Application of Enhanced Recovery After Surgery in Perioperative Period of Tympanoplasty and Mastoidectomy.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speedup recovery. Tympanoplasty and mastoidectomy are common surgical procedures for chronic suppurative otitis media. OBJECTIVE: To compare the efficacy and safety between ERAS and conventional recovery after surgery in the perioperative period of chronic suppurative otitis media. METHODS: From April 2018 to February 2019, a total of 84 patients scheduled for tympanoplasty and/or mastoidectomy due to chronic suppurative otitis media were involved and randomly divided into the ERAS group and the control group. The patients' preoperative anxiety, postoperative pain, and comfort level were determined by comparing the results of Self-Rating Anxiety Scale (SAS), Visual Analog Scale (VAS) and General Comfort Questionnaire (GCQ). The postoperative complications, postoperative hospital stay, and hospitalization cost were calculated. RESULTS: The ERAS group showed a lower SAS score (30 [28-31.5] vs 35 [30-43], P < .05], a higher GCQ score (88 [84-100] vs 83 [78.25-92.25], P < .05), and a lower VAS score (0 [0-0] vs 1 [0-2], P < .05] after surgery. No significant difference (P > .05) was observed between the ERAS group and the control group in postoperative complications, postoperative hospitalization time, and hospitalization cost, respectively. CONCLUSION: Enhanced recovery after surgery can reduce pain and improve comfort in the perioperative period of chronic suppurative otitis media.

Preparing the surgical area for non-shaved ear surgery: a clinical assessment.

OBJECTIVE: To review the clinical experience for non-shaved middle ear/mastoid surgery and evaluate the proper method of preparing the postauricular surgical field. METHODS: This retrospective study reviewed medical records of cases where the non-shaved surgical procedure was carried out for middle ear/mastoid diseases. In all cases, middle ear and mastoid surgery was performed by one otologic surgeon without hair shaving to treat chronic perforation of tympanic membrane, as well as chronic suppurative otitis media, with or without mastoiditis during two years. The prevalence of surgical site infection (SSI) and bacterial culture of the surgical field was assessed just before the skin incision. RESULTS: In this review of 106 cases, the SSI rate was 1.6% for the non-shaved ear surgery. Bacterial colonisation was found on the prepared surgical field in 8.5% of cases and these bacteria was different from true pathogens. SSI of the skin incision occurred in two cases, although no bacterial colonisation of the non-shaved surgical field was found. The surgical exposure of postauricular area was enough to do tympanoplasty or tympanomastoidectomy, even though in cases where a hairline was close to postauricular sulcus. CONCLUSION: This study showed that when preparing the non-shaved ear surgery, the surgeons should not have to worry about skin contamination by hair. We suggest that the non-shaved ear surgery would appear to be preferable for the postauricular approach.

Outcome and cost analysis of bilateral sequential same-day cartilage tympanoplasty compared with bilateral staged tympanoplasty.

BACKGROUND: Few studies have compared bilateral same-day with staged tympanoplasty using cartilage graft materials. METHODS: A prospective randomised observational study was performed of 38 chronic suppurative otitis media patients (76 ears) who were assigned to undergo bilateral sequential same-day tympanoplasty (18 patients, 36 ears) or bilateral sequential tympanoplasty performed 3 months apart (20 patients, 40 ears). Disease duration, intra-operative findings, combined duration of surgery, post-operative graft appearance at 6 weeks, post-operative complications, re-do rate and relative cost of surgery were recorded. RESULTS: Tympanic membrane perforations were predominantly subtotal (p = 0.36, odds ratio = 0.75). Most grafts were harvested from the conchal cartilage and fewer from the tragus (p = 0.59, odds ratio = 1.016). Types of complication, post-operative hearing gain and revision rates were similar in both patient groups. CONCLUSION: Surgical outcomes are not significantly different for same-day and bilateral cartilage tympanoplasty, but same-day surgery has the added benefit of a lower cost.

Development and validation of a low-cost microsurgery Ear Trainer for low-resource settings.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: This study validates our Ear Trainer as a useful training tool for assessing headlight and microsurgical skills required to perform otological procedures.

Therapeutic Mastoidectomy in the Management of Noncholesteatomatous Chronic Otitis Media: Literature Review and Cost Analysis.

