Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery.

BACKGROUND: Cholesteatoma is keratinising epithelium within the middle-ear cleft or mastoid. This disease destroys the peripheral organs of balance and hearing, with possible intracranial sequelae. The management of cholesteatoma is surgical and the primary aim is to remove the disease and prevent recurrence. Secondary aims are to obtain a non-discharging, hearing ear. Cholesteatoma surgery falls into two broad categories: open cavity surgery and combined approach surgery. A third surgical category is reconstruction of an open mastoid cavity after open surgery. This study performed a pooled analysis of the worldwide literature to compare the rates of cholesteatoma not being cured (i.e. recidivism), ear discharge and hearing change among open cavity, combined approach and reconstruction mastoid surgery for primary cholesteatoma. METHODS: A literature search for all types of cholesteatoma surgery in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken. RESULTS: There was no level 1 evidence for the best method of primary cholesteatoma surgery. The highest evidence level found (level 2; 5366 patients) shows no difference in hearing change or discharge rate between open and combined approach surgery; however, these methods fail to cure the cholesteatomas in 16.0 per cent and 29.4 per cent of cases, respectively. In a total of 640 patients, reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques had a failure rate of between 5.3 per cent and 20 per cent. CONCLUSION: The available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may be the best surgical treatment alternative. This technique appears to provide the lowest recidivism rate combined with a low post-operative ear discharge rate.

Conservative management of vestibular schwannomas of 15 to 31 mm intracranial diameter.

OBJECTIVE: To study the natural course of vestibular schwannomas 15 to 31 mm in diameter. METHODS: A retrospective study of 45 patients conservatively managed with interval scanning was performed. Outcome measures were: changes in tumour size, clinical features and hearing. A tumour was considered to be growing if it increased in size by more than 2 mm. RESULTS: Initial tumour sizes ranged from 15 to 31 mm, with a mean (± standard deviation) diameter of 20.1 ± 4.3 mm. The duration of follow up ranged from 6 months to 14 years (median, 3 years). Tumours grew in 11 cases (24.4 per cent), remained stable in 30 cases (66.7 per cent) and regressed in 4 cases (8.9 per cent). The overall mean tumour growth rate was 0.9 ± 2.2 mm per year; in growing tumours, it was 3.6 ± 2.9 mm per year. CONCLUSION: Outcomes were similar to those reported for smaller tumours. These findings suggest that patients with medium or moderately large tumours can be safely offered an initial period of conservative management before intervention is considered.

Tonsil tie simulator.

BACKGROUND: The surgical trainee has to acquire surgical skills in an era of reduced training hours and greater demands for efficient use of operating theatre time. Many surgical specialties are utilising model and simulation-based training to provide safe, low-pressure training opportunities for today's trainee. METHOD AND RESULTS: This paper describes a simple, relatively inexpensive tonsillectomy model that enables the practice of tonsil removal and ligation of bleeding vessels. The model is beneficial for the patient, trainee and trainer. CONCLUSION: The pseudo mouth and active bleeding components of this model provide the trainee with a relatively inexpensive, realistic model with which to gain confidence and competence in the skill of ligating tonsillar blood vessels with a tonsil tie.

Helix advancement meatoplasty.

We describe a new technique of helix advancement meatoplasty. This technique is useful in both mastoid surgery and some cases of otitis externa. The technique is designed to avoid the problems of (1) inferior positioning of the meatoplasty at the time of surgery, and (2) later inferior migration of the pinna (as can occur when the suspensory ligaments of the pinna have been cut or weakened). Such outcomes can result in a mastoid cavity which is difficult to clean as the approach to it is awkward; in such cases, it is common to have to look up into the cavity rather than directly into it. Helix advancement meatoplasty improves post-operative visualisation and aeration. It eases cleaning of the cavity by creating a more superiorly placed meatoplasty, which is supported by the tragus and is therefore less likely to drop.

Papilloedema secondary to venous sinus thrombosis following glomus jugulare tumour surgery.

