Comparing Transcanal Endoscopic Ear Surgery to Post-Auricular Microscope-Guided Surgery in Pediatric Ossiculoplasty: Hearing Outcomes and Post-Operative Pain.

OBJECTIVE: This study compares post-operative hearing outcomes and morbidity after pediatric total ossicular replacement prosthesis (TORP) ossiculoplasty with transcanal totally endoscopic ear surgery (TEES) versus a post-auricular microscope-guided (PAM) approach. PATIENTS: Forty-four children who underwent ossiculoplasty with titanium TORP after previous cholesteatoma surgery. INTERVENTION: Ossiculoplasty using TEES or PAM approach. MAIN OUTCOME MEASURES: Hearing outcome after ossiculoplasty was determined by post-operative air-bone gap (ABG) on audiogram nearest to 1 year after surgery. Post-operative morbidity was measured by total number of opiate doses the child received during hospital stay, along with the highest documented post-operative pain score. Comparisons were made with Mann-Whitney U test. RESULTS: Hearing data were available for 41 patients: 21 had undergone TEES (median preoperative ABG 39 dB) and 20 had PAM surgery (median preoperative ABG 39 dB). Post-operatively at 1 year, ABG closed significantly in each group (TEES 21 dB, p = 0.003; PAM 23 dB, p = 0.01), and there was no difference between groups (p = 0.6). 57% who underwent TEES and 50% who underwent PAM surgery experienced serviceable hearing post-operatively, defined as air conduction pure-tone average (PTA) ≤ 30 dB HL. Visual analogue pain scores from 0 (no pain) to 10 (worst pain imaginable) were available for 13 who underwent TEES and 18 who underwent PAM surgery. In children undergoing TEES, only two reported pain above 0, with the highest pain score being 4. Children undergoing PAM surgery had a median pain score of 3 (median difference = 3, p < 0.001). Children undergoing TEES required fewer weight appropriate doses of opiate analgesic (median = 0) than children who underwent PAM surgery (median = 1) (median difference = 1, p = 0.003). Children undergoing TEES had a significantly shorter surgical time (median 135 min) than those who underwent PAM surgery (median 168 min) (median difference = 33 min, p = <0.006). CONCLUSION: Hearing outcomes in TORP ossiculoplasty are similar in TEES and PAM surgery, and TEES may decrease post-operative pain.

Prospective Comparison of Pediatric Endoscopic Lateral Graft and Interlay Tympanoplasty.

OBJECTIVE: To compare outcomes and complications of endoscopic lateral graft (LGT) and interlay (IT) tympanoplasty. STUDY DESIGN: Prospective observational cohort study of totally endoscopic ear surgery (TEES) tympanoplasty. SETTING: Pediatric tertiary referral center. PATIENTS: One hundred fourteen surgeries for children with tympanic membrane perforation without cholesteatoma. INTERVENTION: Porcine-derived collagen graft tympanoplasty using either LGT or IT. MAIN OUTCOME MEASURES: Closure rates of perforation, hearing outcomes (four-tone average air conduction [AC] and air bone gap), and complications that required further surgery were assessed 12 months postoperatively. RESULTS: Perforation closure rates did not differ between LGT (52/59 (88%)) and IT (45/51 (88%)), (Fisher's exact p = 1.00) (four ears lost to follow-up). AC thresholds (p = 0.32) and air bone gap (p = 0.88) improved similarly after surgery with LGT (median 8.8 dB) and IT (median 7.5 dB). The proportion of ears with serviceably normal hearing (AC ≤ 30 dB HL) postoperatively was similar (LGT 40/49 (82%), IT 36/46 (78%), Fisher's exact p = 0.80). Following IT, three (6%) ears developed inclusion cholesteatoma requiring revision surgery. One (2%) LGT ear developed blunting after myringitis. CONCLUSIONS: IT and LGT provide similar perforation closure rates and hearing outcomes. When choosing between these two techniques to repair pediatric tympanic membrane perforations, LGT would seem to be preferable than IT due to the risk of inclusion cholesteatoma after IT. There is a small risk of anterior blunting after LGT.

Measurement Properties of the Hearing Environments and Reflection of Quality of Life (HEAR-QL) 28-item Questionnaire in Cholesteatoma.

