International Otology Outcome Group and the International Consensus on the Categorization of Tympanomastoid Surgery.

The International Otology Outcome Group (IOOG) was founded in 2017 to encourage and facilitate international collaboration with regard to the surgical outcome of ear surgery. This report outlines the methodology and recommendations of the consensus-based categorization of tympanomastoid surgery produced by the IOOG. The IOOG Steering Committee used the acronym SAMEO-ATO to categorize tympanomastoid operations, representing the stage of surgery, approach, mastoid bone extirpation, external bony wall repair, obliteration of the mastoid cavity, access to the middle ear, tympanic membrane reconstruction, and ossicular reconstruction. A modified Delphi technique was used to obtain international consensus. The expert panels included the chairpersons from 21 otology societies. The approval rate of the SAMEO-ATO system from the otology societies was 95%. The SAMEO-ATO scheme was presented at the 31st Politizer Meeting for field testing. There were no objections or serious concerns raised. Some international otologists wished to see more surgical categories included to reflect the varieties of surgical techniques, but they accepted that it would make the whole system cumbersome. In addition to providing an international categorization of tympanomastoid surgery, the IOOG Steering Committee plans to introduce a common otology dataset that the international otology community could use to record their surgical outcome. The high level of international consensus on the IOOG categorization of tympanomastoid surgery supports this tool for surgeons to pool their surgical data into a large database for research and comparative audit.

The Prevention of Recurrent Cholesteatoma in CWU Surgery: The Use of Titanium Sheeting.

OBJECTIVE: Assessment of the outcomes of a technique of prevention of recurrent cholesteatoma in canal wall up (CWU) mastoidectomy, using titanium sheeting to repair the external auditory canal wall. PATIENTS: Sixty four cholesteatoma cases were managed during a period from 2007 to 2015. The cases were unselected; the surgery was performed by the senior author. Cholesteatoma Patterns Were: Forty two attic, nine pars tensa, seven combined attic-pars tensa, three congenital, and three other. Primary surgery was undertaken in 33 cases. INTERVENTIONS: All cases underwent CWU surgery that employed canal wall repair using fine titanium sheeting combined with overlying organic material to repair canal wall defects. Drum repairs employed cymba conchae cartilage-perichondrium composite grafts. Chain reconstruction used Spanner struts or Grace Alto PORPs or TORPS. RESULTS: Two cases suffered mesotympanic residual disease, and three, mesotympanic recurrence one of which extended into the attic. Two other cases incurred atticomastoid residues. Transient myringitis occurred in three cases. CONCLUSION: The surgery was judged on its ability to avoid atticomastoid recurrence, and was regarded as highly successful. The titanium sheeting offers a relatively simple but effective technique. The mesotympanic complications are those also commonly found in both CWD and other CWU methods. As in other CWU procedures, the problems of the open cavity were avoided.

Paediatric cochlear implantation: adverse prognostic factors and trends from a review of 174 cases.

OBJECTIVES: Identification and evaluation of prognostic factors that are associated with paediatric cochlear implantation (PCI) outcomes was the aim of this study. METHODS: A retrospective review of 174 charts was performed at the Royal Children's Hospital and the Hear and Say Centre, Brisbane. This examined the possible influence of a number of variables (including age at implant, family, additional disabilities, surgical complications, gender, GJB2 mutations, meningitis, inner ear malformations, and prematurity) on outcome measures: receptive, expressive, and total language, receptive and expressive vocabulary, speech articulation and categories of auditory performance at 18-24 months post-implant. Multiple regression analysis was used to identify variables related to language and vocabulary outcomes. RESULTS: The findings suggest that inner ear malformations and family concern are negatively associated with receptive and expressive language and receptive vocabulary scores. There was marginal evidence to suggest that increasing age at implantation was associated with lower receptive and expressive language scores. DISCUSSION: Prognostic factors that have been adequately validated statistically include inner ear malformations, the influence of family and late age at implantation. However, this study identified a need to define better the impact of the various degrees of inner ear malformations, to particularly emphasize the role of family as a strong predictor of PCI outcomes, and to confine the study of 'age at implantation' to pre-lingually deafened children. CONCLUSION: Evaluation of prognostic factors is a key element in PCI. This study confirmed several factors that are strongly associated with outcomes. For better research, there is a need for universal standardized outcome measures and development of a standardized framework for recording patient data.

