUTCOME MEASURES: Presence of residual cholesteatoma was established at follow up clinical encounters, second stage procedures, and with magnetic resonance imaging. Multiple logistic regression was used to determine the influence of surgical field clarity and other factors on rates of residual cholesteatoma. RESULTS: Surgery was completed on 232 ears and residual cholesteatoma found in 45 (19%) ears. Multivariate regression analysis of cases completed with atticotomy or tympanoplasty demonstrated that surgical field clarity was a significant predictor of residual cholesteatoma (OR [odds ratio] 4, 95%CI 1.05-15; p = 0.04). Cholesteatoma extent was the most significant predictor of residual cholesteatoma when including cases requiring combined approach tympanomastoidectomy (OR 2.2, 95%CI 1.4-3.3; p < 0.001). CONCLUSIONS: Impaired surgical field clarity from intraoperative bleeding is associated with increased risk of residual cholesteatoma in surgery for meso/epitympanic cholesteatoma. These findings are of particular significance for endoscopic ear surgery in which management of bleeding can be more difficult and support the use of techniques, such as hypotensive general anesthesia, that minimize surgical site bleeding and improve surgical field visualization.

Recommendations for Potassium-Titanyl-Phosphate Laser in the Treatment of Cholesteatoma.

Potassium-titanyl-phosphage (KTP) lasers possess many characteristics suitable for otologic surgery. The objective of this report is to provide recommendations on the use of KTP laser for cholesteatoma surgery based on a narrative review of currently available evidence. PubMed and the Cochrane Review of randomized control trials were searched for relevant publications on efficacy and adverse effects and relevant articles appraised by the authors using Oxford Centre for Evidence-based Medicine criteria for recommendations. The potential benefits of KTP laser in cholesteatoma surgery include reduced rates of residual cholesteatoma and improved hearing outcomes. Cholesteatoma may be more effectively removed using KTP laser than using mechanical dissection alone. Reduced rates of residual cholesteatoma have been reported with KTP laser with level 2 evidence. In addition, KTP laser may facilitate the removal of cholesteatoma without the risk of mechanical trauma. This potentially allows for improved postoperative hearing outcomes through a) minimizing cochlear trauma and reducing sensorineural hearing loss and b) reducing the need for disruption of an intact ossicular chain. Currently, level 4 evidence exists to support improved postoperative hearing outcomes with the use of KTP laser. KTP laser use appears to be safe in otologic surgery if appropriate guidelines are followed. Current evidence is sufficient to strongly recommend KTP laser use for the prevention of residual cholesteatoma (Grade B recommendation) and an option for KTP laser use for optimizing hearing outcomes (Grade C recommendation).

An Eustachian Tube Neuroendocrine Carcinoma: A Previously Undescribed Entity and Review of the Literature.

Primary sinonasal and middle ear neuroendocrine carcinomas are rare malignancies of the head and neck. Owing to the rarity of these tumors, the clinical behavior and optimal management of these tumors are not well defined. We present a case of an incidentally discovered sinonasal neuroendocrine carcinoma that was found to originate from the Eustachian tube, which has not previously been described in the literature. This patient was treated with primary surgical resection using a combination of transnasal and transaural approaches and achieved an incomplete resection. Follow-up imaging demonstrated continued tumor growth in the Eustachian tube as well as a new growth in the ipsilateral cerebellopontine angle and findings suspicious of perineural invasion. However, the tumor exhibited a benign growth pattern and despite continued growth the patient did not receive additional treatment and he remains asymptomatic 35 months following his original surgery.

Vestibular function following unilateral cochlear implantation for profound sensorineural hearing loss.

BACKGROUND: Many Canadians are affected by sensorineural hearing loss (SNHL) and those with severe or profound hearing loss may have poor hearing function despite optimized hearing aids. Cochlear implants (CI) offer effective hearing rehabilitation for these patients, however, concern continues to exist regarding possible effects of CI on the vestibular system and balance. The objective of this study was to conduct a pilot study assessing the effects of unilateral cochlear implantation (CI) on balance and the vestibular system in post-lingually deafened adults. METHODS: Twelve patients were included in this pilot study and were assessed pre-operatively and at immediate, 1 week, and 1 month post-operative intervals. Assessments consisted of the dizziness handicap inventory (DHI), subjective visual vertical (SVV), and timed up-and-go testing (TUG). When applicable, testing was repeated with the CI on and off. RESULTS: Many patients were found to have deviated SVV at pre-operative and post-operative assessments. However, statistically significant changes were not seen when comparing pre-operative and post-operative SVV or when comparing SVV with the CI on and with the CI off. DHI was found to improve in five patients and worsen in two patients, however, no statistically significant change was found in DHI scores or with TUG testing. CONCLUSIONS: This current pilot study does not indicate that CI surgery or implant activity influence vestibular or balance function, however, this pilot study is underpowered and greater numbers of patients would need be assessed to confirm these findings.

Outcomes of incidentally discovered thyroid nodules referred to a high-volume head and neck surgeon.

BACKGROUND: Incidental thyroid nodules are commonly found by radiological studies done for other indications. The yearly incidence of thyroid cancer is increasing, in part because of detection of nonpalpable nodules on imaging performed for unrelated issues. METHODS: All new patients referred to a high-volume thyroid surgeon for thyroid nodules were reviewed between February 2009 and January 2011. Data regarding patient demographics, risk factors, referring physician, radiologic findings, fine-needle aspiration (FNA) results, and management were reviewed. RESULTS: One hundred thirty-three of 729 patients (18.2%) had a thyroid nodule or nodules incidentally found on ultrasound, MRI, CT, nuclear imaging, or chest x-ray. Fifty-five patients (41.4%) were managed surgically, with 35 (63.6%) of those having thyroid cancer on final surgical pathology. CONCLUSION: Based on radiologic findings, risk factors, and FNA results, many incidental thyroid nodules can be observed. Incidental thyroid nodules should be evaluated in the same fashion as a palpable thyroid nodule.

Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures.

OBJECTIVES: The objectives of this study were to classify and analyze perioperative complications following free flap reconstruction in the head and neck and investigate potential predictors of these complications. METHODS: A retrospective chart analysis of 304 consecutive free flap reconstructions for defects in the head and neck were examined. Patient and operative characteristics as well as complications were recorded prospectively and analyzed using ordinal logistic regression. RESULTS: The overall complication rate was 32.6% with a perioperative mortality rate of 0.3%. The flap loss rate was 2.0% and the partial flap necrosis rate was 1.0%. Multivariate analysis demonstrated a significant correlation between perioperative complication and tumor stage as well as reconstruction site. CONCLUSIONS: The rate and grade of complications with free flap reconstruction in the head and neck were found to be low. Higher tumor stage and pharyngoesophageal reconstruction were found to be associated with increased complication grades, whereas preoperative radiation alone and chemoradiation were not. Smoking and alcohol use, age, diabetes mellitus, peripheral vascular disease, and preoperative myocardial infarction as well as preoperative cerebrovascular accident were not found to be associated with increased complications. No statistically significant difference in complication grades was found with different flap types or indications for reconstruction.