Is cartilage interposition required for ossiculoplasty with titanium prostheses?

OBJECTIVE: To demonstrate that cartilage interposition between the head of a titanium prosthesis and the tympanic membrane is not necessary to prevent extrusion. STUDY DESIGN: Retrospective review. SETTING: District general hospital. PATIENTS: A retrospective review of 73 ears in patients aged between 5.9 and 64.5 years, which had an ossiculoplasty performed using a titanium prosthesis between the stapes footplate or stapes head and the tympanic membrane. INTERVENTIONS: Use of Spiggle and Theis two part, shortenable titanium PORP and TORP and Grace Alto titanium TORP and PORP. MAIN OUTCOME MEASURES: Number of extruded prostheses. Audiometric results. RESULTS: Five extrusions occurred in 4 patients, follow-up between 6 and 98 months. Extrusions were related to retraction of the tympanic membrane around the prosthesis. Audiometric results compared favorably with other ossiculoplasty techniques. CONCLUSION: The titanium head of the Spiggle and Theis and Grace Alto titanium prostheses interact well with the undersurface of the tympanic membrane in patients with favorable middle ear conditions. In our experience, cartilage interposition is not mandatory.

Blood transfusion requirements for endoscopic sinonasal inverted papilloma resections.

BACKGROUND: Endoscopic resection of sinonasal Inverted Papilloma (SNIP) tumors has been shown to reduce intra-operative blood loss and recovery time compared to open approaches. The purpose of this study is to investigate the incidence and requirements of blood transfusion for endoscopic SNIP surgeries. METHODS: An individual retrospective cohort study of endoscopic SNIP surgeries over a 10-year period was performed. Age, sex, pre-existing co-morbidity, use of anti-coagulants, tumor type and stage, time of surgery, estimated blood loss and the requirement for blood transfusion were recorded. RESULTS: 82 patients were included (57 males, 25 females). 4 (5%) Stage 1, 7 (8.5%) Stage 2, 62 (75.5%) Stage 3 and 9 (11%) Stage 4 SNIP tumors were identified according to the Krouse staging system. 3 (4%) patients required blood transfusion. 3 of the 9 (33%) Stage 4 tumors required blood transfusion. Stage 4 tumors were significantly associated with blood transfusion (p < 0.05). Higher staged tumors were associated with greater blood loss (p < 0.05) than lower staged cases. No other tumor stage required blood transfusion and no other pre-operative variable was associated with requirement for blood transfusion. CONCLUSION: Endoscopic SNIP resections rarely require blood transfusions. No pre-operative factor other than tumor stage is associated with the requirement for blood transfusion. We would therefore suggest that only Stage 4 SNIP tumors require pre-operative type and screen.

Validation of a grading system for the attachment of the superior turbinate to the sphenoid face.

BACKGROUND: The attachment of the superior turbinate to the sphenoid face may be an important factor in determining the approach for sphenoidotomy. We sought to validate a previously described 4-type grading system for superior turbinate attachment (Type: A, within its medial one-third; B, in its middle one-third; C, to its lateral one-third; and D, directly to the orbit) to the face of the sphenoid sinus and to make recommendations for its use in determining the method of sphenoidotomy (transethmoidal vs transsphenoethmoidal). METHODS: Single-slice images through both sphenoid sinus ostia were obtained from axial series of computed tomography (CT) scans. Eighteen (36 ostia) sets of scans were used. Attachment type (A-D) in each image was classified by 10 experienced sinus surgeons and compared against a "gold standard" grading performed by the senior author (A.J.), who was the developer of the grading system. RESULTS: Mean accuracy was 63% (95% confidence interval [CI], 54%-72%) for the 4-type grading system. When Types A+B and Types C+D were grouped together, mean accuracy was 91% (95% CI, 84%-97%). For the 2-group classification system, bootstrap analysis suggested that 97% of physicians attain an accuracy of at least 80%. CONCLUSION: Accuracy using the 4-type classification is too low to be practically useful. Accuracy using the 2-group system may be sufficiently high to be a useful aid in selecting a surgical approach. We recommend a transethmoid sphenoidotomy for Types A and B and a transsphenoethmoidal approach to the sphenoid for Types C and D.

Blood transfusion requirements for endoscopic sinonasal inverted papilloma resections.

BACKGROUND: Endoscopic resection of sinonasal inverted papilloma (SNIP) tumours has been shown to reduce intraoperative blood loss and recovery time compared to open approaches. OBJECTIVE: The purpose of this study was to investigate the incidence and requirements of blood transfusion for endoscopic SNIP surgeries. STUDY DESIGN: Individual retrospective cohort study. SETTING: St. Paul's Sinus Centre, a tertiary referral rhinology centre. METHODS: An individual retrospective cohort study of endoscopic SNIP surgeries over a 10-year period was performed. Age, sex, pre-existing comorbidity, use of anticoagulants, tumour type and stage, time of surgery, estimated blood loss, and requirement for blood transfusion were recorded. MAIN OUTCOME MEASURES: Incidence of blood transfusion, type and screen, and crossmatch requisitions. RESULTS: Eighty-two patients were included (57 males, 25 females). Four (5%) stage 1, 7 (8.5%) stage 2, 62 (75.5%) stage 3, and 9 (11%) stage 4 SNIP tumours were identified according to the Krouse staging system. Three (4%) patients required blood transfusion. Three of the nine (33%) stage 4 tumours required blood transfusion. Stage 4 tumours were significantly associated with blood transfusion (p < .05). Higher-staged tumours were associated with greater blood loss (p < .05) than lower-staged cases. No other tumour stage required blood transfusion, and no other preoperative variable was associated with the requirement for blood transfusion. CONCLUSION: Endoscopic SNIP resections rarely require blood transfusions. No preoperative factor other than tumour stage is associated with the requirement for blood transfusion. We therefore suggest that only stage 4 SNIP tumours require preoperative type and screen testing.

Topical anaesthetic or vasoconstrictor preparations for flexible fibre-optic nasal pharyngoscopy and laryngoscopy.

BACKGROUND: Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. OBJECTIVES: To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. SELECTION CRITERIA: Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. MAIN RESULTS: We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste.There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta-analysis. AUTHORS' CONCLUSIONS: The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre-optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed.