Prolonged intra-operative thermal exposure in endoscopic ear surgery: is it really safe?

OBJECTIVE: The aim of this study was to assess change in temperature, audiometric outcomes and post-operative complications following exposure to different light sources during endoscopic ear surgery. METHOD: A total of 64 patients diagnosed with chronic otitis media with central perforation and pure conductive hearing loss underwent endoscopic type 1 tympanoplasty. The patients were randomised into two groups based on the light source used: xenon or light-emitting diode. Temperature was measured using a K type thermocouple at the promontory and round window niche. Mean temperature change with respect to operating time, mean audiometric change, incidence of vomiting in the first 24 hours, vertigo and tinnitus at the end of the first week were observed. RESULTS: Mean temperature change showed a statistically significant difference with increasing length of operating time with the xenon light source and when the two light sources were compared for a particular time interval. Mean audiometric change showed statistically significant deterioration at higher frequencies (4, 6 and 8 kHz) with the xenon light source but only at 8 kHz for the light emitting diode source. When the mean audiometric change was compared between light sources for a particular frequency, statistical significance was found at 4, 6 and 8 kHz. Post-operative complications were vomiting, vertigo and tinnitus (p-values of 0.042, 0.099 and 0.147, respectively, between two groups). CONCLUSION: Light emitting diodes are associated with less significant middle-ear temperature rises and audiometric changes at higher frequencies when compared to xenon light sources. Hence, xenon should be replaced with cooler light sources.

Investigating the learning curve in endoscopic compared to microscopic myringotomy and ventilation tube insertion.

OBJECTIVE: Rate of learning is often cited as a deterrent in the use of endoscopic ear surgery. This study investigated the learning curves of novice surgeons performing simulated ear surgery using either an endoscope or a microscope. METHODS: A prospective multi-site clinical research study was conducted. Seventy-two medical students were randomly allocated to the endoscope or microscope group, and performed 10 myringotomy and ventilation tube insertions. Trial times were used to produce learning curves. From these, slope (learning rate) and asymptote (optimal proficiency) were ascertained. RESULTS: There was no significant difference between the learning curves (p = 0.41). The learning rate value was 68.62 for the microscope group and 78.71 for the endoscope group. The optimal proficiency (seconds) was 32.83 for the microscope group and 27.87 for the endoscope group. CONCLUSION: The absence of a significant difference shows that the learning rates of each technique are statistically indistinguishable. This suggests that surgeons are not justified when citing 'steep learning curve' in arguments against the use of endoscopes in middle-ear surgery.

[Advances in the development of otologic surgery robots].

In recent decades, surgical robots have made great progress and are widely used in many clinical departments.It can eliminate the doctor's hands tremor, reducing postoperative complications and shortening the operation time due to the many advantages of robot such as stability, high precision and intelligence. Based on the huge economic benefits and good performance, the surgical robots have become a hot spot in the field of medicine and industry. Although no otologic robot has been approved for clinical use, many breakthroughs have been raised. This article reviewed the development of otologic robots in the past years and provided some ideas for future research.

Day-surgery in otology: Impact study of a dedicated organizational model.

AIM: Day surgery (DS) in otology in France is insufficiently implemented compared to other countries of comparable socio-economic level. The aim of the present study was to evaluate changes in surgical practice in "major otology" cases in a hospital center after launching a dedicated ENT DS unit. MATERIAL AND METHODS: This new unit, designed in collaboration with the surgeons, was inaugurated in 2014. Number of procedures, patient demographics, surgery durations, and rates of crossover from DS to conventional management were recorded prospectively for the year before and the year after the launch. All otologic surgery procedures with at least tympanomeatal flap elevation were included; minor surgeries such as grommet insertion were excluded. RESULTS: Between the two time periods, major otology day cases increased from 106 to 153 procedures (+43%). In 2013, the DS rate was 27%, versus 56% in 2015. Otosclerosis surgeries represented 7% in 2013 and 15% in 2015, and type II and III tympanoplasties 3% and 24% respectively. Difference in patient age between DS and conventional surgery was lower in 2015. Crossover rates were 10% in 2013 and 21% in 2015, mainly due to nausea/vertigo (56%) and surgery ending too late in the day (33%). CONCLUSION: Major otologic cases are suitable for DS. Launching this dedicated unit with its specific organization enabled a very significant increase in DS rates, probably due to greater patient satisfaction and surgeons' growing confidence. The main pitfall was in scheduling, with surgery ending too late in the day for discharge home; this has since been corrected.