OBJECTIVE: We present a case of a patient who had undergone embolisation and resection of a left glomus jugulare tumour, who presented three weeks post-operatively with magnetic resonance venography confirmed symptomatic cerebral venous sinus thrombosis. METHOD: We present a case report and a review of the world literature concerning glomus jugulare tumours and cerebral venous sinus thrombosis. CASE REPORT: A 42-year-old man presented with blurred vision and reduced Snellen visual acuity just three weeks after glomus jugulare tumour surgery. Fundoscopy revealed bilateral haemorrhagic optic disc oedema. Urgent magnetic resonance venography confirmed a left lateral venous sinus thrombosis. It was felt that this was responsible for inadequate cerebrospinal fluid drainage, resulting in raised intracranial pressure and papilloedema. CONCLUSION: To the authors' knowledge, this is the first account of a magnetic resonance venography confirmed venous sinus thrombosis and secondary papilloedema following glomus jugulare tumour surgery. Patients undergoing surgery involving resection or manipulation of the internal jugular vein may be at higher risk of developing thrombosis superior to the level of resection, and magnetic resonance venography ought to be considered an important diagnostic adjunct.

Single dose injection snoreplasty: investigation or treatment?

INTRODUCTION: Many surgical and nonsurgical procedures have been designed for the treatment of snoring due to palatal flutter. All work in some, but not all, snorers. The difficulty lies in making the definitive diagnosis of palatal flutter as the cause of snoring, and in deciding which patients should undergo which treatment, which in some cases are relatively radical. AIMS: This study aimed to assess the usefulness of injection snoreplasty in differentiating palatal flutter from other forms of snoring. This was done in the hope of determining which patients would benefit from definitive palatal surgery such as uvulopalatopharyngoplasty and laser-assisted uvuloplasty. MATERIALS: Sixty consecutive patients referred for habitual snoring were treated with sodium tetradycil sulphate during their first consultation visit. No patients were excluded and none refused the treatment. Forty patients received a single 1 ml dose of 1 per cent sodium tetradycil sulphate, and twenty patients received a single 1 ml dose of 3 per cent sodium tetradycil sulphate under topical anaesthesia. Visual analogue snoring scales were completed by the patient and their partner six weeks, three months, six months and 12 months after the procedure. RESULTS: Forty of the 60 patients showed improvement in snoring and therefore were considered for definitive surgery. Four of the 60 patients found the investigation unpleasant and did not want any further treatment. Of the 40 patients who showed improvement, 29 maintained this at one year. The other 11 underwent uvulopalatopharyngoplasty or laser-assisted palatoplasty. All patients had successful snoring scale outcomes following the surgery. CONCLUSION: A significant number of the patients, 62 per cent, were demonstrated to have significant improvement in the short term. Single dose injection snoreplasty seems not only to be an effective investigation but may constitute a safe and simple treatment within the clinic. At the very least, patients in whom the palate appears not to be the problem are prevented from undergoing painful, unpleasant surgery. Our results support the use of injection snoreplasty, both as an investigation and in some patients as a treatment, for habitual snoring.

Malleus osteotomy: improving access to the anterior tympanum.

Access to the anterior tympanic cavity is often restricted by the handle of the malleus. The aim of this paper is to describe a surgical malleus osteotomy that allows the malleus handle to swing superiorly. The authors have found few problems related to this technique, especially with regard to restoration of normal post-operative hearing.

Myringoplasty using a subcutaneous soft tissue graft.

A retrospective study was performed on patients who underwent myringoplasty using an autologous subcutaneous soft tissue graft over a 5-year period. Details including age, site and size of perforation, grade of surgeon, surgical approach, postoperative dressings, overnight stay, complications and outcome were recorded and analysed. Fifty-two patients underwent myringoplasty using a subcutaneous soft tissue graft. Their ages ranged from 4 to 78 years (median = 36 years). The mean follow-up period was 19 months. Successful closure to give an intact tympanic membrane was obtained in 82.7% of patients. Thresholds improved on pure tone audiometry in 57.1% and deteriorated in only one patient. There was no case of dead ear as a result of surgery. Subcutaneous tissue graft has comparable outcomes with temporalis fascia graft with additional advantages of a smaller incision, minimum dissection and a lower risk of bleeding.

Falls and vestibular impairment.

Unexplained fall is one of the commonest presentations to the Accident and Emergency (A & E) department of a hospital. The objective of this study is to assess the proportion of patients with symptoms of vestibular impairment among those presenting to an A & E department with an unexplained fall. Out of the total 3139 patients (fallers) presenting to an A & E department in 6 months, 546 had no known cause for the fall. Of these, 428 (76%) completed the vestibular symptom scale questionnaire. The presence and severity of vestibular symptoms for the past 12 months were assessed. The results showed that 80% of these patients had symptoms of vestibular impairment. We conclude that a large proportion of unexplained fallers suffered from symptoms of vestibular impairment within the last year, which may be responsible for their imbalance and falls. Identifying this group of patients is important as their symptoms and the resultant postural instability can be ameliorated by vestibular rehabilitation exercises.

