Experiences of Percutaneous Endoscopic Approach for the Mastoid Lesions: A Novel Minimally Invasive Ear Surgery.

OBJECTIVES: We developed a novel keyhole surgery, named "percutaneous endoscopic ear surgery" (PEES), with the aim of further reducing the invasiveness of otologic surgery. We reported the cases we encountered and retrospectively analyzed the invasiveness of PEES. METHODS: We analyzed the ears of eight patients who underwent PEES for mastoid lesions that could not be manipulated with transcanal endoscopic ear surgery (TEES) at our hospital between July 2021 and November 2022. We performed PEES alone in three patients, including one case of type A (preauricular incision) and two cases of type B (retroauricular incision). The last five patients underwent combined endoscopic ear surgery, which is simultaneous PEES and TEES. In these cases, one patient underwent type A PEES, and four patients underwent type B PEES. RESULTS: PEES was performed in all patients without converting to conventional microscopic mastoidectomy. The mean length of skin incisions was 19.1 ± 4.5 mm, which was smaller than that in conventional mastoidectomy. In all cases, the average length of the major axis of the keyhole was <10 mm, indicating that sufficient minimally invasive surgery was achieved. The average depth from the keyhole to the deepest site was 21.6 ± 8.9 mm. There was no change in the mean hearing level before and after the surgery. CONCLUSION: PEES is a minimally invasive procedure for manipulating lesions in the mastoid. In addition, the combination of PEES and TEES is an ideal, minimally invasive procedure that can be used to treat all regions of the temporal bone.

Hearing rehabilitation in children with malformed ears: The endoscopic-assisted approach for cochlear implantation.

BACKGROUND: Cochlear implantation (CI) in children with malformed ears can be challenging through the standard surgical technique. Several alternative approaches have been described. The endoscopic-assisted approach can be chosen as an effective and safe surgical technique, overcoming the drawbacks of the traditional approach. MATERIAL: We further describe a combined technique based on a limited mastoidectomy with no posterior tympanotomy and an endoscopic transmeatal approach to the round window (RW): the electrode is driven from the mastoid to the middle ear through the attic. RESULTS: The concomitant endoscopic assistance allows for improved surgical vision, reducing the risk of major complications. The main advantages of this technique are related to better visualization of the RW for safe insertion of the electrode; avoidance of damage to the facial nerve (FN), due to direct visualization, and sparing the posterior tympanotomy; avoidance of subtotal petrosectomy, if not necessary. CONCLUSION: The purpose of this article, supported with a video file, is to describe step by step this endoscopic-assisted procedure in a patient with middle ear malformation.

The growth of the mastoid volume in children with a cochlear implant.

The aim of this study was to understand the mastoid volume development in children who undergo cochlear implantation surgery. Cochlear implant (CI) database of our clinic (Kuopio University Hospital) was reviewed for computed tomography (CT) images of CI patients (age under 12 years at the time of implantation) with a minimum time interval of twelve months between their pre- and postoperative CT. Eight patients (nine ears) were found eligible for inclusion. Three linear measurements were taken by using picture archiving and communication systems (PACS) software and the volume of the MACS was measured with Seg 3D software. The mastoid volume increased on average 817.5 mm3 between the pre- and the postoperative imaging time point. The linear distances measured between anatomical points like the round window (RW)- bony ear canal (BEC), the RW-sigmoid sinus (SS), the BEC-SS, and the mastoid tip (MT)-superior semicircular canal (SSC) increased significantly with the age of the patient at both the pre-op and post-op time points. The linear measurements between key anatomical points and mastoid volume showed a positive linear correlation. The correlation between linear measurement and volume were significant between the MT-SSC (r = 0.706, p = 0.002), RW-SS (r = 0.646, p = 0.005) and RW-BEC (r = 0.646, p = 0.005). Based on our findings from the CI implanted patients and comparing it with the previous literature findings from non-CI implanted patients, we could say that the CI surgery seem to have no effect on the development of mastoid volume in children.

Benefits of medially based perichondrio-adipo-dermal flap in cartilage sparing prominent ear surgery.