The Current Limitations and Future Direction of Instrument Design for Totally Endoscopic Ear Surgery: a Needs Analysis Survey.

OBJECTIVE: This study aimed to identify limitations and challenges associated with existing instruments and techniques used in totally endoscopic ear surgery (TEES). BACKGROUND: Otologic instruments, traditionally developed for two-handed surgery with operating microscopes, are not necessarily optimized for the TEES environment. Better understanding of technical challenges and the limitations of current instrumentation may allow advances in instrument design for TEES surgery. METHODS: This cross-sectional study employed a mixed-methods nine-question survey that was distributed internationally to surgeons with an interest in TEES. Respondents were asked to classify their TEES experience and instrumentation used, rate their need for better instrumentation to address six TEES-related challenges using visual analog scales, and comment on how to modify or develop new instrumentation. RESULTS: With 51 respondents, we quantified a need for better instruments to address the following 6 potential TEES challenges ordered from greatest to least need: 1) reaching structures visualized by the endoscope, 2) dissection and removal of cholesteatoma, 3) cutting and/or removing bone, 4) bleeding control, 5) keeping the endoscope lens clean, 6) moving and positioning a graft into the intended place. The majority of surgeons perceive a need for improved instrumentation to address each challenge. Challenges 1) and 2) were associated with significantly greater need than the others (p < 0.05, Wilcoxon method for nonparametric pairwise comparisons). CONCLUSION: In addition to highlighting and quantifying some of the common TEES challenges, these findings provide valuable insight into the design requirements for developing improved surgical instrumentation and techniques.

Trend in otolaryngological surgeries in an era of super-aging: Descriptive statistics using a Japanese inpatient database.

OBJECTIVE: To reveal the age distribution and capture the longitudinal trend in otolaryngological surgeries performed in Japan, where society is rapidly aging. METHODS: Using the Diagnosis Procedure Combination database, we extracted data on patients who were hospitalized and underwent any type of otolaryngological surgery in departments of otolaryngology or head and neck surgery from fiscal year 2007 to fiscal year 2013. Type of surgery, patient's age, and fiscal year were compared. We categorized >200 types of surgeries into eight specialties: ear surgery, functional endoscopic sinus surgery (FESS), other types of paranasal surgery (except for malignancy), head and neck cancer surgery, benign tumor surgery, upper airway surgery (including pharynx and larynx), removal of foreign body, and other. RESULTS: In total, 558,732 patients were included. The proportions of patients in each age category formed two peaks in middle age and in children aged ≤9years. The proportion of all surgeries made up by FESS, other paranasal surgery, benign tumor surgery, and head and neck cancer surgery gradually increased with age, forming a peak in patients in their 60s. The proportion of ear surgery was highest in patients aged ≤9years (34.0% of all surgeries, mostly myringotomy and transtympanic ventilation tube insertion) and formed a gradual peak in patients in their 60s (mostly tympanoplasty). The proportion of upper airway surgery (tonsillectomy and adenoidectomy) was highest in patients aged ≤9years (25.3% of all surgeries). The proportion of foreign body removal was highest in patients aged ≤9years (52.2% of all surgeries) and increased slightly with age. In 2013, compared with 2007, those aged 65-74 years and ≥75years made up a larger percentage of patients undergoing each specific surgery, including tympanoplasty, stapedectomy/stapedotomy, FESS, head and neck cancer surgery, pharyngolaryngectomy, total/subtotal glossectomy, thyroid lobectomy, parotidectomy (for a benign tumor), submandibular gland resection, tonsillectomy, and vocal fold polypectomy. CONCLUSION: The age distribution of otolaryngological surgeries varied by specialty. We found an increased proportion of patients aged 65-74 and ≥75years in most specific surgeries.