Defining and evaluating success in paediatric cochlear implantation--an exploratory study.

OBJECTIVES: This work is a preliminary study that sought to investigate and develop a method for defining and evaluating "success" in paediatric cochlear implantation (PCI) and to apply a process by which a clinical team could optimally achieve this aim. METHODS: A pilot group of 25 profoundly deaf children who received a unilateral cochlear implant from 1995 to 2008 was used to develop the process. The cases displayed features that are commonly encountered in PCI. Individual case records were examined retrospectively for adverse factors that might impact on the implantation outcome with particular reference to the probability and severity of impact of each factor. Case prognosis was then rated on a 1-4 basis (1: excellent, 2: good, 3: fair, 4: poor). The subsequent outcomes were assessed using standardised speech (GFW, DEAP), language (PLS-4; CELF) and vocabulary (PPVT; EVT) assessments. Auditory performance outcomes were assessed using a new Categories of Auditory Performance Index (CAPI) that incorporated criteria, testing and scoring aspects. Family issues were also evaluated. Case outcomes were rated 1-4 as above and the prognoses and outcomes were then compared. RESULTS: Accurate prognostication was seen in 14 cases, 5 had better outcomes than expected and 6 obtained poorer results. "Success", where the outcome equalled or exceeded the prognosis, occurred in 19 (76%) of cases. The successful group contained some "limited gains" cases where the results were nonetheless in line with expectations and parental satisfaction. The detrimental effect of delayed implantation was evident; Connexin 26 (GJB2) mutation had little influence. Poor general medical condition and adverse family situations commonly produced poorer outcomes. CONCLUSIONS: Success in PCI is achieved when the outcome matches or exceeds the pre-operative expectations of the well-counselled family, without adverse side effects. The assessments achieved a good success rate, but further research is required to clearly identify potential problems and a skilled team is needed to evaluate their risk to the PCI outcome. Unforseen events may also intervene. Currently, differing outcome evaluation techniques impede comparison of studies, particularly in the speech and hearing domains. Rationalisation of these is recommended to facilitate future research.

Keyhole cochlear implantation: current status.

INTRODUCTION: Past cochlear implantation (CI) techniques have included a variety of soft tissue and bony trauma to place and stabilize the implant body. Despite minimalist approaches, the surgery invites further refinement. MATERIALS AND METHODS: A restricted access "keyhole" CI technique was developed through a series of 547 cases undertaken from 1997. The surgery used a 20-mm-diameter mini C-incision on the rear of the auricle and avoided the use of a bony retention well or suture fixation. Initial body migration rates were successfully countered using small titanium mesh "bridges." The series was free from other problems specific to the technique. DISCUSSION: The study demonstrates that CI can be performed with only restricted exposure, disposing of well and suture fixation methods, and without a wound that may be adjacent to the implant body or electrode arrays. CONCLUSION: The keyhole approach proved atraumatic and brief. It is particularly suited to simultaneous bilateral implantation in the infant and proved adaptable to all ages.

Acquired cholesteatoma: classification and outcomes.

OBJECTIVE: Reclassification of acquired cholesteatoma into the commonly observed presentations of this condition to provide a simple and clear grouping that indicates the pathology, management, and outcomes of the group cases. PATIENTS: Virgin acquired cholesteatoma cases from a single center managed from 1986 to 2008 (515 cases). INTERVENTIONS: Cases were managed by transcanal (20%) or intact canal wall techniques. Wall repairs successively used autograft cartilage (transcanal and early intact canal wall mastoidectomy cases), hydroxylapatite plates (1989-2007), or titanium sheeting (2007). Drum repairs used cartilage-perichondrial composite grafts. Assembly techniques were the preferred ossiculoplasty method. RESULTS: Distribution: attic, 41%; pars tensa, 45%; and combined attic-pars tensa, 14%. Unclassifiable cases (n = 14) were excluded. Contralateral disease was present in 15% and effusions in 34% during or after surgery. Cell formation was most extensive in attic disease, least in combined patterns. Ossicular pathology was worse in the collapsed drum cases. Attic cases had the best hearing outcomes but risked recurrent disease, which required precise countermeasures. Overall, the combined pattern group carried the worst prognosis. CONCLUSION: Compared with previous methods, the clinical classification proved simple, descriptive, and comprehensive. It provides a readily discerned practical basis for clinical management and research purposes.

Prognostic indicators in paediatric cochlear implant surgery: a systematic literature review.