BACKGROUND: Cartilage-cutting and cartilage-sparing techniques are the two types of otoplasty procedures. Because of the significant risk of haematoma, skin necrosis, and ear deformity, cartilage-cutting techniques have been questioned. As a result; suture-based cartilage-sparing procedures such as Mustarde and Furnas suture procedures have grown in popularity. However, these techniques have a tendency for deformity recurrence due to cartilage memory and suture fatigue, as well as the possibility of suture extrusion and pinpricking sensation of the sutures. METHODS: In this study, we used a medially based adipo-dermal flap including perichondrium which is elevated from the back of the auricle to cover and support a cartilage-sparing otoplasty, thirty-four patients (14 female and 20 male) were operated using this technique. The medially based perichondrio-adipo-dermal flap is advanced anteriorly and fixed to the helical rim under cover of the distal skin flap. This procedure sought to cover the suture line preventing suture extrusion and support in the repair of the deformity preventing its recurrence. RESULTS: The average operative time was 80min, ranging from 65 to 110min. The patients passed the early postoperative period uneventfully except for 2 patients; one patient (2.9%) developed haematoma, and the other patient developed a small area of necrosis on the new antihelical fold. In late the postoperative period recurrence of the deformity developed in one patient. No patients developed suture extrusion or granuloma. CONCLUSION: The treatment to repair prominent ears is easy and safe, with benefits such as a natural-looking antihelical fold and minimal tissue stress. The medially or proximally based adipo-dermal flap may help to lower recurrence rates and suture extrusion.

Ear and Nose Foreign Body Removal in Pediatric Patients.

Pediatric patients frequently present to emergency departments with complaint of foreign bodies in the ear and/or nose. Emergency nurse practitioners need the knowledge base to safely and effectively manage ear and nose foreign bodies in urgent and emergent care settings. The purpose of this article is to teach the common anatomical sites where foreign bodies are placed, the make-up of foreign body material, procedural technique of removal, and specific circumstances that require specialty referral.

To drain or not to drain following posttraumatic ear reconstruction with Dieffenbach's postauricular flap in patients with antithrombotic therapy.

PURPOSE: To measure the association between drainage use and postoperative complications (POCs) after posttraumatic ear reconstruction (PTER) with Dieffenbach's postauricular flap (DPF) in patients with antithrombotic therapy (ATT). METHODS: This was a retrospective double-cohort study of patients undergoing posttraumatic DRF with vs. without drainage in 4 maxillofacial units during a 7-year interval. The primary predictor variable was drainage use, and the main outcome was POCs (i.e., auricular haematoma and infection). Descriptive, bi- and multivariate statistics were computed with P ≤ 0.05 defined as statistically significant. RESULTS: The sample was composed of 365 unilateral PTER patients (14% POCs, 15.6% ATT, 34.5% females) aged 58.1 ± 19.7 years (range, 18-101). Among subjects with ATT, drainage use significantly reduced POCs (OR, 0.5; 95% CI, 0.3 to 0.8; P = 0.009; absolute risk reduction [ASR], 34.04%; NNT, 3), especially when delayed surgery > 5 h after trauma was evident (forward stepwise logistic modelling: OR, 20.6; 95% CI, 2 to 215.9; P = 0.012). Drainage placement under DPF in ATT patients with smoking habit, concomitant diseases (e.g. diabetes mellitus), ear cartilage loss, or wound contamination almost halved POC rates (ASR, 34.5 ± 12.1%; range, 22.1% to 49%). Patient's age, gender, American Society of Anesthesiologists (ASA) class, alcohol misuse, ATT and antibiotic type, and international normalised ratio (INR) before surgery had no meaningful effect on POCs. CONCLUSIONS: Drainage should be placed under DPF in patients with ATT, regardless of age, gender, ATT and antibiotic type, and preoperative INR.

Dogs with cropped ears in the UK: A population-based study using electronic health records.

BACKGROUND: Ear cropping for cosmetic purposes was made illegal in the UK in 2006. Despite this, a lack of import regulations and celebrity and media influences mean cropped dogs are increasingly reported. METHODS: The demographics, temporal trends and patient-level associated factors for dogs with cropped ears were evaluated in a large sentinel population of dogs visiting UK veterinary practices. RESULTS: A total of 132 dogs with cropped ears were identified, with rates peaking in 2021. In 84 cases (63.6%), there was evidence of importation, most commonly from countries where cropping is also illegal, including Romania, Hungary, Bulgaria, Serbia, Spain, Poland and Ireland. American Bulldogs, Dobermanns, Italian Mastiffs (Cane Corso), Bulldogs and Mastiffs were all significantly overrepresented. Affected dogs were more likely to be unneutered (odds ratio 11.04, 95% confidence interval 5.84-20.90). LIMITATIONS: The study likely underestimates true levels of ear cropping. Identified cases are from a sentinel network of veterinary practices, and as such may not be representative of the wider UK population. CONCLUSION: These data suggest a need to educate owners and veterinary surgeons about the welfare and legal implications of ear cropping. The data presented can inform future targeted policies in veterinary practices and at a governmental level.