OBJECTIVE: Despite evidence that therapeutic mastoidectomy does not improve outcomes in noncholesteatomatous chronic otitis media, it remains widely performed. An up-to-date systematic review is undertaken and conclusions drawn regarding the best evidence-based practice of its management. DATA SOURCES: PubMed, Google Scholar, Medline Embase, Cochrane, and Web of Science. REVIEW METHOD: A combination of the following words was used: chronic otitis media, chronic suppurative otitis media, COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retraction, tympanic perforation, and therapeutic. RESULTS: From 1742 studies, 7 were selected for full analysis with respect to the benefit of mastoidectomy in the management of active and inactive mucosal chronic otitis media. Most were retrospective studies, with 1 prospective randomized controlled trial available. Overall, there was no evidence to support routine mastoidectomy in conjunction with tympanoplasty in chronic otitis media. For ears with sclerotic mastoids, the evidence suggested that there may be some benefit as a staged procedure. Two studies were analyzed for the benefit of mastoidectomy in addition to tympanoplasty for the management of the atelectatic ear (inactive squamous chronic otitis media). The conclusion was also that mastoidectomy added no benefit. CONCLUSIONS: Examination of the available literature supports the notion that therapeutic mastoidectomy does not lend any additional benefit to the management of noncholesteatomatous chronic otitis media. This has implications for patient care, both clinically and financially. Further research, ideally in the form of a prospective, multi-institutional, geographically wide, ethnically diverse, randomized controlled trial, is needed to further support this notion.

[FEATURES OF OTOGENIC INTRACRANIAL COMPLICATIONS AT THE PRESENT STAGE].

A retrospective analysis of treatment was made in 127 adult patients with acute and chronic otitis media complicated by suppurative-inflammatory pathology of the brain. Purulent meningitis was revealed in 52 (40.9%) of hospitalized patients. Meningoencephalitis was often diagnosed in the cases of acute otitis media (15.4%) and in cases of chronic otitis (22.7%). The otogenic brain abscess was detected in 13.5% of otitis media cases and it was noted to be twice frequent (33.3%) in cases of purulent otitis media. The patients 124 (97.6%) have been operated. An extended mastoidotomy and antromastoidotomy were performed in the acute purulent otitis media. An extended radical operation on the ear was applied in case of chronic otitis media. Performance of craniotomy and complete removal of the abscess using modern systems of neuronavigation showed a higher clinical efficacy as compared with transtemporal approach during sanitizing intervention on the ear including the opening and abscess drainage in surgery of otogenic abscesses of the brain.

[Assessment of short-term results of Tos modified combined approach tympanoplasty].

OBJECTIVE: To observe the short-term results of Tos modified combined approach tympanoplasty (MCAT) in chronic suppurative otitis media. METHOD: This study is an observational study. The data of 26 patients (28 ears) underwent MCAT were collected. The surgical techniques, complications and preoperative and postoperative air-bone gap (ABG) were analyzed. RESULT: Of 28 ears, 26 ears (92.86%) get dry after surgery. 3 ears (10.71%)repaired tympanic membranes and reperforate postoperatively in which 2 minimal perforations were cured to close up patient treatment. One ear develops posterosuperior retraction pocket and one ear re-occurs cholesteatoma. One ear occurs blunting in the anterior sulcus and one ear has lateralization of the tympanic membrane. There are no hearing worsen and facial nerve palsy. For hearing, the postoperative pure tone threshold is better than preoperation (42.8 +/- 17.97 vs 47.49 +/- 18.01, P < 0.05) and postoperative ABG shrinks significantly (19.76 +/- 7. 49 vs 30.65 +/- 10.02, P < 0.01). CONCLUSION: Based on the short-term results, Tos' MCAT can successfully dissect the diseases of tympanic cavity and mastoid and develop a stable aerating middle ear with a complete hearing conduction. It is safe and feasible in the treatment of chronic suppurative otitis media, as well as in the poor-pneumatic mastoid.

A comparison of three MDCT post-processing protocols: preoperative assessment of the ossicular chain in otitis media.

