Study of morphologic variability of incudostapedial angle and its relation with temporal bone pneumatization.

INTRODUCTION: Optimal sound transmission across the ossicular chain is dependent on the appropriate alignment of the middle ear ossicles. Incudostapedial joint (ISJ) is conventionally considered to be at right angle. OBJECTIVE: We intended to study the ISJ anatomy and the impact of temporal bone pneumatization on the same. METHODS: In a cadaveric study comprising of 47 human temporal bones, canal wall down mastoidectomy was carried out under microscopic guidance keeping the ossicular chain intact. The morphology of ISJ was recorded and analysed with respect to the pneumatization status of the temporal bone. The data analysis was performed using statistical software Stata version 12.0. RESULTS: The mean ISJ angle for the 47 bones was 90.50 (SD-150; range:540-1220). The mean angle in well pneumatized bones was 93.70 (SD-16.5; Range:54°-1220) and in sclerotic mastoids was 88.70 (SD-14; Range:68°-1180). The difference in the ISJ angle in these two conditions was not statistically significant (p = 0.27). The mean angle was found to be significantly more obtuse in the cases with partially eroded ISJ (111.40 {SD-8.8; range:100.30-121.90}; p = 0.0001) and in the cases with an 'adherent/tilted morphology' of the stapes suprastructure with the promontory (mean-95.80{SD-13.8; range:70.70- 120.40); p- <0.00001). CONCLUSION: The ISJ angle shows considerable variations. This variability needs to be taken into account when undertaking middle ear reconstructive procedures, specifically the ones involving the stapes footplate. The mastoid pneumatization does not appear to have an impact on the ISJ angle.

Comparing Outcomes of the Standard Technique of Endoscopic DCR with Its Modifications: A Retrospective Analysis.

OBJECTIVE: To compare the outcomes of various techniques of endoscopic dacryocystorhinostomy (DCR). STUDY DESIGN: Retrospective case record analysis. SETTINGS: Tertiary care referral center. SUBJECT AND METHODS: Retrospective analysis of case records was carried out pertaining to the period from January 1996 to September 2017 with respect to patients who had undergone endoscopic DCR with either the standard technique or one of its modifications. Case notes showing well-documented preoperative evaluation, operative details, postoperative assessment, and minimum 6-month follow-up were considered. The outcomes were measured on the basis of patients' postoperative symptoms, clinical examination, and sac-syringing results. RESULTS: A total of 423 patients were included in the study. Of these, 169 underwent standard endoscopic DCR; 87, endoscopic DCR with stent; 19, endoscopic DCR with mitomycin C; 62, powered DCR; 29, laser-assisted DCR; and 57, balloon DCR. There was no statistically significant difference in success rates, recurrences, or complications of various techniques at 3 or 6 months. Mean operating time was lowest for balloon DCR (mean ± SD, 27.1 ± 3.1 minutes), followed by standard endoscopic DCR (38.2 ± 3.6 minutes; P = .001). CONCLUSION: Standard endoscopic DCR and its more sophisticated modifications were equally effective and safe in managing distal nasolacrimal drainage obstruction. Balloon DCR, followed by standard endoscopic DCR, was significantly faster than other techniques.

Salvaging cochlear implant after wound infection: Well worth a try.

BACKGROUND: Cochlear implant (CI)-related wound infections are known to happen even years after the implant procedure and present a challenging clinical situation. Due to the formation of biofilm on the implant surface such infections are difficult to eradicate. Invariably explantation of the device is required for wound healing. METHOD: A 10-year-old patient presented with recurrent CI-related wound infection 8 years after implantation. The implant was salvaged with wound debridement and treating it with tea tree oil which is known for its biofilm eradicating properties. It was then covered with double layer of vascularised soft tissue. Combination of intravenous vancomycin and oral rifampicin known for their efficacy in biofilm-related infection was also used. RESULTS: The implant could be salvaged using this novel technique of treating the implant with a biofilm eradicating agent, wound debridement, double layer vascularised soft tissue cover, and long-term antibiotics. CONCLUSION: Agents having anti-biofilm activity when used in conjunction with surgical debridement and judicious antimicrobial therapy can be used for salvaging the implant and limiting the morbidity associated with these infections.