BACKGROUND: Paediatric cochlear implantation (PCI) requires complex case evaluation and counselling, surgical intervention, and habilitation. Outcomes vary and many cases have sub-optimal outcomes as a result of a broad spectrum of adverse influences. OBJECTIVE: To systematically review the literature to identify research papers that indicate a demonstrated outcome or prognostic factor in paediatric CI, the overall aim being to develop a prognostic index for clinical use. METHODS: Six main literature domains were assessed: medical/surgical; audiology; psychology; speech/language; education; and family. Search strategies were applied to appropriate databases and journals. A strict inclusion criterion was utilized. A critical appraisal tool was administered to evaluate the final eligible citations. RESULTS: The review identified 92 citations, of which 38 were eligible. Heterogeneity in study design prevented a quantitative meta-analysis of the data. Discussion While there are a large range of factors that impact PCI outcomes, well-constructed case control studies are limited in number and scope and relatively few demonstrated significant prognostic factors. Only four factors were identified as consistently influencing PCI outcomes: age at implantation, Connexin 26, inner ear malformations, and meningitis. CONCLUSION: Evaluation of relevant adverse prognostic factors in paediatric CI remains a largely unreported field. Better identification of these factors is required for improving vital pre-operative counselling and resultant surgical expectations and outcomes.

Use of titanium in repair of external auditory canal defects.

INTRODUCTION: Canal wall defect repairs commonly result from cholesteatoma, surgery for chronic ear disease, or exostosis and also from congenital deformities. Reconstructions of these defects are often difficult and unstable. This article reports the use of titanium sheeting to repair external auditory canal wall defects. METHODS: Titanium sheeting was used to repair a variety of wall defects. The sheeting was used as a support material, lying deep to the wall defect, which was sealed with an autograft cartilage layer that was fitted to fill the defect. Middle temporal or temporalis fascia vascular flaps were used to cover large-defect repairs to promote rapid healing. The sheeting was used in 56 external auditory canal defect cases, including 35 deep canal defects, 4 lateral bony wall repairs, 12 open-cavity reconstructions, and 5 anterior wall repairs. RESULTS: There were no evident biomaterial complications, and infection was absent from the series. The sheeting was simpler touse than ceramics, being easily shaped and bent to fit the individual case. Second-look cavity reinspections were simpler than when ceramics or autografts had been used for reconstructions. DISCUSSION & CONCLUSION: Titanium sheeting has been proven an effective method of canal wall repair when combined with the supplementary techniques used with biomaterials in this role (cartilage cover and vascular flaps). Its ease of use, versatility, and reliability are superior to previous organic or ceramic methods.

Keyhole cochlear implantation surgery.

A limited access 'keyhole' cochlear implantation (CI) surgical technique is presented. The surgery employs a 15-18 mm diameter C-incision on the rear of the auricle. The implant is retained in a snug pericranial pocket. A bony retention well is avoided. Minimal mastoid cell clearance is used. The surgery is brief, atraumatic and well suited to small infant cases. Used in 315 sequential routine CI cases from 1997-2007, the complication rates compare favourably with past reports. The outcomes of the series question the use of larger incisions and implant retention wells. Current implant designs should be modified for better adaptation to the cranial contours.

Collaborating to conquer cancer: a comprehensive approach to cancer control.

Despite substantial contributions on the part of public, non-profit, and private sector organizations, the burden of cancer in the United States remains high. As public health organizations, particularly county, state, tribal, and territorial health departments, try to reduce the significant burden of cancer, they face additional issues that make it difficult to address cancer in a comprehensive way. These challenges along with the need to accelerate progress in reducing the U.S. cancer burden, prompted the Centers for Disease Control and Prevention (CDC) and its national partners to begin to work together to further define and describe comprehensive cancer control (CCC) as an approach to reducing the burden of cancer. CCC is defined as "an integrated and coordinated approach to reducing cancer incidence, morbidity, and mortality through prevention, early detection, treatment, rehabilitation, and palliation." This article describes the national effort to support comprehensive cancer control, outlines national and state level success in comprehensive cancer control, and provides a call to action to public, private, and non-profit organizations, governments of all levels, and individuals to renew their commitments to reducing the burden of cancer.

Using data to motivate action: the need for high quality, an effective presentation, and an action context for decision-making.

