The socio-demographic determinants of the outcome of type 1 cartilage tympanoplasty in children: Results from a tertiary-care teaching institute in India.

OBJECTIVE: To explore whether and how the established socio-demographic parameters pertaining to a lower-middle income nation influence the outcome of cartilage tympanoplasty in children with chronic otitis media (COM), inactive mucosal variety. METHODS: In this prospective cohort study, children aged 5-12 years with COM (dry, large/subtotal perforation) were considered for type 1 cartilage tympanoplasty following definite selection criteria. Relevant socio-demographic parameters were noted for each child. These included parents' education (literate/illiterate), living area (slum/village/others), mothers' occupation (laborer/business/housewife or home-maker), family type (nuclear/joint), and monthly family income. Outcome at 6 months follow-up was interpreted as "success" (favorable; anatomically intact and well-epithelialized neograft and dry ear) and "failure" (unfavorable; residual or recurrent perforation and/or discharging ear). The role of individual socio-demographic factor in determining the outcomes was analyzed with relevant statistical methods. RESULTS: The average age of the 74 children included in the study was 9.30 ± 2.13 years. At six months, 86.5% had a successful outcome, with a statistically significant hearing gain (closure of the air-bone gap) of 17.02 ± 8.96 dB (p = .003). Mothers' education had a significant influence on the success rate (Chi: 4.13; significant at p < .05); children of ∼97% of the literate mothers had a successful outcome. Living area was significantly associated with success (Chi: 13.94; significant at p < .01); ∼90% of children living in the slum areas had success, compared to 50% of those residing in villages. The family type also significantly influenced the surgical outcome (Chi: 3.81; significant at p < .05); ∼97% of the children belonging to the joint families encountered success, compared to ∼81% of those brought up in the nuclear families. The success also depended on the mothers' occupation (Chi: 6.47; significant at p < .05); ∼97% of the housewife mothers had children who were successful, against ∼77% of mothers engaged as laborers. Another factor significantly associated with success was the monthly household income. Nearly 97% of the children belonging to families with a monthly household income of >₹3000 (cut-off limit set by the median value) experienced success, in contrast to 79% of those having a monthly family income of <₹3000 (Chi: 4.83; significant at p < .05). CONCLUSION: Socio-demographic parameters are valuable determinants of the outcome of surgical management of COM in children. For type 1 cartilage tympanoplasty, mothers' education and occupation, family type, living area, and monthly family income significantly influenced the surgical outcome.

Sequestered, Iatrogenic Epidermoid Implantation Cysts Associated With Retroauricular (Wilde's) Incision.

OBJECTIVE: To report two patients with iatrogenic, epidermoid implantation cysts associated with the standard retroauricular (Wilde's) incision, to establish their etiology, to explore means to prevent them, and to ensure that this experience adds to the learning curve of the surgical training of the residents. METHODS: Case series with the review of literature. RESULTS: One of the two patients, who had an unremarkable follow-up period after cortical mastoidectomy and cartilage tympanoplasty performed three years back, presented with a retroauricular cystic swelling visible since two months. It was hyperintense on T2-weighted magnetic resonance imaging. A sequestered cystic mass was encountered at surgery in the subcutaneous plane in association with the retroauricular scar tissue from previous surgery. In the other patient, two similar cysts (one of them sequestered) were incidental findings at revision tympanomastoid surgery. Histopathology in both instances was consistent with epidermoid cyst. Given their subcuticular location and intimate association with a pre-existing surgical scar, they were considered to be of implantation in origin. This was a potential outcome of persistent inversion of one or both skin edges following simple interrupted suturing. The reason could be a faulty surgical technique, due to improper placement of the needle with respect to skin, inadequate or uneven tissue bite, a tight knot, or failure to manually evert the apposing edges at the point(s) of suspicion. CONCLUSIONS: Sequestered epidermoid implantation cysts due to persistent inversion of sutured skin edges are unusual complications. The illustrations in this case series emphasize the need to adhere to the basic principles of surgical practice. They provide a caveat to the resident surgeons and the faculties who supervise them, that inadvertent and apparently innocuous misses, even at the elementary steps of surgery (like suturing), could lead to complications that are unwanted and potentially avoidable.

Endonasal endoscopic removal of intra-orbital (extralacrimal, extraconjunctival) oculosporidiosis: Anatomical and surgical considerations.

This report illustrates the successful removal of a proper intra-orbital oculosporidiosis (extralacrimal, extraconjunctival) exclusively by the endonasal endoscopic approach. It also introduces the naso-orbital pseudofontanelle as an important surgical landmark and describes a hitherto undefined intra-orbital extramucosal three-dimensional potential wedge that harbored the Rhinosporidium seeberi infestation as a nodular conglomerate. The patient, a 50-year-old woman, was operated on three years ago for rhinosporidiosis of the nasal cavity and the distal lacrimal drainage system (lacrimal sac and nasolacrimal duct). The resulting alterations in regional anatomy were evident on imaging. They could explain the present recurrence and formation of the pseudofontanelle that allowed the conglomerate to bulge through the lateral nasal wall on digital pressure, making endoscopic intervention feasible. The primary principle for adopting this approach was to protect the facial skin from possible seeding. With an angled endoscope, the pseudofontanelle was breached and the intra-orbital extramucosal wedge between the bony orbital wall and the peri-orbita entered. The nodules that formed the conglomerate were densely adherent with the peri-orbita and skin. They were carefully and meticulously removed to avoid inadvertent injury to vital intra-orbital structures. Endonasal endoscopic intervention for a true intra-orbital oculosporidiosis has never been documented before. The surgical approach, the newly defined anatomical domain for the intra-orbital extramucosal oculosporidiosis, and the concept of pseudofontanelle characterize this report as a novel clinical experience worth presenting.