OBJECTIVE: We sought to assess the reliability and construct validity of the Hearing Environments and Reflection on Quality of Life Adolescent (HEAR-QL 28) quality of life measure (QoL) in cholesteatoma. STUDY DESIGN: Observational. SETTING: Tertiary referral center. PATIENTS: One hundred seventeen patients with a diagnosis or history of cholesteatoma completed HEAR-QL 28. In addition to patients within the age range recommended for HEAR-QL 28 (13-18 yr), patients under 13 years old who were able to complete HEAR-QL 28 without parental assistance were included. INTERVENTION S: Completion of HEAR-QL 28 QoL measure. MAIN OUTCOME MEASURE S: HEAR-QL 28 score, four tone average pure tone audiogram hearing threshold and categorical classification of hearing loss as mild, moderate, and severe. RESULTS: HEAR-QL 28 did not demonstrate discriminative ability on the basis of audiometric threshold, but did discriminate between participants hearing normally (four tone average pure tone audiogram <30 dB HL) (HEAR-QL 86/100) after cholesteatoma surgery from those with unilateral hearing loss (HEAR-QL 73/100) (p < 0.001). Those with unilateral loss could in turn be differentiated from those with bilateral loss (HEAR-QL 60/100) (p < 0.006). CONCLUSION: HEAR-QL 28 is valid measure of QoL in cholesteatoma with no evidence of redundancy and excellent internal consistency. The importance of considering QoL impact of cholesteatoma is highlighted by 17% of participants reporting the normality or abnormality of their hearing differently from their audiometric threshold. The HEAR-QL 28 provides insight into the ability to cope with their hearing environment in a specific environment.

Design, prototype development and pre-clinical validation of a novel instrument with a compliant steerable tip to facilitate endoscopic ear surgery.

This work presents the design of a novel compliant steerable tip (CST) instrument to facilitate transcanal (or totally) endoscopic ear surgery (TEES). The evolution of the instrument's design is shown, where prototypes were evaluated by surgeons and their feedback was used to inform the design changes for the next prototype iteration. The final prototype enables the surgeon to articulate the compliant tip to achieve the desired bending curvature while automatically locking in place and providing dissection and suction capabilities. Pre-clinical validation testing was performed in goat and human cadaver models by two surgeons who successfully removed an allograft from the middle ear. Time and the number of blockages while suctioning saline in both cadaver models were measured and compared with current instruments used during TEES. The CST took significantly less time to suction saline within a flooded middle ear compared to the Panetti suction dissector (PSD) for atticus and underwent less blockages than the PSD for atticus, ear drum and sinus tympani instruments, Wilcoxon Method p < .05. Our study demonstrates the development and successful clinical evaluation of a minimally invasive surgical instrument designed to facilitate endoscopic approaches to the ear.

Management of squamous cell carcinomas of the skull-base.

PURPOSE: The purpose of this review is to assess the recent evidence regarding the management of squamous cell carcinoma of the skull-base and to discuss the implications of these findings on clinical practice. METHOD: Free text Medline and MeSH term search of publications relating to Squamous Cell Carcinoma & Skull-base and Skull base, Neoplasm respectively. Multidisciplinary clinical guidelines were also reviewed. RESULTS: The primary search yielded a total of 271 papers which following initial review was reduced to 28. Secondary search yielded 56 papers. There were no randomised controlled trials relating to squamous cell carcinoma of the skull-base and as such this review is based on cohort studies, case series and expert opinion. CONCLUSION: Squamous cell carcinoma (SCC) is the most common cancer occurring in the Head and Neck. Squamous cell carcinoma is also the most common cancer arising within the nose and sinuses of which skull-base squamous cell carcinoma is a rare subgroup. Evidence relating to the management and survival of skull-base SCC is based on expert opinion and. retrospective analyses Clinical examination and biopsy, imaging and a broad multidisciplinary team are key to the management of skull-base SCC. The information gathered should be used to guide informed discussion by suitably trained experts with patients regarding surgical approach, post-operative recovery and adjuvant or neoadjuvant treatments. The standard of care is currently to perform skull base resection with or without additional craniotomy, pedicled or free flap reconstruction in multiple layers and post-operative radiation (usually photons or protons). Open approaches have traditionally been the mainstay, however in certain cases endoscopic approaches can yield equivalent results and offer many advantages. Despite advances in care survival remains poor with a nearly one in five risk of nodal recurrence within two years.