Three common barriers to the effective use of data to inform decisions and motivate action for the planning of cancer control are (1) failure to recognize the availability of high-quality data, (2) not presenting the data in a compelling format, and (3) failing to place the data in a historical and action context. Overcoming these barriers will go a long way toward demonstrating that high-quality data can be used to accomplish the desired outcomes in a Comprehensive Cancer Control (CCC) program. The article identifies existing sources of high-quality data, provides examples of effective presentation, and discusses successes in using data for program planning and implementation. The paper is not meant to provide a comprehensive discussion of using data for decision making, instead providing options to help key CCC stakeholders improve the effectiveness of their decisions as CCC plans are developed and implemented.

The evaluation of comprehensive cancer control efforts: useful techniques and unique requirements.

This article discusses evaluation of comprehensive cancer control efforts as developed in the United States by involved partners at all levels -- community, regional, state, tribal, territorial, and national. Evaluation of comprehensive cancer control can concern the evaluation of a program, a plan or activities from a plan. In its development, it is grounded in both theory and practice, and the results are used in program development and implementation to document activities, inform decision making, and demonstrate accountability. Various types of evaluation have been shown to be important. Challenges to evaluating comprehensive cancer control include incorporating and working with a broad group of stakeholders; developing an agreed upon plan and evaluation, ensuring the necessary infrastructure for overseeing, facilitating, and disseminating results of evaluations; conceptualizing and communicating desired changes; and potentially implementing (and evaluating) programs at the community, regional, tribal, territorial, state, or national level. Using the CDC Framework for Evaluation, selected examples of state program evaluations are presented. These examples show the use of both process and outcome evaluations to illustrate programmatic improvement and the accomplishment of proposed objectives. As evaluation of comprehensive cancer control continues to be developed and results communicated, our ability to evaluate comprehensive cancer control programs increases and the growth of comprehensive cancer control efforts are encouraged.

Reporting results in ossiculoplasty.

OBJECTIVE: To review and modify past methods of reporting ossiculoplasty results, improve analysis, standardize presentation formats, and achieve greater veracity of the reported outcomes. STUDY DESIGN: A review of past and present evaluation methods. BACKGROUND: Past ossiculoplasty evaluation methods have been often poorly comparable, based on questionable methodology, and frequently failed to adequately verify the results described. Guidelines set by the American Academy in 1995 to improve matters appear unsatisfactory in several respects. METHODS: Past evaluation techniques and the Academy modifications are examined for areas that may be subject to modification and improvement, particularly the choice of audiologic frequencies, the calculation of the air-bone gap, and the description of the pathologic findings within the caseload itself. FINDINGS: Some audiologic measures and disease evaluations are potentially inaccurate or inadequate. The Academy frequency selections may be flawed. Insufficient emphasis is given to the evaluation of case pathologic findings, which is the major factor pertinent in series comparisons and preoperative case prognostication. CONCLUSIONS: Further in-depth analysis of reporting methods is overdue. The matter is one of an international measure standard and should be subject to a global discussion, written and oral, to produce an adequately researched and formulated consensus. This in turn may provide the clinical and theoretical tools by which this troubled area can be more effectively analyzed.

Neomalleus ossiculoplasty.

OBJECTIVE: To evaluate the role of ossiculoplasty techniques using neomalleus struts combined with assembly prostheses, in middle ear reconstruction. STUDY DESIGN: A retrospective case review of 272 consecutive ossiculoplasty cases in which the malleus was replaced with an autograft strut. BACKGROUND: Current ossiculoplasty methods have experienced tangible difficulties, including extrusion and displacement (columellae), plus inefficiency and instability (assemblies). SETTING: Private single-surgeon tertiary referral otologic practice. PATIENTS: Ossiculoplasty candidates in whom the malleus was unsuitable for assembly reconstructions because of disease or malpositioning. INTERVENTIONS: Ossicular reconstructions using an autograft strut to replace an absent or malpositioned malleus, combined with Spanner assembly prostheses. MAIN OUTCOMES MEASURES: Pure tone audiology, subdivided into Austin groups, and also progressive pathologic severity groups, using Surgical, Prosthetic, Infection, Tissues, Eustachian (SPITE) indicators. RESULTS: Two months postoperatively, neomalleus cases returned favorable results in comparison with those of previous techniques, in equivalent situations. The technique appeared to be durable in the longer term. CONCLUSIONS: Neomalleus techniques offer enhanced success rates when the malleus handle is displaced, diseased, or absent.