Endoscopic Transnasal Management of Meningoceles and Encephaloceles in Children: A Systematic Review.

OBJECTIVE: To review surgical techniques used in the endoscopic transnasal repair of pediatric basal meningoencephaloceles and compare perioperative outcomes in children <2 and ≥2 years old. DATA SOURCES: MEDLINE, EMBASE, and CENTRAL. REVIEW METHODS: Data sources were searched from inception to August 22, 2022, using search terms relevant to endoscopic transnasal meningoencephalocele repair in children. Reviews and Meta-analyses were excluded. Primary outcomes were the incidence of intraoperative and postoperative complications, including cerebrospinal fluid leak, recurrence, and reintervention. Quality assessments were performed using Newcastle-Ottawa Scale, ROBIN-I, and NIH. RESULTS: Overall, 217 patients across 61 studies were identified. The median age at surgery was 4 years (0-18 years). Fifty percent were female; 31% were <2 years. Most defects were meningoencephaloceles (56%), located transethmoidal (80%), and of congenital origin (83%). Seventy-five percent of repairs were multilayered. Children ≥2 years underwent multilayer repairs more frequently than those <2 years (P = 0.004). Children <2 years more frequently experienced postoperative cerebrospinal fluid leaks (P = 0.02), meningoencephalocele recurrence (P < 0.0001), and surgical reintervention (P = 0.005). Following multilayer repair, children <2 years were more likely to experience recurrence (P = 0.0001) and reintervention (P = 0.006). CONCLUSION: Younger children with basal meningoencephaloceles appear to be at greater risk of postoperative complications following endoscopic endonasal repair, although the quality of available evidence is weakened by incomplete reporting. In the absence of preoperative cerebrospinal fluid leak or meningitis, it may be preferable to delay surgery as access is more conducive to successful repair in older children.

Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach.

OBJECTIVE: To evaluate factors that influence the rate of cholesteatoma recurrence (growth of new retraction cholesteatoma) in children. METHODS: Review of children with primary acquired or congenital cholesteatoma. Severity was classified by extent and EAONO-JOS stage, and surgery by SAMEO-ATO. Primary outcome measure was 5-year recurrence rate using Kaplan-Meier or Cox regression analysis. RESULTS: Median age was 10.7 years for 408 cholesteatomas from which 64 recurred. Median follow up was 4.6 years (0-13.5 years) with 5-year recurrence rate of 16% and 10-year of 29%. Congenital cholesteatoma (n = 51) had 15% 5-year recurrence. Of 216 pars tensa cholesteatomas, 5-year recurrence was similar at 14%, whereas recurrence from 100 pars flaccida cholesteatomas was more common at 23% (log-rank, p = 0.001). Sub-division of EAONO-JOS Stage 2 showed more recurrence in those with than without mastoid cholesteatoma (22.1% versus 10%), with more in Stage 3 (31.9%; p = 0.0003). Surgery without mastoidectomy, including totally endoscopic ear surgery, had 11% 5-year recurrence. Canal wall-up tympanomastoidectomy (CWU) and canal wall-down/mastoid obliteration both had 23% 5-year recurrence. Multivariate analysis showed increased recurrence for EAONO-JOS Stage 3 (HR 5.1; CI: 1.4-18.5) at risk syndromes (HR 2.88; 1.1-7.5) and age < 7 years (HR 1.9; 1.1-3.3), but not for surgical category or other factors. CONCLUSION: Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. When controlling for these factors, surgical approach does not have a significant effect on this outcome. Other objectives, such as lower post-operative morbidity and better hearing outcome, may prove to be more appropriate parameters for selecting optimal surgical approach in children.

Use of a Caprine Model for Simulation and Training of Endoscopic Ear surgery.