The aim of this study was to examine and assess comparative values of HRCT-based multiplanar reformation (MPR), volume rendering (VR) and virtual endoscope built on three-dimensional (3D) shaded-surface display (SSD-based CTVE) for detections of ossicular chain's damage in patients with otitis media. 70 human ears from 70 patients suffering by chronic otitis media or cholesteatoma, who were examined with a preoperative multi-slice computer tomography (MSCT) examination and tympanoplasty in our hospital were collected. The patients ossicular chains were reconstructed with the aforementioned three protocols and assessed via a three-point scoring system by three radiologists. Then, all the patients ossicular chains were reviewed by a surgeon and a radiologist via the same three-point scoring system used during surgeries at same time. By calculation, the Youden's index and coincidence rate were acquired without a significant difference for display of malleus. With regard to the incus, the Youden's index and coincidence rate of VR and MPR did not show any difference, however, both were higher than CTVE. For representation of the stapes, the accuracy of these three modalities is very low; especially, for the CTVE. In conclusion, both MPR and VR are relative robust, and CTVE is not effective for evaluation of small ossicular structures, particularly the stapes. Furthermore, the VR images are real 3D ones. Therefore, it could be the more valuable protocols for detection of the damage of ossicular chain in the patients with otitis media, and should be further applied in the future work.

CT two-dimensional reformation versus three-dimensional volume rendering with regard to surgical findings in the preoperative assessment of the ossicular chain in chronic suppurative otitis media.

PURPOSE: To assess the role of three-dimensional volume rendering (3DVR) in the preoperative assessment of the ossicular chain in chronic suppurative otitis media (CSOM). MATERIALS AND METHODS: Sixty-six patients with CSOM were included in this prospective study. Temporal bone was scanned with a 128-channel multidetector row CT and the axial data was transferred to the workstation for multiplanar reformation (MPR) and 3DVR reconstructions. Evaluation of the ossicular chain according to a three-point scoring system on two-dimensional reformation (2D) and 3DVR was performed independently by two radiologists. The evaluation results were compared with surgical findings. RESULTS: 2D showed over 89% accuracy in the assessment of segmental absence of the ossicular chain in CSOM, no matter how small the segmental size was. 3DVR was as accurate as 2D for the assessment of segmental absence. However, 3DVR was found to be more accurate than 2D in the evaluation of partial erosion of segments. CONCLUSION: Both 3DVR and 2D are accurate and reliable for the assessment of the ossicular chain in CSOM. The inclusion of 3DVR images in the imaging protocol improves the accuracy of 2D in detecting ossicular erosion from CSOM.

[One-step rhinootosurgery. Clinical, economic and social aspects].

The objective of this work was to estimate from the clinical, economic, and social standpoints the efficacy of medical aid provided to the patients with chronic suppurative otitis media (CSOM) and concomitant pathology of the nasal cavity by means of the one-step surgical intervention. The study included a total of 208 patients presenting with CSOM of whom 108 ones were treated by the traditional multistage method and the remaining 108 by simultaneous rhinootosurgery. The latter approach was shown to be much more efficacious in terms of clinical, economic, and social considerations.

[Assessment of immune disorders in patients presenting with various forms of chronic suppurative otitis media in the postoperative period].

The present study was designed for immunological examination of 46 patients presenting with various forms of chronic suppurative otitis media. All the patients underwent surgical intervention on mastoid process (processus mastoideus). It was shown that exacerbation of catarrhal inflammation provoked a significant decrease of the total lymphocyte, T-helpers, and B-lymphocyte (CD22) count whereas the concentration of T-suppressors increased. In patients with the distractive form of chronic suppurative otitis media, the absolute number of total lymphocytes, T-lymphocytes, T-helpers, and B-lymphocytes was also reduced while the concentration of IgG was elevated. The level of serum cytokines (IL-1-beta, IL-6, TNF-alpha) increased in both forms of the disease although the rise in case of catarrhal inflammation was much more pronounced. These data suggest beneficial effect of supplemental corrective immunotherapy.

[Grommets (ventilation tubes) for recurrent acute otitis media in children--assessment of a Cochrane review]. / Draenbehandling af recidiverende otitis media hos børn--en gennemgang af et Cochrane-review.

A recently published Cochrane review on grommets (ventilation tubes) for recurrent acute otitis media in children included only two studies involving 148 children. The review showed that ventilation tube insertion led to a mean reduction of approximately one episode of acute otitis media in the first six months after treatment. We examined three excluded studies and found that their results were comparable even if all five studies had different designs. Clinicians should consider the possible adverse effects of grommet insertion before performing the surgery.

[Multispiral computed tomography for the assessment of the extent of surgical intervention in patients with chronic suppurative otitis media].

The utility of the data obtained by multispiral computed tomography (MSCT) for the choice of surgical techniques is discussed with special reference to chronic suppurative otitis media. Specific features of bone tissue destruction are described in patients with cholesteatoma and without it. Results of MSCT were used to estimate the optimal extent of surgical intervention. Intraoperative findings were in excellent agreement with MSCT data.

