O uso do retalho de fáscia parietotemporal no tratamento do colesteatoma recidivado: caso clínico / The use of parietotemporal fascia flap in the treatment of recurrent cholesteatoma: clinical case

O colesteatoma consiste em um processo inflamatório que resulta na migração do epitélio escamoso queratinizado para o ouvido médio. Embora considerada uma entidade histopatologicamente benigna, pode se comportar de forma bastante agressiva sendo uma importante causa de surdez em todos os países. Descarga, dor, ruptura do tímpano com extensão para o ouvido interno levando à surdez e vertigem, são as manifestações clínicas mais comuns. O tratamento consiste na excisão cirúrgica de todo o epitélio estranho da orelha média. As recorrências podem chegar a 50% e são um desafio para os médicos de ouvido, nariz e garganta. Neste relato de caso descrevemos um caso de colesteatoma recorrente adquirido em um hospital terciário em Portugal, tratado com ablação radical de ouvido médio e cavidade mastóide pelos médicos otorrinolaringologistas. A opção reconstrutiva escolhida foi a obliteração do espaço morto com retalho fascial temporo-parietal pelo Serviço de Cirurgia Plástica.

Cholesteatoma consists of an inflmmatory process that results in the migration of squamous keratinized epithelium into the middle ear. Although regarded as a histopathologically benign entity it can behave quite aggressively being an important cause of deafness in all countries. Ear discharge, pain, ear drum rupture with extension into the inner ear leading to deafness and vertigo, are the most common clinical manifestations. Treatment consists of surgically excising all the foreign epithelium from the middle ear. Recurrences can be as high as 50% and are a challenge to Ear, Nose and Throat doctors. In this case report we describe a case of an acquired recurrent cholesteatoma in a tertiary hospital in Portugal, treated with radical ablation of middle ear and mastoid cavity by the otolaryngologists. The chosen reconstructive option was obliteration of the dead space using a temporo-parietal fascial flap by the Plastic Surgery Department

Comparison of palonosetron-dexamethasone and ondansetron-dexamethasone for prevention of postoperative nausea and vomiting in middle ear surgery: a randomized clinical trial / Comparação entre palonosetrona-dexametasona e ondansetrona-dexametasona na prevenção de náuseas e vômitos no pós-operatório de cirurgia do ouvido médio: estudo clínico randomizado

Abstract Background: Postoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60-80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron-dexamethasone and ondansetron-dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery. Methods: Sixty-four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron-dexamethasone and ondansetron-dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded. Results: Demographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2-6 hours only (p = 0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0-24 hours postoperatively) was 37.5% in group O and 9.4% in group P (p = 0.016). Absolute risk reduction with palonosetron-dexamethasone was 28%, the relative risk reduction was 75%, and the number-needed-to-treat was 4. The patient's satisfaction score was higher in group P than group O (p = 0.016). The frequency of rescue medication was more common in group O than in group P patients (p = 0.026). Conclusion: The combination of palonosetron-dexamethasone is superior to ondansetron-dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.

Resumo Justificativa: Náusea e vômito no pós-operatório é a segunda queixa pós-operatória mais frequente após a dor. Sem profilaxia antiemética, a incidência de náusea e vômito no pós-operatório foi de 60−80% após cirurgia do ouvido médio. Dada a alta incidência relatada de náusea e vômito no pós-operatório, nosso objetivo foi avaliar o efeito da combinação de palonosetrona-dexametasona e ondansetrona-dexametasona na prevenção de náusea e vômito no pós-operatório em pacientes submetidos a cirurgia do ouvido médio. Método: Sessenta e quatro pacientes programados para cirurgia de ouvido médio foram aleatoriamente divididos em dois grupos. Um recebeu a combinação de palonosetrona-dexametasona (grupo P) e o outro ondansetrona-dexametasona (grupo O) por via intravenosa antes da indução anestésica. A técnica anestésica foi padronizada em todos os pacientes. No pós-operatório, foram registradas incidência e gravidade das náuseas e vômitos, necessidade de antiemético de resgate, efeitos colaterais e índice de satisfação dos pacientes. Resultados: As características demográficas foram semelhantes nos grupos estudados. A diferença na incidência de náusea foi estatisticamente significante entre os grupos O e P apenas no intervalo de tempo entre 2 e 6 horas (p = 0,026). A incidência e gravidade de vômito não foram estatisticamente significantes entre os grupos O e P durante todo o período do estudo. A incidência geral de náusea e vômito no pós-operatório (0−24 horas de pós-operatório) foi de 37,5% no grupo O e de 9,4% no grupo P (p = 0,016). A combinação palonosetrona-dexametasona associou-se com redução do risco absoluto de 28%, redução do risco relativo de 75%, e o número necessário para tratar foi 4. O escore de satisfação do paciente foi maior no grupo P (p = 0,016). A frequência da medicação de resgate foi mais comum no grupo O (p = 0,026). Conclusão: A combinação de palonosetrona-dexametasona é superior à ondansetrona-dexametasona na prevenção da náusea e vômito no pós-operatório após cirurgia de ouvido médio.

Assessment of Post-Operative Hearing Loss after Middle Ear Surgery: A Prospective Study

Background: At the end of surgery for chronic ear disease,various forms of packing have been applied to the externalauditory canal (EAC) and the middle ear cavity (MEC). Hence;under the light of above mentioned data, we planned thepresent study to assess post-operative hearing loss aftermiddle ear surgery.Materials & Methods: The present study involved assessmentof postoperative hearing loss in patients undergoing middle earsurgeries. A total of 30 patients scheduled to undergo middleear surgery were included in the present study. Middle earsurgeries were carried out under the hands of skilled andexperienced ENT surgeons. Postoperative middle earfunctioning was assessed using a pure tone audiogram. All thereadings were obtained after one week of surgery. All theresults were recorded in Microsoft excel sheet and wereanalyzed by SPSS software.Results: Hearing loss and Otorrhoea were the most commonpreoperative symptoms found to be present in the presentstudy. In majority of the patients (83.3 %), postoperativehearing improvement was within the normal range.Conclusion: Early identification of the patients with developingpost-operative sensorineural hearing loss should be done assoon as possible so that prompt treatment could be initiated.

Assessment of Efficacy of Nalbuphine and Dexmedetomidine versus Nalbuphine and Propofol in Middle Ear Surgeries under Monitored Anaesthesia Care: A Comparative Study

Background: For middle ear surgery, familiarity with theinterrelationships of the anatomical structures is as essential asknowledge of their individual morphology, as surgery isstrongly influenced by the close spatial relations between thedifferent components. In the present study, we assessed andcompared the efficacy of nalbuphine and dexmedetomidineversus nalbuphine and propofol in middle ear surgeries undermonitored anaesthesia care.Materials & Methods: A total of 40 patients scheduled toundergo MESs were included in the present study and werebroadly divided into two categories as follows: Group 1:Included patients who received injection dexmedetomidinealong with nalbuphine (intravenously), Group 2: Includedpatients who received injection propofol along with nalbuphine(intravenously). Visual analogue score (VAS) was used forassessing the intraoperative and postoperative pain. Recoveryto be assessed using Modified Aldrete scoring system (scoreranging from 0 to 10) in the recovery room every 5 min, tillscore of 10 was achieved. Adverse events were recorded. Bothpatient satisfaction score (PSS) and surgeon satisfaction score(SSS) were recorded on a scale on 1 to 7; with 1 indicatingextremely dissatisfied and 7 indicating extremely satisfied.Results: Significant results were obtained while comparing themean VAS, number of patients with PSS of 5 to 7 and numberof patients with SSS of 5 to 7 in between the two study groups.Non-significant results were obtained while comparing theincidence of complications between the two study groups.Conclusion: In patients undergoing middle ear surgeries,Nalbuphine/ dexmedetomidine appeared to be significantlymore effective combination in comparison to the nalbuphine/propofol combination.

Esmolol and Dexmedetomidine for Controlled Hypotension in Middle Ear Surgeries – A Prospective, Open-Labeled, Single-Center Study

Backgroundand Aims: Controlled hypotension has been used to reduce bleeding, the need for blood transfusions and provide a satisfactory bloodless surgical field. Esmolol, a short-acting cardioselective beta-blocker and dexmedetomidine, a central ?-2 adrenergic agonist both cause controlled hypotension. The aim was to study the effect of dexmedetomidine and compare it to esmolol for controlled hypotension, surgical field, dose requirement of induction agent, requirement of inhalational agent, and muscle relaxant in middle ear surgeries. Method: This study is a prospective, open-labeled, and single-center study. 100 patients of American Society of Anesthesiologists physical Status I and IIscheduled for middle ear surgeries lasting for 2–3 hunder general anesthesiawere included. Patients were divided into two groups of 50 each by computer-generated random numbers.Group E (n=50) patients esmolol infusion and Group D patients received dexmedetomidine infusion. Results:The two groups were comparable in terms ofhemodynamic parameters and surgical field assessment. The thiopentone dose requirement was 494 ± 12.93 mginGroup E and 354.50 ± 17.26 mg in Group D (P-0.022). The mean isoflurane concentration used in GroupsE andD was 45.30 ± 5.85 mland 13.79 ± 4.51 ml, respectively (P-0.002).The requirement of vecuronium was 11.19 ± 0.71mg in Group E and 4.58 ± 0.46 mg in Group D (P-0.009). Conclusion: The drugs provide controlled hypotension, good surgical field and reduce pressor response equally. In addition, dexmedetomidine reduces the dose requirement of induction agent, inhalational agent, and skeletal muscle relaxant.

Sinus tympani y recidiva en cirugía de colesteatoma / Sinus tympani and recidiva in cholesteatoma surgery

RESUMEN Introducción: El sinus tympani (ST) es una de las áreas que más presenta colesteatoma residual. Recientemente se ha clasificado en 3 tipos de acuerdo a su morfología. Objetivos: Determinar el tipo de ST en los pacientes sometidos a cirugía de colesteatoma y analizar su impacto como factor de recidiva. Material y método: Revisión de fichas clínicas de pacientes sometidos a cirugía de colesteatoma entre los años 2004 y 2015 en el Hospital Regional de Concepción. Análisis de la tomografía axial computarizada (TAC) preoperatoria y posterior evaluación clínica de los pacientes operados mediante mastoidectomía canal wall down (CWD). Resultados: En el periodo descrito se operaron 271 oídos. El 60% de los casos analizados presentó ST tipo A y 40% ST tipo B. Se identificaron 12 casos de recidiva, 3 ST tipo B y 9 ST tipo A, sin diferencia estadísticamente significativa entre ambos. Discusión: Distinto a lo reportado en la literatura el tipo de ST más frecuente en nuestro estudio fue el tipo A, lo que podría corresponder a una variable étnica. Conclusión: El estudio preoperatorio con TAC es una herramienta útil para evaluar el tipo y compromiso del ST. Las diferencias anatómicas entre ST tipo A y B parece no ser un factor determinante de recidiva en mastoidectomías CWD.

ABSTRACT Introduction: Sinus tympani (ST) is one of the areas with the most residual cholesteatoma. Recently it has been classified in 3 types according to its morphology. Aim: To determine the type of ST in patients undergoing cholesteatoma surgery and to analyze its impact as a relapse factor. Material and method: Review of clinical files of patients submitted to cholesteatoma surgery between 2004 and 2015 at the Regional Hospital of Concepción. Preoperative computed axial tomography (CT) analysis and subsequent clinical evaluation of patients operated by canal wall down mastoidectomy (CWD). Results: In the described period 271 ears were operated. 60% of the cases analyzed had ST type A and 40% ST type B. Twelve cases of relapse were identified, 3 ST type B and 9 ST type A, with no statistically significant difference between the two. Discussion: Unlike to what is reported in the literature, the most common ST type in our study was type A, which could correspond to an ethnic variable. Conclusion: The preoperative study with CT is a useful tool to evaluate the type and commitment of ST. The anatomical differences between ST type A and B seems not to be a determinant factor of relapse in CWD mastoidectomies.

The Protecting Effects of the Technique on the Chorda Tympanic Nerve in Middle Ear Surgery / 听力学及言语疾病杂志

Objective To investigate the different exposure and treatment methods for the chorda tympanic nerve in middle ear surgery, and discuss the surgery techniques and the feasibility of the chorda tympanic nerve protection.Methods From September 2013 to March 2016, 155 cases of middle ear surgeries at Zhujiang hospital were included in this study, including 24 cases of type I tympanoplasty, 6 cases of atticotomy and type I tympanoplasty, 22 cases of atticotomy and type II tympanoplasty, 23 cases of canal-wall-up mastoidectomy and tympanoplasty,74 cases of canal-wall-down mastoidectomy and tympanoplasty, 6 cases of stapedotomy.The conditions of exposure and protection of the chorda tympanic nerve in the operation were compared, and their taste function at 3 days to 1 months postoperatively through questionnaires were evaluated.Results The preservation rate of the chorda tympanic nerve was up to 89.03%(138/155).There were 17 cases of chorda tympanic nerve injuries, of which 15 cases suffered hypogeusia with the rate being 88.2%(15/17).In 126 cases of the complete protection of the chorda tympanic nerve, 13 of them appeared hypogeusia at 10.3% (13/126), but they recovered within 1 months postoperatively.One case of delayed facial paralysis occurred in 16 days postoperatively, and recovered completely after 2 weeks of treatment with glucocorticoids.There was a significant difference in the incidence of postoperative abnormal taste between the complete protection of the chorda tympanic nerve and fracture during operation.Conclusion According to the different position and exposure of chorda tympanic nerve, the individual measures should be taken in middle ear surgery to protect the chorda tympanic nerve.

Comportamiento quirúrgico y complicaciones preoperatorias del colesteatoma gigante / Surgical behavior and preoperative complications of the giant cholesteatoma

INTRODUCCIÓN: aunque ha disminuido la incidencia de complicaciones en las infecciones crónicas del hueso temporal, estas continúan siendo un peligro potencial de morbilidad y mortalidad. OBJETIVO: caracterizar a los pacientes pediátricos tratados quirúrgicamente por colesteatomas adquiridos gigantes complicados. MÉTODOS: se realizó un estudio descriptivo, prospectivo, en 11 pacientes pediátricos con grandes colesteatomas y complicaciones preoperatorias, atendidos y tratados quirúrgicamente en el servicio de Otorrinolaringología del Hospital Pediátrico Universitario "William Soler", desde enero de 2001 hasta 2013 (13 años). Tuvieron un seguimiento posoperatorio mínimo, de 6 años. Se realizó otoscopia, otomicroscopia, rayos X de mastoides, tomografía computarizada de oído, así como estudios audiométricos preoperatorios y posoperatorios. La técnica quirúrgica utilizada fue técnica abierta combinada con timpanoplastia y osiculoplastia en una sola etapa. Se analizaron las afectaciones funcionales auditivas posquirúrgicas y las recidivas. RESULTADOS: las localizaciones de las perforaciones marginales más frecuentes fueron: pars fláccida anteroposterior (n= 5, 45,46 %), seguida por mesotimpánica posterosuperior (n= 4, 36,46 %). Prevalecieron las complicaciones preoperatorias extracraneales (81,82 %). Se observó anacusia preoperatoria (n= 2, laberintitis). No hubo complicaciones transquirúrgicas. El hallazgo quirúrgico más relevante, fue facial timpánico dehiscente (n= 7, 63,64 %), que coincidió con la tomografía preoperatoria. Se realizó timpanoplastia y osiculoplastia en 7 pacientes, tipo III (n= 5; 71,42 %), con pérdida auditiva promedio preoperatoria 53 dB y posoperatoria 38 dB.Fueron reintervenidos 4 pacientes. CONCLUSIONES: la técnica utilizada reporta resultados quirúrgicos y funcionales posquirúrgicos satisfactorios.

INTRODUCTION: although the incidence of complications in the chronic temporal bone infections has decreased, they remain a potential threat in terms of morbidity and mortality. OBJECTIVE: to characterize the pediatric patients who are operated on for complicated acquired giant cholesteotomas. METHODS: prospective and descriptive study of 11 pediatric patients with giant cholesteatomas and preoperative complications; they had been attended to and operated on at the otorrhinolaryngology service of "William Soler" pediatric hospital in the period of January 2001 through January 2013. The postoperative follow-up lasted 6 year. These patients were performed otoscopy, otomicroscopy, mastoid X rays, CT for hearing, as well as audiometric studies preoperatively and postoperatively. The surgical technique was the open one combined with timpanoplasty and ossiculoplasty in one-stage. Postsurgical functional hearing problems and relapses were all analyzed. RESULTS: the most frequent locations of marginal perforations were anteroposterior flaccid pars (n= 5, 45.46 %) followed by posterosuperior mesotympanic (n= 4, 36.46 %). Preoperative extracranial complications prevailed (81.82 %). There was preoperative anacusia (n= 2, laberintitis). There were no perioperative complications. The most relevant surgical finding was facial tympanic dehiscence (n= 7, 63.64 %) that matched the results of the preoperative tomography. Tympanoplasty and ossiculoplasty were performed in seven patients, type III (n= 7, 71.42 %), with average preoperative hearing loss of 53dB and postoperative one of 38 dB. Four patients were reoperated. CONCLUSIONS: the used technique shows satisfactory surgical and postsurgical functional results.

Comparison of ramosetron and ondansetron for preventing nausea and vomiting after middle ear surgery under general anesthesia with sevoflurane and remifentanil / 대한마취과학회지

BACKGROUND: In this randomized, double-blinded study, we evaluated the efficacy of ramosetron and ondansetron for preventing postoperative nausea and vomiting (PONV) after middle ear surgery. METHODS: Seventy patients of either sex, ASA 1-2, scheduled middle ear surgery (mastoidectomy and tympanoplasty) under general anesthesia with sevoflurane and remifentanil were included. Patients were randomly divided into two groups and received IV ramosetron 0.3 mg (group R) or ondansetron 4 mg (group O) before the end of operation (n = 35 each). The incidence and severity of PONV, pain score (VAS), rescue antiemetic, rescue analgesic and side effects were assessed following 6 hr, 24 hr and 48 hr after surgery. RESULTS: The incidence of PONV showed no significant difference between groups at each time points after surgery. There were no difference in the severity of nausea, pain score, rescue antiemetic, analgesic drug usage and side effects between groups. CONCLUSIONS: Prophylactic therapy with ramosetron is as effective and safe as conventional prophylactic therapy with ondansetron for preventing PONV in patients undergoing general anesthesia for middle ear surgery.

Effect of Midazolam upon the Prevention of Nausea and Vomiting after Middle Ear Surgery / 대한마취과학회지

BACKGROUND: Midazolam has been reported to decrease postoperative nausea and vomiting (PONV). We studied the antiemetic effect of midazolam after middle ear surgery. METHODS: In this prospective, randomized, double-blind, placebo-controlled study, 90 healthy patients were scheduled for middle ear surgery (tympanomastoidectomy and tympanoplasty). Patients were randomly divided into two groups; Midazolam 0.075 mg/kg (n = 45) or normal saline (n = 45) was administered after induction of anesthesia. The incidence of PONV, metoclopramide and ketorolac usage, pain, sedation, and other side effects were assessed at 6, 24 h after the operation. RESULTS: The incidences of PONV were 15 (33%) in midazolam group and 27 (60%) in placebo group during 24 h postoperatively. The incidence of PONV in midazolam group was significantly lower than that in placebo group (P < 0.05). There were no significant differences between groups in adverse events. CONCLUSIONS: Midazolam 0.075 mg/kg was effective for preventing PONV after middle ear surgery without significant adverse effects.

The Changes of Taste Sense after the Injury of Unilateral Chorda Tympani Nerve during Middle Ear Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Currently, the changes of taste sensation after unilateral injury of chorda tympani nerve during middle ear surgery remains unclear, particularly in objective methods, like threshold to each taste stimulus. This study aims to evaluate the objective changes of taste threshold according to the degrees of injury of chorda tympani nerve. MATERIALS AND METHODS: In 36 patients who underwent middle ear surgery, the degrees of injury were described as "intact", "stretched" and "sacrificed". The taste threshold to citric acid, NaCl, and sucrose were measured preoperatively, and 1 week, 1 month, 3 months after surgery. Subjective changes of taste sensation were questioned together. The amount of changes in threshold according to the degree of injury were statistically analyzed. RESULTS: There were no significant differences of threshold according to the degrees of injury in each taste. Several patients documented subjective taste changes, such as hypogeusia and parageusia. But there were no relationship between subjective and objective findings. CONCLUSION: These results suggest the probability of some compensatory mechanism after unilateral injury of chorda tympani nerve. There might be some discrepancy between taste threshold and real-world taste sensation.