Endoscopic ear surgery - a complement to microscopic ear surgery.

Wullstein, the founder of modern microscopic ear surgery, already used an oto-endoscope intraoperatively. However, it is only after the recent development of modern video-endoscopy with high-definition, 4K, and 3­dimensional imaging that endoscopically guided surgery of the middle ear is gaining some importance. Key ventilation routes like the isthmus tympani and the epitympanic diaphragm can be visualized far better using an endoscope than with a microscope. Going through the external meatus, surgery of middle ear pathologies is possible without external incision. This type of primary endoscopic ear surgery has to be distinguished from secondary endoscopic ear surgery, where standard microscopic ear surgery is supplemented by endoscopic surgery. Having to hold the endoscope in one hand, surgery has to be performed single-handedly, which is awkward. In cases of extensive bone removal or excessive bleeding, the view through the endoscope lens is obscured; therefore; the endoscope cannot fully substitute the microscope. It is, however, an interesting adjunct to microscopic ear surgery.

Evolution in surgical management of superior canal dehiscence syndrome.

PURPOSE OF REVIEW: This manuscript will review the progression of surgical techniques currently being used to repair a defect in the superior semicircular canal in symptomatic patients. Originally described via the middle cranial fossa route, larger series of patients have been demonstrated through less invasive approaches. These new innovative approaches will be discussed. RECENT FINDINGS: Recently, the surgical indications for the repair of superior canal dehiscence have been broadened. As a result, several surgical techniques have been demonstrated to limit inherent risks to patients while still adequately treating the symptoms known to be associated with superior canal dehiscence. Transmastoid plugging, transmastoid resurfacing, endoscopic resurfacing and endaural approaches will be described and recent results discussed. SUMMARY: Although the optimal surgical approach for superior canal dehiscence has yet to be determined, clearly a progression in techniques has been demonstrated. Surgical management of superior canal dehiscence syndrome began requiring a craniotomy but has now progressed to transmastoid and even endaural approaches.

Introducing endoscopic ear surgery into practice.

The otolaryngologist will find in this article a direct and frank discussion and useful advice for how to get started performing solely endoscopic ear surgery for abnormalities of the middle ear. The author provides discussion and photos based on his experience with this procedure. Presented herein are selection of the endoscope, how to approach the first fully endoscopic procedure, patient selection, preoperative planning, setting up the operating room, pitfalls typically encountered, and how to gain skills to perform this procedure successfully.

Microsurgery versus stereotactic radiation for small vestibular schwannomas: a meta-analysis of patients with more than 5 years' follow-up.

OBJECTIVE: To compare the long-term outcome of hearing and tumor outcome of small vestibular schwannomas treated with stereotactic radiation and microsurgery. DATA SOURCES: A thorough search for English-language publications and "in process" articles dating from 1948 to December 2011 was conducted using Ovid MEDLINE. STUDY SELECTION: The principal criteria were patients having had microsurgery or radiation therapy as their sole treatment, with a follow-up of at least 5 years, and a useful hearing level at diagnosis. DATA EXTRACTION: Sixteen studies met our criteria. Hearing preservation outcome (worse or preserved) and tumor outcome (failure, control) data, as well as all other significant observations, were collected from the articles. Stereotactic radiation was the only radiation therapy analyzed. DATA SYNTHESIS: The Pearson χ test was our primary statistical analysis. CONCLUSION: Stereotactic radiation showed significantly better long-term hearing preservation outcome rates than microsurgery (p < 0.001). However, long-term tumor outcome was not significantly different in stereotactic radiation as compared with microsurgery (p = 0.122). Although stereotactic radiation demonstrates a more favorable long-term hearing preservation outcome as compared with microsurgery, additional studies are required to provide the medical field with a better understanding of vestibular schwannoma treatment.

