Racial Disparity in Tympanostomy Tube Placement in Inpatient Pediatric Admissions.

This study aims to evaluate if race and ethnicity affect rates of tympanostomy tube (TT) placement during inpatient pediatric admissions in children with otologic conditions. A review of the 2016 Kids' Inpatient Database was conducted based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for common otologic conditions. Among 85 827 weighted pediatric inpatient discharges with ICD-10-CM codes for common otologic conditions, 213 underwent TT placement. Odds ratios (ORs) for children of Hispanic ethnicity and Asian or Pacific Islander race undergoing TT placement when compared to other ethnicities and races were 0.60 (P = .011) and 0.21 (P = .040), respectively. Multiple logistic regression showed Hispanic ethnicity was associated with lower rates of TT placement when compared to non-Hispanic white children (OR = 0.62; 95% confidence interval = 0.40-0.96). Future studies should assess why these differences exist and if these differences are associated with racial/ethnic bias or attributed to patient/family preference.

Can floseal™ be applied safely during otologic surgery? Assessment of ototoxicity in a chinchilla animal model.

BACKGROUND: In otologic surgery good visualization is paramount, and patients with bleeding diatheses or who need to be anti-coagulated can present a significant challenge. Here, we determine whether Floseal™, a hemostatic matrix, is ototoxic in a validated animal model. METHODS: Nine chinchillas housed in the animal care facilities of the Montreal Children's Hospital Research Institute were used for the study. After a myringotomy incision was made in each tympanic membrane, baseline auditory brainstem response measurements were performed at 8, 20, and 25 kHz. In each animal one ear was randomized to receive Floseal™ to the middle ear cavity, whereas the other ear served as the control and received 0.9% sodium chloride. Outcome measures included early (day 7) and late (day 30) auditory brainstem response, clinical evidence of facial nerve or vestibular disturbance and histological evidence of ototoxity. RESULTS: There was no significant hearing threshold shift on auditory brainstem response across all tested frequencies for both experimental and control ear. No animals receiving Floseal™ developed facial or vestibular nerve dysfunction and there was no histological evidence of ototoxicity. CONCLUSION: Based on the preliminary ototoxicity assessment on nine chinchillas, transtympanic Floseal™ does not appear to be ototoxic. More studies are warranted to assess the safety and applicability of the product in humans.

Comparison of different computed tomography post-processing modalities in assessment of various middle ear disorders.

Several anatomic structures of the middle ear are not optimally depicted in the standard axial and coronal planes. Several 2D and 3D image-processing modalities are currently available for CT examinations in clinical radiology departments. Till now 3D reconstructions of the temporal bone have not been widely used yet, and attracted only academic interest. The aim of this study was to compare axial (source images), 2D and 3DCT post-processing modalities, and to evaluate the value of 3D reconstructed images/virtual endoscopy (VE) in assessment of various middle ear disorders for identification of the best modality/view for assessment of a particular middle ear structure or pathology. 40 patients with various middle ear disorders, planned for surgical intervention were included in prospective study. Multi-slice CT was performed for all patients. Scans were acquired in the axial plane. The axial source datasets were utilized for generation of 2D reformations and 3D reconstructed images. All studied images were divided into three categories: axial (source images), 2D reformations (MPR and sliding-thin-slab MIP) and 3D reconstruction (virtual endoscopy). The visibility of middle ear structures and pathologies with each modality were scored qualitatively using three-point scoring system in reference to operative findings. Stapes superstructure and footplate, incudostapedial joint, oval and round windows, tympanic segment of the facial nerve and tegmen were not optimally depicted in the axial plane. Sinus tympani and facial recess were best visualized with axial images or VE. 3D reconstruction/VE allowed good visualization of all parts of ossicular chain except stapes superstructure. Regarding pathologic changes, 2D reformations and 3D reconstructed images allowed better visualization of erosion of ossicles and tegmen. 3D reconstruction/VE did not allow detection of foci of otospongiosis. 2D reformations can be considered the mainstay in assessment of most middle ear structures and pathologies. 3D reconstruction/VE seems to provide a useful method for a preoperative general overview of the middle ear anatomy, particularly for the ossicular chain, round window and retrotympanum.