BACKGROUND: The objective of this study was to evaluate the utility of a caprine model in endoscopic ear surgical education using the index procedures of tympanoplasty and ossiculoplasty. Specifically, this study assessed the face and content validity of the caprine model, and the potential impact of anatomical differences on trainee understanding of human middle ear anatomy. METHODS: Twelve otolaryngology trainees attended a 3-hour endoscopic ear surgery course utilizing the caprine model in which they completed canalplasty, tympanoplasty, and ossiculoplasty. Prior to the course, the trainees completed a self-reported needs assessment and knowledge assessment of human middle ear anatomy. Following the course, the trainees repeated the knowledge assessment and completed evaluation and validation questionnaires. Five-point Likert scores were used for the needs assessment and validation questionnaire. RESULTS: Of the 12 trainees, 9 participated in the study. All domains of the learner needs assessment showed an average improvement of 1 point on the post-course evaluation with 6 of 9 domains being significantly improved using the Wilcoxon signed-rank test (P< .05). The model achieved validation in the domains of face, content, and global content validity with an average Likert score > 4. Knowledge assessment scores increased by 7% (P=.23) after the course compared to before. CONCLUSION: The caprine model offers an effective surgical simulation model for endoscopic ear surgery training with good face and content validity. We find it to be readily available and affordable. We currently use it routinely to give otolaryngology residents the experience of endoscopic ear surgery before operating on patients.

Endoscopic Repair of Round Window Cochleocele.

OBJECTIVE: To describe the novel presentation, implications, and endoscopic management of a congenital round window cochleocele. PATIENT: A 16-month old girl with profound hearing loss from bilateral incomplete partition type 1 (IP1) anomaly of the cochlea plus left-sided cochlear nerve aplasia and cochleocele. INTERVENTION: Anomalies were identified with computed tomographic scanning and magnetic resonance imaging during cochlear implant candidacy assessment. While under general anesthesia for right-sided cochlear implantation, the cochleocele was removed and packed with temporalis fascia using transcanal endoscopic ear surgery. The endoscope was held by an assistant while the surgeon packed the round window using a two-handed technique to counter the gush of cerebrospinal fluid. RESULTS: The child made an uneventful recovery with no cerebrospinal fluid leak or meningitis. CONCLUSIONS: Cochleocele can protrude through the round window of a cochlea with incomplete partition type 1 anomaly. An increased risk of meningitis secondary to acute otitis media is expected given the known risk from cochleocele arising through a stapes footplate fistula. Care should be taken to check for the presence of a cochleocele in hearing loss from congenital malformations involving the basal turn of the cochlea on imaging and also at the time of cochlear implant surgery. Repair should be considered at the first opportunity to prevent meningitis. If early cochlear implant surgery is not feasible or appropriate (as, for example, with cochlear nerve aplasia), transcanal endoscopic ear surgery provides good access for a low-morbidity approach.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review.

Importance: Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions. Objective: To review airway injuries, including long-term sequelae, after BB ingestion in children. Evidence Review: For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis. Conclusions and Relevance: Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Esterified Hyaluronic Acid Placed in the Middle Ear Does Not Improve Outcomes in Cholesteatoma Surgery.

BACKGROUND: The aim of this article is to assess the efficacy of esterified hyaluronic acid as a barrier to formation of adhesions and improvement of tympanomastoid ventilation. METHODS: A prospective cohort analysis was performed at a tertiary referral centre. 126 ears were analysed in children with cholesteatoma. Esterified hyaluronic acid was placed on the promontory of 63 ears at primary canal wall intact surgery for cholesteatoma. No esterified hyaluronic acid was used in 63 control ears. Cholesteatoma recurrence, histopathological analysis of scar tissue following second-stage procedure, and middle ear pressure were the main outcome measures. RESULTS: At 5 years, esterified hyaluronic acid (7%) and non-esterified hyaluronic acid (10%) did not differ in cholesteatoma recurrence (Kaplan- Meier log rank analysis, P=.52). Esterified hyaluronic acid (n=11) and non-esterified hyaluronic acid (n=2) ears formed scar at the site of packing material (n=11) (Fisher's exact test, P=.04). Foamy histiocytes/macrophages were found in esterified hyaluronic acid (n=15) and non-esterified hyaluronic acid ears (n=1) (Fisher's exact test, P-125 daPa) in 44% (14/32) esterified hyaluronic acid ears and 42% (15/36) non-esterified hyaluronic acid ears (P=1.0, Fisher's exact test). CONCLUSIONS: We have discontinued the use of esterified hyaluronic acid in cholesteatoma surgery due to lack of detectable benefit. Esterified hyaluronic acid in the middle ear neither reduces cholesteatoma recurrence nor appears to improve the ventilation of the middle ear. Furthermore, esterified hyaluronic acid alters the inflammatory process within the middle ear, the significance of which remains unclear.

Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma: A Multi-institutional Series.

OBJECTIVE: To assess outcomes of transcanal endoscopic ear surgery (TEES) for congenital cholesteatoma. STUDY DESIGN: Case series with chart review of children who underwent TEES for congenital cholesteatoma over a 10-year period. SETTING: Three tertiary referral centers. METHODS: Cholesteatoma extent was classified according to Potsic stage; cases with mastoid extension (Potsic IV) were excluded. Disease characteristics, surgical approach, and outcomes were compared among stages. Outcomes measures included residual or recurrent cholesteatoma and audiometric data. RESULTS: Sixty-five cases of congenital cholesteatoma were included. The mean age was 6.5 years (range, 1.2-16), and the mean follow-up was 3.9 years (range, 0.75-9.1). There were 19 cases (29%) of Potsic stage I disease, 10 (15%) stage II, and 36 (55%) stage III. Overall, 24 (37%) patients underwent a second-stage procedure, including 1 with Potsic stage II disease (10%) and 21 (58%) with Potsic stage III disease. Eight cases (12%) of residual cholesteatoma occurred. One patient (2%) developed retraction-type ("recurrent") cholesteatoma. Recidivism occurred only among Potsic stage III cases. Postoperative air conduction hearing thresholds were normal (<25 dB HL) in 93% of Potsic stage I, 88% of stage II, and 36% of stage III cases. CONCLUSION: TEES is feasible and effective for removal of congenital cholesteatoma not extending into the mastoid. Recidivism rates were lower with the TEES approach in this large series than in previously reported studies. Advanced-stage disease was the primary risk factor for recidivism and worse hearing result. As minimally invasive TEES is possible in the youngest cases, children benefit from early identification and intervention.

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.

The Influence of Ciprofloxacin-Dexamethasone Ear Drops on Perforation Closure Rates After Endoscopic Tympanoplasty.

OBJECTIVE: Topical ciprofloxacin and dexamethasone have both been shown to disrupt healing of tympanic membrane perforations in animal models. There have been no clinical studies evaluating the effect of ciprofloxacin-dexamethasone (CD) ear drops on success of tympanoplasty. We compare perforation closure rates in pediatric endoscopic tympanoplasty with and without use of postoperative CD. STUDY DESIGN: Retrospective comparative cohort study. SETTING: Tertiary referral centre. PATIENTS: One hundred sixty-two totally endoscopic tympanoplasties with porcine-derived collagen graft in children, mean age 12.0 years (range 2.3-17.9 yrs). INTERVENTION: Prescription of CD versus no ear drops in the immediate postoperative period. MAIN OUTCOME MEASURE: Perforation closure rate 2 months after totally endoscopic tympanoplasty. RESULTS: Postoperative CD was given to 65 (40%) ears and no drops given to the remainder. Overall, successful closure of tympanic membrane perforation was achieved in 140 (86%) of ears. The closure rate was not significantly different in those ears given CD postoperatively than those not given CD (54/65 [83%] vs 86/97 [89%], Fisher's p = 0.35). Multiple logistical regression revealed no confounding effect of other variables on outcome including age, revision surgery, graft position, or type of postoperative packing material. CONCLUSIONS: Our results reveal no harm or benefit with prescription of drops containing ciprofloxacin and dexamethasone on success of perforation closure after tympanoplasty. Allocation to treatment in this retrospective study was nonrandomized and was predominantly based on a change in practice. No other variables are known to have influenced this finding but a randomized prospective study could be justified for more reliable evidence.

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.

Totally endoscopic tympanic membrane repair.

BACKGROUND: Transcanal totally endoscopic ear surgery (TEES) has become increasingly popular internationally; however, for surgeons trained with a two-handed microscope-guided approach, the potential challenges of adopting TEES can appear off-putting. OBJECTIVES: This article outlines the pros and cons of TEES for tympanic membrane repair and describes aspects of surgical technique relevant to those who might adopt this approach. MATERIALS AND METHODS: Data are provided from the author's experience along with a review of relevant literature, including several meta-analyses of tympanoplasty outcome. RESULTS: Meta-analyses show that TEES tympanoplasty is as effective at closing tympanic membrane perforations and improving hearing as microscope-guided surgery. Yet patients benefit from avoidance of a skin incision and faster recovery. CONCLUSION: Repair of the tympanic membrane with TEES is feasible and effective. This minimally invasive approach is very appealing to patients.