Evolution in management of otogenic brain abscess.

OBJECTIVE: To present the therapeutic results related with treating 103 patients with cerebral abscesses of otogenic origin during 3 various time frames (1953-1977, 1978-1989, and 1990-2011). PATIENTS: A total of 103 patients with cerebral abscess of otogenic origin. INTERVENTIONS: Diagnostics and treatment. MAIN OUTCOME MEASURES: Analysis of mortality rates, abscess location and its basis, coexisting complications, neurological condition at admittance, bacteriological tests, and presentation of the results of abscess treatment with the use of neuronavigation. RESULTS: Mortality rates dropped systematically from the initial value of 35% observed between 1953 and 1977, to 14% between 1978 and 1989, and finally reached 3% between 1990 and 2011. Abscesses were mainly located within the temporal lobe. They predominantly resulted from chronic inflammation of the middle ear. A wide panel of complications was associated with them. Strong concurrence between results of cultures taken from the ear and the abscess was noted. CONCLUSION: Cerebral abscesses remain one of the most severe complications related with inflammation of the middle ear. Both the operative methods and the postoperative care evolved (introduction of surgical microscope, new generation of antibiotics), the preoperative diagnostics facilitating the diagnosis and localization of the abscess progressed; nonetheless, the principles underlying the operative treatment remained unchanged. Neuronavigation constitutes a very important and supportive element in the management of otogenic brain abscesses.

Time trend analysis of mastoidectomy procedures performed in Ontario, 1987-2007.

CONCLUSIONS: There has been a reduction in the number of modified radical mastoidectomy and revision mastoidectomy surgeries per head of population in Ontario between 1987 and 2007, we believe that this represents a true reduction in prevalence of cholesteatoma. The increase of cases performed at the University Hospital Network, Toronto (UHN) may represent a shift to subspecialization in the treatment of chronic ear disease. OBJECTIVE: To analyze the trends in mastoid operations for chronic middle ear disease in the Canadian province of Ontario between 1987 and 2007 and to determine whether an increasing proportion of these procedures are being performed in tertiary referral centres. METHODS: The year on year population and number of mastoid procedures performed per year in Ontario and at the UHN between 1987 and 2007 were obtained from Statistics Canada and the Ministry of Health and Long-Term Care, Ontario, respectively. Population-adjusted rates of mastoid surgery for Ontario and the UHN. These data were collated and graphically represented for trend analysis. RESULTS: The population-adjusted number of mastoid procedures for Ontario declined from 7.1 cases per 100,000 in 1986 to 4.1 cases per 100,000 in 2006. During this time the number of both modified radical mastoidectomies and revision mastoid surgeries at UHN increased.

[Surgical treatment of vestibular vertigo: methods and indications]. / Die operative Therapie des vestibulären Schwindels: Verfahren und Indikationen.

After the failure of medical treatment of dizziness or vertigo, surgical treatment is chosen according to functional diagnosis and duration and severity of symptoms. Surgery is contraindicated in patients with incomplete vestibular compensation, central nervous disorders and bilateral vestibular deficits. Surgery is obligatory in cases of sudden loss of labyrinthine function with traumatic perilymph fistula, middle ear and temporal bone processes. Endolymphatic hydrops and pathological endolymph pressure of other etiology as impaired middle ear ventilation, EVAS or superior semicircular canal dehiscence can be treated surgically. Resurfacing of dehiscence with glas ceramic implants is presented. Occlusion of the posterior semicircular canal is restricted to extremely rare conditions with non-responders to repositioning maneuvers. Ablative procedures, such as cochleosacculotomy and vestibular neurectomy are rarely indicated. More than 85% of non-responders to conservative treatment procedures in vestibular dysfunction can be improved by means of surgical procedures. Otologists have access to procedures for differentiation, indications and therapy via the network of general practitioners and hospital physicians.