Medida do grau de correção das orelhas proeminentes utilizando algoritmo de tratamento padronizado / Assessment of the degree of correction of prominent ears using a standardized treatment algorithm

The goal of aesthetic otoplasty is the correction of ear deformities by creating harmonious and symmetrical external ears, without visible scars. Otoplasty techniques based on the excision of postauricular skin are associated with high recurrence rates. Modern otoplasty is based on cartilage-cutting and cartilage-sparing techniques, alone or in combination, which lead to lower recurrence rates. Objective: We evaluated the efficacy of otoplasty combined with other techniques in the correction of ear deformities, based on a modified version of the "algorithm for otoplasty at the Craniofacial Center at Texas Children's Hospital". Methods: Forty patients, who underwent otoplasty for prominent ears in our institution between March and September of 2009, were prospectively assessed. The mastoid-helix distance was measured preoperatively (baseline) and at 1, 3, and 6 months postoperatively. Results: The most common deformities were scaphoconchal angle greater than 90° (51.3%, 41/80 ears) and conchal hypertrophy > 2.5 cm (46.3%, 37/80 ears). Recurrence occurred in 2 (5%) patients and partial stenosis of the ear canal in 1 (2.5%). Significant reductions in the mastoid-helix distance were observed at the three time points compared with baseline (P

O objetivo da otoplastia estética é a correção de deformidades da orelha, criando orelhas externas harmoniosas e simétricas. As técnicas de otoplastia, baseadas na excisão da pele pós-auricular, estão associados com a recorrência elevada. A otoplastia moderna é baseada nas técnicas de ressecção e/ou modelagem da cartilagem, que levam que menores taxas de recorrência. Objetivo: Foi avaliada a eficácia da otoplastia com técnica combinada na correção de deformidades da orelha, baseado numa versão modificada do "algoritmo para otoplastia", na Centro Craniofacial do Hospital Infantil do Texas". Método: Quarenta pacientes submetidos à otoplastia por orelhas proeminentes, entre março e setembro de 2009, foram avaliados prospectivamente. A distância mastoide-hélice foi medida no pré-operatório e após 1, 3 e 6 meses após a cirurgia. Resultados: As deformidades mais comuns foram ângulo escafo_concha I maior que 90° (51,3%, 41/80 orelhas) e hipertrofia de concha> 2,5cm (46,3%, 37/80 orelhas). Reduções significativas na distância mastoide_hélice foram observadas nos três períodos em comparação com os valores basais (P

Major otology day case surgery: viable, cost efficient and safe.

BACKGROUND: There has been no study or institution in Ireland promoting major ear surgery performed as a day case procedure in adults. At present, there is a strong political and financial drive for increased elective day case surgery and also a public responsibility to reduce surgical waiting times. METHODS: A prospective study of 43-day case otology patients who underwent major otological surgeries over an 18-month period in a tertiary referral center. We recorded morbidity, readmission rates and assessed the relationships between procedures performed and complications observed. RESULTS: We report a same day discharge rate of 88.4% with a next day readmission rate of 2.3%. We report no major morbidities and found no association between the otological procedure performed and complications observed. Furthermore, there was no statistical association between age and complications observed. We have reduced our waiting list from 9 months to 4 weeks over the 18-month period. CONCLUSION: Major day case otology surgery is an acceptable alternative to an inpatient procedure with favorable discharge rates in comparison to the UK results. Day surgery in this context is safe, cost efficient and expands the surgical possibilities within our department and specialty.

Clinical indication as an ethical appraisal: the example of imaging before middle ear surgery.

PURPOSE OF THE STUDY: Asking whether imaging is indicated before middle ear surgery requires us to examine the question of indication more generally. PROCEDURES: Clinical indication integrates different levels, which are distinguished in this paper. As deciding whether or not an intervention is indicated requires different approaches on each of these levels, these approaches are also explored. RESULTS: Even when sufficient data are available to determine whether an intervention brings some benefit, knowing whether or not this intervention is indicated still requires us to answer 3 additional questions: (1) Is the intervention sufficiently beneficial to be clinically relevant? (2) Is the intervention 'reasonable' in terms of its opportunity costs? (3) How are we to decide which interventions 'make the cut', and which do not? Although we may all have an informed opinion on this topic, the question of the thresholds we ought to apply to very marginal benefits is one where the best answer can only be the one we have all agreed on. This requires a guideline integrating elements of procedural fairness, developed in conditions of protection from the risks of conflicts of interests. CONCLUSION: Although some of these questions integrate considerations of costs, not all do. However, all integrate value judgements, making clinical indication in part a question of ethical appraisal.

Do we need imaging before middle ear surgery? When is imaging useful, when is it mandatory and when is it only interesting, profitable or defensive?

This article summarizes an opinion on preoperative imaging based upon a personal composite of observations and experience in otological and skull base surgery that spans 35 years in several Swiss and US academic centers and 10 years in private practice.

Outcome of mobile ear surgery units in Thailand.