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.

Evaluation of Residual Disease Following Transcanal Totally Endoscopic vs Postauricular Surgery Among Children With Middle Ear and Attic Cholesteatoma.

Importance: Transcanal totally endoscopic ear surgery (TEES) improves tympanic cavity visibility during cholesteatoma resection but does not readily permit 2-handed surgery, which is possible with a postauricular approach and use of an operating microscope. Improved visibility and 2-handed access may reduce rates of incomplete surgical clearance and residual cholesteatoma. Objective: To compare rates of residual cholesteatoma after TEES vs those after open surgery with a postauricular approach for initial disease limited to the middle ear and/or attic. Design, Setting, and Participants: This propensity score-matched cohort study considered a consecutive sample of 209 pediatric cases of cholesteatomas resected at a tertiary referral center between January 1, 2005, and December 31, 2017, by either TEES or postauricular approach. The 177 cases (84.7%) in 172 patients that were eligible for inclusion in the study had undergone at least 1 of the following assessments: second-look tympanoplasty, diffusion-weighted magnetic resonance imaging, or in-clinic follow-up examination at least 2 years after the operation. Ears were matched on the basis of the propensity score, a function of age, sex, comorbid diagnoses, etiology, disease extent, ossicular chain condition, presence or absence of tympanic membrane perforation, and otorrhea status at the time of surgery. Exposures: Transcanal totally endoscopic ear surgery was defined as a transcanal approach with surgeon-reported use of an endoscope for resection of cholesteatoma. Use of an operating microscope was permitted in the TEES group for graft placement during tympanoplasty. The postauricular approach was characterized by a postauricular incision and use of an operative microscope with or without adjunct use of an endoscope. Main Outcomes and Measures: Residual cholesteatoma. Results: Of 177 cases included in the study, the unmatched cohort consisted of 65 ears that had undergone TEES (mean [SD] age, 9.9 [3.6] years; 33 [50.8%] female) and 112 ears of patients who had undergone surgery with a postauricular approach (mean [SD] age, 9.9 [3.5] years; 72 [64.3%] male). Propensity score matching was accomplished for a total of 128 cases, with 64 in each group. After matching, standardized differences between TEES and postauricular approaches were less than 0.20 for all measured baseline characteristics, indicating balanced groups. The TEES group had a residual disease incidence of 4 of 64 (6.3%) compared with 7 of 64 (10.9%) in the propensity score-matched postauricular approach group (absolute risk difference, -4.7%; 95% CI, -14.8% to 5.4%). Conclusions and Relevance: This study's findings suggest that there was no apparent advantage of the 2-handed postauricular microscopic approach with respect to surgical clearance of cholesteatoma limited to the middle ear and/or attic. Transcanal totally endoscopic ear surgery may be an effective alternative to a postauricular approach for removal of limited cholesteatoma in children.

International Collaborative Assessment of the Validity of the EAONO-JOS Cholesteatoma Staging System.

OBJECTIVE: Assessment of validity of the Japanese Otological Society and the European Academy of Otology and Neurotology (EAONO-JOS) cholesteatoma staging system (EJS) through international collaboration to investigate: (a) feasibility of retrospectively staging previously acquired data, (b) strengths and weaknesses of the staging system. METHOD: Nine centers with prospective cholesteatoma databases were recruited. Cases were allocated to EJS Stage at each center using details from time of initial surgery. An independent rater also staged the cases and noted any discrepancies. At one center results from database staging were compared with staging based on contemporaneous operative records. Inter and intrarater reliabilities were calculated, and recidivism rates calculated according to Stage. RESULTS: Of 1482 cases of cholesteatoma, 320 (22%) were Stage 1, 977 (67%) Stage 2, 153 (11%) Stage 3 and 4 (0.3%) Stage 4. No database contained details of all parameters required for accurate staging. Staging discrepancies occurred in >10% cases but inter and intrarater reliability of staging were high (Kappa 0.8; 95% confidence interval between 0.7-0.9). At 5 years, 11% had residual and 8% had recurrent cholesteatoma: rates increased with Stage but generally not significantly (Kaplan-Meier Log Rank analysis). CONCLUSION: The EJS Staging system provides an internationally agreed standard for collecting data to classify cholesteatoma severity. Although data can be applied retrospectively with reasonable reliability, prospective data collection would prevent inaccuracies that arise from missing data fields. To enhance validity of the EJS system, we propose clearer definitions of some categories. Refinements to definitions of stage may improve prognostic utility of the EJS but should be made using evidence powered by large-scale collaboration.