Is there a role for virtual otoscopy in the preoperative assessment of the ossicular chain in chronic suppurative otitis media? Comparison of HRCT and virtual otoscopy with surgical findings.

The aim of this study was to assess the role of virtual otoscopy and 3D ossicular reconstruction in the preoperative assessment of the ossicles in chronic suppurative otitis media. Thirty three patients of chronic suppurative otitis media with conductive deafness (air-bone gap > 35 dB) were included in this prospective study. All patients underwent axial multidetector CT. The axial CT data set was utilized for multiplanar 2D reformations as well as virtual otoscopy (VO) and 3D reconstructions. The imaging findings on these two techniques were read independently by two radiologists with respect to different parts of the ossicular chain by using a three-point scoring system and were compared with surgical findings. Both imaging techniques had comparable accuracy for evaluation of larger ossicular parts. However, for evaluation of stapes superstructure, VO/3D images were more accurate (85.29%) than 2D images (76.97%). Assessment of the lenticular process and incudostapedial joint by HRCT and 2D reformatted images was not reliable (P > 0.1); however, significant correlation (P < 0.001) was present between VO/3D and the operative findings. Virtual otoscopy improves evaluation of the ossicular chain particularly that of smaller structures such as the lenticular process, incudostapedial joint and stapes superstructure which may influence decisions regarding planning of ossiculoplasty.

Cost-utility analysis of tympanomastoidectomy for adults with chronic suppurative otitis media.

OBJECTIVE: To undertake cost-utility analysis for tympanomastoid surgery to analyze its cost-effectiveness in treating adult chronic suppurative otitis media (CSOM). METHODS: Seventy-seven patients with CSOM were evaluated with the Chronic Ear Survey (CES) before and 1 year after tympanomastoid surgery. Direct health care cost data during the 1st year after operation were retrieved. The utility gain was defined as change in the CES total score. The cost-utility ratio (CUR) was defined as cost per utility gain. Patients were stratified by disease type into wet-ear and dry-ear groups. RESULTS: The average total direct cost attributable to tympanomastoid surgery is (in New Taiwan dollars) 45,716.3 in the 1st postoperative year, and the average CUR is 1850.9 New Taiwan dollars. The lower CUR of 1280.9 New Taiwan dollars for the wet-ear group is due to the greater utility gain (37.6 +/- 3.4 versus 24.4 +/- 6.8, P < 0.05) despite its higher cost (48,163.2 New Taiwan dollars versus 38,419.7 New Taiwan dollars, P < 0.05). CONCLUSIONS: Treating continuously or intermittently draining ears is more cost-effective, as compared with managing a quiescent infection, because of its favorable utility gain.

[The role of high-resolution CT in the preoperative assessment of chronic otitis media].

OBJECTIVE: To assess the high-resolution CT scan in depicting the middle ear structures. METHOD: The surgical findings of 51 ears operated on were retrospectively compared with the CT findings. The followings were analysed: diagnostic features of chronic otitis media (COM) on CT status of the middle ear structures (ossicles, facial nerve canal, semicircular canals and tegmen tympani), and anatomical variations. RESULT: The radio-surgical agreement was excellent for the malleus (kappa statistics, k = 0.840) and tegmen (0.788), good for the incus (0.700) and semicircular canals (0.56), but poor for the stapes (0.366) and facial nerve dehiscence (0.310). Potential surgical hazards detected by the scans included: Low lying dura, high jugular bulb, anterior lying sigmoid sinus, facial nerve dehiscence and other situations brought about by the destructive nature of the lesion. CONCLUSION: There is a good radio-surgical correlation in COM for most middle ear structures except for the integrity of the facial canal and stapes. The scan alerts the surgeon the potential surgical dangers and complications of disease. High-resolution CT scan should be a routine examination prior to middle ear and mastoid surgery.

The role of computerized tomography in the preoperative assessment of chronic suppurative otitis media.

Twenty patients awaiting mastoid surgery for chronic suppurative otitis media underwent preoperative high resolution computerized tomography (CT) of the temporal bones. The CT scans were compared with the intraoperative findings. CT was helpful in determining the anatomy of the middle ear and mastoid, and accurately predicted the extent of the disease process in the sinus tympani and facial recess. However, it was unable to distinguish between cholesteatoma, mucosal disease and fluid, and it contributed little to the surgical management of the patients. This suggests that routine preoperative CT scanning of patients before uncomplicated virgin mastoid surgery is of questionable value.