[Hearing rehabilitation with the Vibrant Soundbridge in patients with congenital middle ear malformation]. / Die Vibrant Soundbridge zur Versorgung von Patienten mit kongenitalen Mittelohrfehlbildungen.

BACKGROUND: Congenital aural atresia, which is usually unilateral, causes hearing loss and aesthetic impairment. Besides tympanoplasty with/without canalplasty and bone conduction devices, active middle ear implants are also available for functional rehabilitation. OBJECTIVE: This article aims to present a contemporary review on the treatment possibilities for middle ear malformations, with a focus on audiological rehabilitation with the Vibrant Soundbridge. MATERIALS AND METHODS: A selective literature search for treatment possibilities was performed in PubMed up to October 2020, and personal clinical experiences are reported. RESULTS: The Vibrant Soundbridge, which is approved for children ≥ 5 years, is suitable for treatment of middle ear malformations with a Jahrsdoerfer score ≥ 5. Although implantation of a Vibrant Soundbridge is surgically more demanding than implantation of a bone conduction device, the method is safe, delivers good auditory results (superior to bone conduction devices in terms of speech understanding and spatial hearing), does not involve intensive postsurgical care, and rarely requires revision surgery. The Vibrant Soundbridge can be coupled to (remnants of) the ossicular chain or the round window. CONCLUSION: The Vibrant Soundbridge is an appropriate treatment method in patients with middle ear malformations who have suitable anatomical preconditions.

Repair of auricular defects following Mohs micrographic surgery or excision: a systematic review of the literature.

Repair of auricular defects following tumor removal can be challenging. Many techniques have been described, but the literature lacks a comprehensive review of these methods. To perform a systematic review to compile and describe methods of reconstruction for post-surgical defects on the ears, eight databases were searched using terms related to ear anatomy, Mohs and excisions, and repair methods. Articles were eligible for inclusion if they contained repair data for ear defects following Mohs or excision for at least 4 subjects and were published in English between 2004 and 2019. Two reviewers screened all abstracts, and then evaluated the remaining full text articles to determine eligibility. The authors' specialties, study design, subject information, tumor and defect characteristics, procedure, repair methods, outcomes, and complications were then extracted. Most articles were written by dermatologic surgeons (66.7%). Repair methods included wedge excisions (19 cases), second intention healing (376), linear closures (294), purse strings (4), locoregional flaps (221), and grafts (2003). Most studies were small observational case series or cohort studies that lacked clear outcome measures. The available evidence on this topic is low quality. Further research utilizing improved study designs and standardized outcome measures is needed.

Congenital aural atresia: hearing rehabilitation using active middle-ear implants.

OBJECTIVE: To assess hearing rehabilitation in patients with congenital aural atresia using an active middle-ear implant (Vibrant Soundbridge). METHODS: Of a cohort of 70 microtia and atresia patients, 10 underwent Vibrant Soundbridge implantation between 2008 and 2021. Two of the 10 patients had binaural implantation, resulting in 12 ears for analysis. Pre- and post-operative audiometry data were analysed, and patient satisfaction was evaluated. Surgical issues regarding coupling sites and outcomes were analysed. RESULTS: Pure tone average (0.5, 1, 2 and 4 kHz) improved from a pre-operative mean (standard deviation) of 65.3 (8.7) dB HL to a post-operative mean of 26.8 (4.9) dB HL. This resulted in a mean pure tone average gain of 38.5 dB HL. The results indicate no obvious difference between stapes (n = 8) and incus (n = 4) coupling. The mean effective gain for 0.5, 1, 2 and 4 kHz was -17.8 dB HL (standard deviation = 4.3). Concerning effective gain, Vibrant Soundbridge performed best at 2 kHz. Patients reported high overall satisfaction, good sound quality and strongly improved directional hearing. CONCLUSION: An active middle-ear implant (Vibrant Soundbridge) allows hearing rehabilitation in selected atretic ears, and provides long-term hearing stability in children and adults.

Acoustic Reflex After Surgical Repair in Patients with Congenital Aural Atresia.