Extrusion of straight cochlear implant electrodes May be diminished by proximal fixation.

OBJECTIVES: To determine if proximal fixation of the cochlear implant helps reduce the rate of straight electrode array extrusion/migration. METHODS: Records of 278 children implanted with a straight electrode at a tertiary pediatric hospital from 1990 to 2017 were reviewed. Demographics, operative reports, electrode type, radiological studies and audiological assessments including impedance and stimulation parameters were collected. Significant abnormalities were defined by >75% change in impedance relative to 1 month post-implant values. The main outcome is the incidence of electrode extrusion based on significant changes in impedance and comparative radiological imaging looking for electrode extrusion. RESULTS: During this period, straight electrodes were chosen infrequently (298/1781 devices implanted (16.73%) in 278 children). They were used prior to the introduction of pre-curved electrodes (153/298) and subsequently for hearing preservation (33/298) and in anomalous cochleae (48/298). Most recently they were used in a comparative study of children receiving one perimodiolar and one straight array (64/298). All electrodes were proximally fixated with a suture around the incus buttress (Ned's knot). None of the 298 electrodes required repositioning. Comparative radiographs after long duration implant use were available in 72 of 298 devices (24.2%) revealing no changes in electrode position. Significant impedance changes (>75%), indicative of open circuits, were noted in 6/298 devices (2%); ≤2 electrodes at various array positions were affected in each child. In one case, repositioning of the receiver/stimulator may have damaged the electrodes as they exited the device body but no changes in electrode position were evident on the post-repositioning radiograph. CONCLUSIONS: Extrusion of straight electrodes is a recognized complication of cochlear implant surgery but was not observed in our cohort with proximal electrode fixation.

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.

Endoscope or microscope-guided pediatric tympanoplasty? Comparison of grafting technique and outcome.

OBJECTIVES/HYPOTHESIS: To review experience from the introduction of totally endoscopic ear surgery (TEES) to a pediatric tympanoplasty practice to identify factors influencing technique selection and successful outcome. STUDY DESIGN: Prospective cohort study. METHODS: Analysis of prospectively acquired data from a consecutive series of 295 surgeries for tympanic membrane perforation over a 12-year period. Success of perforation closure was compared between microscope and TEES grafting techniques. Impact of the acquisition of endoscopic techniques and equipment were compared with annual proportion of cases completed by TEES. RESULTS: Of 267 tympanoplasties, 109 (41%) were completed with TEES and 158 by a postauricular approach. The proportion completed with TEES increased gradually to 97% of cases as equipment and expertise were acquired. Young age did not prevent TEES tympanoplasty. Two hundred nineteen of 250 (88%) perforations were closed successfully by tympanoplasty, with equivalent closure rates between TEES and postauricular approaches. Underlay of tragal perichondrium was less successful than lateral graft technique using TEES (P = .04, Fisher exact test). "Push-through" myringoplasty using a microscope or endoscope was least successful (19 of 28 (68%), P = .005). The median length of stay was 13 hours shorter for TEES than postauricular tympanoplasty (P = .04, Mann-Whitney rank sum test). Wound complications occurred in five (3%) postauricular cases and one TEES case. CONCLUSIONS: TEES tympanoplasty is feasible in a large majority of children given appropriate equipment and surgical experience. Nonautogenous graft material is ideal for this minimally invasive approach. TEES is recommended as providing equivalent likelihood of perforation closure to the post-auricular approach but with less postoperative morbidity. LEVEL OF EVIDENCE: 2b. Laryngoscope, 127:2659-2664, 2017.

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.