OBJECTIVES: To evaluate the outcome of mobile ear surgery, in terms of tympanic membrane perforation closure, absence of otorrhoea and hearing threshold improvement. STUDY DESIGN: Descriptive study. METHODS: The study enrolled patients with chronic ear disorders requiring surgery who presented to the mobile ear surgery unit at Sakaeo Hospital, Thailand, from 1 to 4 July 2008. The following data were recorded: pre-operative audiogram, post-operative middle-ear and mastoid infection, wound infection, graft condition, any complications, and post-operative audiogram. Patients were followed up at one week, two weeks, four weeks and 24 weeks post-operatively. RESULTS: For the 31 cases of tympanic membrane perforation, the closure rate was 90.3 per cent. For the 32 patients with otorrhoea, the rate of ear dryness was 87.5 per cent. All 35 patients had impaired hearing initially; the rate of hearing improvement was 74.3 per cent (95 per cent confidence intervals = 56.7-87.5 per cent). Patients' mean hearing improvement was 22.9 dB. CONCLUSION: The assessed ear surgery procedures had good results.

Clinical assessment of gustatory function before and after middle ear surgery: a prospective study with a two-year follow-up period.

OBJECTIVES: Middle ear surgery can affect gustatory function because of the course of the chorda tympani nerve (CTN) close to the tympanic membrane. The aim of the study was to evaluate the sense of taste before and after middle ear surgery with a test suitable for clinical routine. Moreover, subjective complaints were assessed over a relatively long period of time. METHODS: Forty-seven patients (26 female, 21 male; mean age, 42 years) were investigated before and 4 days after surgery on both sides of the anterior part of the tongue. Self-assessment of taste function was performed by visual analog scales. RESULTS: The mean (+/- SD) taste scores significantly decreased on the side ipsilateral to the operated ear in patients with major manipulation of the CTN (12.0 +/- 4.5 before surgery and 6.9 +/- 4.5 after surgery; p < 0.001), whereas no significant changes were measured in patients with minor manipulation of the CTN (12.5 +/- 3.1 before surgery and 11.2 +/- 3.9 after surgery; p = 0.14). Self-assessed ratings of taste function significantly decreased after surgery in all patients (p < 0.001). Reassessment of subjective taste function after 2 years indicated no persisting complaints. CONCLUSIONS: Depending on the amount of manipulation of the CTN, taste function is decreased after surgery. However, long-lasting changes of gustatory function seem to be rare.

Impact of a self-developed planning and self-constructed navigation system on skull base surgery: 10 years experience.

CONCLUSION: Our self-developed planning and navigation system has proven its capacity for accurate surgery on the anterior and lateral skull base. With the incorporation of augmented reality, image-guided surgery will evolve into 'information-guided surgery'. OBJECTIVE: Microscopic or endoscopic skull base surgery is technically demanding and its outcome has a great impact on a patient's quality of life. The goal of the project was aimed at developing and evaluating enabling navigation surgery tools for simulation, planning, training, education, and performance. This clinically applied technological research was complemented by a series of patients (n=406) who were treated by anterior and lateral skull base procedures between 1997 and 2006. MATERIALS AND METHODS: Optical tracking technology was used for positional sensing of instruments. A newly designed dynamic reference base with specific registration techniques using fine needle pointer or ultrasound enables the surgeon to work with a target error of < 1 mm. An automatic registration assessment method, which provides the user with a color-coded fused representation of CT and MR images, indicates to the surgeon the location and extent of registration (in)accuracy. Integration of a small tracker camera mounted directly on the microscope permits an advantageous ergonomic way of working in the operating room. Additionally, guidance information (augmented reality) from multimodal datasets (CT, MRI, angiography) can be overlaid directly onto the surgical microscope view. The virtual simulator as a training tool in endonasal and otological skull base surgery provides an understanding of the anatomy as well as preoperative practice using real patient data. RESULTS: Using our navigation system, no major complications occurred in spite of the fact that the series included difficult skull base procedures. An improved quality in the surgical outcome was identified compared with our control group without navigation and compared with the literature. The surgical time consumption was reduced and more minimally invasive approaches were possible. According to the participants' questionnaires, the educational effect of the virtual simulator in our residency program received a high ranking.

Acquired external auditory canal stenosis: assessment and management.

PURPOSE OF REVIEW: Although uncommon, acquired external auditory canal stenosis is an entity that is encountered by many otolaryngologists. This paper reviews the causes, pathogenesis, assessment, and management options for external auditory canal stenosis. RECENT FINDINGS: Initially, acquired external auditory canal stenosis was described as resulting from a number of different causes. Since then, histology and imaging studies of this disease have shown that a common cascade of inflammatory changes resulting from these different causes is the primary pathogenesis leading to medial canal fibrosis. Once there is complete obstruction of the external auditory canal, surgery is the primary treatment. Understanding the strong role of inflammation in the pathogenesis of external auditory canal stenosis may lead to new preventative medical therapies. SUMMARY: Although acquired external auditory canal was described several years ago, its underlying pathophysiology is now better understood. From this knowledge, improved medical as well as surgical approaches can be developed.

[3D-Visualisation of the middle ear by computer-assisted post-processing of helical multi-slice CT data]. / 3D-Darstellung des Mittelohres mittels computergestützter Nachverarbeitung helikaler Mehrschicht-CT-Daten.