Manejo quirúrgico y recurrencia de la fístula preauricular congénita / Surgical management and recurrence of congenital preauricular fistula

El artículo describe el manejo quirúrgico y recurrencia postoperatoria de la fístula preauricular (FPA) ya que el tratamiento quirúrgico se caracteriza por elevada recurrencia. Los antecedentes clínicos, operatorios y postoperatorios fueron recogidos retrospectivamente de expedientes de pacientes que fueron sometidos a manejo quirúrgico primario de la FPA en cinco hospitales en Guadalajara, Jalisco, durante el periodo de enero 2001 a diciembre 2006. Un total de 44 escisiones de FPA se realizaron en 38 pacientes (15 hombres, 23 mujeres).Infección recurrente y secreción fueron los síntomas más comunes. El manejo quirúrgico incluyó 25 intervenciones con técnica estándar(sinectomía) y 19 abordajes supra-auriculares. La recurrencia global ocurrió en el 59% de las FPA y difirió ampliamente entre las técnicas utilizadas. Con la técnica estándar, la recurrencia fue significativamente elevada 52,2 vs 6,8% resultante mediante el abordaje supraauricular (p= 0,01). También, los pacientes en quienes no se realizó escisión de la raíz del hélix, 84,6% recurrieron vs 15,3% cuando el cartílago fue extirpado (p=0,01). Los resultados muestran que, independientemente de la presentación clínica de la FPA, la técnica estándar y la falta de escisión de la raíz del hélix contribuyeron a recurrencia. Recomendamos el abordaje supra-auricular, en particular en casos con historia de abscesos (AU)

In this paper we describe the surgical management and postoperative recurrence of preauricular fistula (PAF) since the surgical treatment is characterized by high recurrence rates. All clinical, operative and postoperative data were collected from a retrospective review of patients’s charts who underwent primary surgical management between January 2001 and December 2006 at five Hospitals in Guadalajara, Jalisco. Thirty-eight patients (15 male, 23 female) with PAF underwent 44 surgical procedures. Recurrent acute infection and discharge were the most common symptoms. The surgical management included 25 standard techniques (sinectomy) and 19 supra-auricular approaches. The overall rate of recurrence was 59%, it differed widely between surgical techniques employed. The 52.2% recurrence rate of standard technique was significantly higher than the 6.8% recurrence rate of the supra-auricular approach (p = 0.01). Also, the patients in whom a portion of the cartilage of the helix was not excised from the base of the tract, 84.6% recurred vs. 15.3% when cartilage was excised (p = 0.01). Our experience has shown that independently of clinical presentation of PAF, the standard technique and not to remove a portion of the cartilage at the base of the helix contributed to recurrence. We advise the supra-auricular approach particularly when there are abscess prior to surgery (AU)

Time trend analysis of otological procedures performed in England, 1989 to 2005.

OBJECTIVE: To observe trends in the number of major otological procedures performed in England, in the context of advances in the understanding of disease. METHODS: The data used were obtained from the Hospital Episode Statistics statistical database, published by the UK Department of Health, for England, 1989 to 2005. Specific otological procedures were identified using the Classification of Surgical Operations and Procedures system (fourth revision) of the Office of Population, Censuses and Surveys. Trend analysis of different procedures was performed using exponential smoothing (using the Statistical Package for the Social Sciences version 13 software). RESULTS: Our study did not confirm any reduction in the number of surgical procedures performed for cholesteatoma or otosclerosis. We noted a sharp decline in the number of endolymphatic sac surgical procedures performed, probably attributable to the increased use of intratympanic therapy. CONCLUSION: The number of major otological procedures (other than endolymphatic sac surgery) was consistent over the period examined. The generally perceived reduction in the number of procedures performed by individual surgeons may be due to a dilutional effect. This can only support the need for subspecialisation, particularly regarding the training of junior surgeons.