BACKGROUND: This study aimed to examine the plasticity of nerves indirectly by acoustic reflex after surgical repair of unilateral congenital aural atresia. METHODS: This study is a retrospective study including 80 patients who had undergone surgical repairs of congenital aural atresia before 18 years old and for whom acoustic reflex testing was performed postoperatively. Several variables correlated with acoustic reflex were analyzed to find factors affecting the presence of acoustic reflex. RESULTS: Among 80 patients, 44 were positive for acoustic reflex. As a result of multivariate analysis, good postoperative hearing (P = .017), younger age at surgery (P = .028), and the longer time interval between surgery and acoustic reflex test (P = .040) were revealed as factors affecting the acoustic reflex. CONCLUSION: Acoustic reflex was present in 55% of surgically managed patients with congenital aural atresia. The results of this study imply that the reflex arc of acoustic reflex may be restored after proper surgical reconstruction and prolonged use of reconstructed ear in patients with unilateral congenital aural atresia.

Surgical Techniques for the Repair of Webbed Neck: A Scoping Review.

Webbed neck is a rare condition characterized by bilateral subcutaneous bands, which extend from approximately the mastoid to the acromion. Given its rarity, the literature lacks a review of the techniques used in the repair of this condition. We performed a scoping review to define and summarize the surgical techniques been used in the treatment of webbed neck, with the goal of better equipping the surgeons' armamentarium. Two databases, PubMed and Scopus, were searched from inception through December 27, 2021. Studies were considered for inclusion if they (1) described the webbed neck condition and (2) reported results of surgical correction of this condition. Surgical outcomes and follow-up durations were reported as available. Twenty-two manuscripts were analyzed and included data on 60 patients. The most common syndrome associated with webbed neck was Turner syndrome (48 patients). The most frequently documented procedure technique was a Z-Plasty (38 patients). Other procedures described included: butterfly correction, V-Y Plasty, posterior cervical lift, skin excision, tissue expansion plus skin excision, T to M rearrangement, and subcutaneous fascial excision. Documented complications included hypertrophy of procedure scars or webbed neck recurrence. In summary, we present the first full literature review of the surgical techniques used in the repair of webbed neck. When selecting the technique for repair of the webbed neck, function and cosmesis are important considerations. Future studies should collect standardized outcomes data to appropriately assess and compare the described procedures.

Audiometric Outcomes After Surgical Repair of Congenital Aural Atresia: Does Age Matter?

OBJECTIVE: To determine if there is an age-based difference in audiometric outcomes for patients undergoing primary congenital aural atresia (CAA) repair. STUDY DESIGN: Retrospective chart review. SETTING: Single academic, high-volume, tertiary care hospital. PATIENTS: Individuals undergoing primary CAA repair by a single surgeon between 2004 and 2020. INTERVENTIONS: CAA repair. MAIN OUTCOME MEASURES: Preoperative and postoperative four tone (500, 1,000, 2,000, 4,000 Hz) air-conduction pure-tone average (PTA), bone-conduction PTA, air-bone gap and speech reception threshold, and preoperative to postoperative change in values. RESULTS: We identified 247 patients (262 ears) who underwent repair. The mean and median ages were approximately 12 and 8.5 years, respectively, both of which served as cutoff ages to compare younger versus older patients. The average preoperative to postoperative improvement values in air-conduction PTA, air-bone gap, and speech reception threshold for individuals younger than 12 years were 26.6 ± 10.2, 23.8 ± 12.6, and 30.1 ± 12.1 dB hearing level (HL), respectively, and those for individuals 12 years or older were 25.9 ± 15.7, 26.2 ± 10.3, and 31.3 ± 12.8 dB HL, respectively. For individuals younger than 8.5 years, the values were 25.8 ± 9.5, 24.9 ± 9.4, and 30.0 ± 10.6 dB HL, respectively, and those for individuals 8.5 years or older were 27.1 ± 13.5, 25.7 ± 11.0, and 30.0 ± 14.6 dB HL, respectively. The improvement did not differ significantly between the younger and older groups, using both cutoff ages. There was no difference in revision surgery rates or complications between groups. CONCLUSION: An individual at any age can enjoy audiometric improvement from atresia repair.

Contemporary Management of Microtia.

Microtia techniques have evolved to improve esthetic outcomes, reduce donor site morbidities, and reduce complications. Patients with microtia commonly have aural atresia associated with conductive hearing loss. We present the evolution of our technique for microtia reconstruction and considerations for hearing management in these patients.