Post-processing of CT-data allows non-invasive 3D-Visualisation of the middle ear for diagnosis and surgical planning. In this study different post-processing techniques and the clinical application of a 3D-postprocessing algorithm in a large number of patients are presented. 20 normal patients, 6 dissected temporal bones and 213 patients with suspected middle ear pathology were examined using a low-dosage Multi-Slice CT protocol. Virtual endoscopic views of the middle ear and 3D-images of the ossicles were generated using a standardised algorithm. Evaluation of the image quality was performed. The virtual views of the dissected temporal bones were compared to real views. In 32 patients high-quality 3D-models of the individual anatomical structures were generated and displayed using different visualisation techniques. The standardised and evaluated method enabled visualisation of the normal middle ear anatomy. Assessment of different pathologies, especially malformation, trauma, implants and postoperative alterations, was facilitated. The high-quality 3D-models allowed precise imaging of the anatomical structures. 3D-Visualisation of the middle ear using CT-data is beneficial for radiological diagnosis and surgical planning in cases of complex middle ear pathology as a complementary examination technique.

Middle-ear disease in remote Aboriginal Australia: a field assessment of surgical outcomes.

Chronic middle-ear disease is highly prevalent among Australian Aboriginal people, and many undergo surgical treatment. However, the outcomes of surgery in this group have not been fully evaluated. This is a descriptive study of operations for middle-ear disease (excluding grommets) on Aboriginal patients in Kimberley hospitals between 1 October 1986 and 31 December 1995. Logistic regression was used to model predictors of surgical outcome. Success was defined by an intact tympanic membrane and air-bone gap of < or = 25 dB at review at, or later than, six months post-operation. A success rate of 53 per cent was observed; increasing age was the only variable predictive of success. Successful outcomes were more likely in adults and children aged > 10 years, however, this does not take into account the necessity of hearing for language acquisition and learning. Dedicated resources must be allocated for post-operative follow-up of Aboriginal patients so that much-needed, rigorous evaluations of ENT surgery can be conducted.

[Evaluation of informed consent in ear, nose, and throat practice]. / Valoración del consentimiento informado en ORL.

The patient has a right to information about his or her disease and therapeutic options. A retrospective study was made of the opinion that 40 patients who underwent ear, nose and throat surgery had of this information. After receiving verbal and written information, they completed a questionnaire. Only 1 patient (2.9%) wanted no information, 100% wanted information about the evolution of the disease without treatment, 20.6% were more alarmed after receiving information, and 41.1% thought that written information was essential.

The results of two years operation of the visiting specialist service to the Waikato mobile ear clinic.

AIM: To review the function and results of the Health Waikato mobile ear clinic service 1993-4. METHOD: Data were collected on all children reviewed at the fortnightly specialist clinics conducted in the mobile ear clinics during 1993-4. An overall pathological assessment of the middle ear and eardrum was made for each ear. RESULTS: Of the 467 children examined 311 children were wait listed for elective surgery. Pathology ranged from recurrent acute otitis media to cholesteatoma. Large numbers of children were found with atelectasis of the tympanic membrane. Children as young as seven years of age required modified radical mastoidectomy for treatment of otorrhea due to cholesteatoma. CONCLUSIONS: The results of this survey show the mobile ear clinic service requires a large amount of resources to operate. The mobile ear clinic generates a large operative workload which creates an imbalance between resources devoted to finding the disease and those devoted to treating it. Recommendations include a tighter integration between the mobile ear clinic and the hospital, and appropriate allocation of treatment services to treat the children identified by the service.

Detecting and remediating external meatal collapse during audiologic assessment.

We present a case study in which the jaw/mouth-open procedure during air-conduction testing is employed to both detect and remediate external auditory meatal collapse. A prospective investigation was also conducted to compare the efficacy of the proposed jaw/mouth-open procedure with that of the traditional insert receivers in remediating meatal collapse during audiologic assessment. Meatal collapse was present in 6 of the 136 subjects evaluated. In these 6 subjects, the air-conduction thresholds under supra-aural headphones in the jaw/mouth-open condition were similar to those under insert receivers. We discuss the implications of this finding in clinical settings where insert receivers are not available.

Clinical and surgical aspects of cholesteatomas in children.

A review of 101 charts of pediatric patients who underwent surgery for cholesteatoma in the Hospital das Clínicas, São Paulo, Brazil, showed that the peak incidence was in the 10- to 15-year-old age group (mean age, 10.7 years). A high incidence of complications (45.5%) and a significant functional impairment (air-bone gap greater than 40 dB in 49% of patients) were some of the particular features of our patients. Radical or modified radical mastoidectomies were performed in 75 cases (74.3% of cases). The open technique was chosen primarily to eradicate cholesteomatous disease, but the satisfactory functional results also achieved support our preference for this technique.