Day-case myringoplasty: five years' experience.

A retrospective study of patients who underwent myringoplasty as a day-case procedure in two freestanding day-surgery units during a five-year period was carried out. Their case notes were identified and details including age, site and size of perforation, grade of surgeon, surgical approach, graft material, post-operative dressings, overnight stay, complications, and outcome were noted and analysed. The total number of patients including both children and adults who had myringoplasty as a day case was 144. Of these, 125 patients with 143 procedures were included in this study. Their ages ranged from four to 74 years (mean = 31 years). The perforation size was small in 40 cases, medium in 61 cases, and large/subtotal in 42 cases. The overnight stay rate was 2.7 per cent and this was for immediate post-operative problems such as nausea and bleeding from the wound. The readmission rate for post-operative complications was 2.1 per cent. The follow-up ranged from six months to five years (mean = 19 months). The success rate was 83.3 per cent and thresholds on pure tone audiometry improved in 69.2 per cent of cases. The age of the patient, grade of the surgeon, and graft material did not influence the surgical outcome. There was no case of dead ear as a result of surgery. Myringoplasty can be safely performed in both adults and children as a day-case procedure with low overnight stay and readmission rates. Success rates are comparable to when the procedure is performed on an in-patient basis.

Simple, painless, cosmetic closure of endaural incisions.

Endaural incisions provide a cosmetic approach to the middle-ear cleft, tympanic membrane for myringoplasty, and attic and antrum for small cavity mastoidectomy. These wounds have traditionally been closed with sutures, but platelet or fibrin adhesives provide an alternative. However, discomfort at the time of suture removal, particularly in children, and the risk of transmission of blood-borne infections in gels are limitations to these wound closure techniques. This paper describes our experience with Histoacryl glue (butyl-2-cyanoacrylate) in closing endaural incisions.

Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients' acceptability and various factors affecting the success of this procedure.

BACKGROUND AND OBJECTIVES: Endonasal endoscopic laser dacryocystorhinostomy is now a well established, effective approach to relieve nasolacrimal duct obstruction. Whereas attempts have been made to comment on the efficacy of the procedure, no study has been conducted to evaluate the acceptability of this procedure by those at the receiving end, ie, the patients. An attempt has been made in the present study to critically evaluate the procedure from the point of view of patients' acceptability and also to evaluate certain factors which may influence the success rate of this procedure. PATIENTS AND METHODS: Forty-six eyes from 40 patients underwent endonasal endoscopic laser dacryocystorhinostomy, performed by the same surgeon, over a period of 15 months. Various aspects of the procedure were evaluated by patients by filling out a simple questionnaire (Figure 1). In addition to recording patients' views, success of the procedure was confirmed by performing a postoperative sac washout in the clinic. Patients were also subdivided according to their age, duration of symptoms and history of previous surgical intervention. The data were statistically analysed using chi-square tests with the Yates correction. RESULTS: The percentage of patients who declared themselves completely cured was 65.22%. A partial resolution was felt by 23.91% of patients and no improvement was reported by 10.87% of patients. Forty-two out of the 46 eyes (91.3%) achieved anatomical success by the procedure, as shown by a postoperative sac washout performed in the clinic. Some of them, however, did not have complete resolution of their symptoms perhaps due to an additional factor of lacrimal pump dysfunction in these patients. During the procedure 60.86% of eyes felt no discomfort at all whereas 39.14% of eyes felt some discomfort at some point of time during the procedure (Table 1). When directly asked 86.12% of patients recommended the procedure (implying that the procedure had some good effect on their quality of life), 8.33% of patients did not recommend it and 5.55% of patients made no comments. Various factors affecting the success of this procedure were analysed (Table 2) and it was found that eyes which had no previous surgical intervention showed a complete cure rate which was significantly higher than that seen in eyes which had some sort of previous intervention (P = 0.0003); eyes with a short (<6 mths) duration of symptoms showed significantly higher success rates (P = 0.0098) in comparison to that shown by eyes with longer (>6 mths) duration of symptoms; and younger patients (<50 yrs) had a complete resolution rate much higher than patients over 50 yrs of age (P = 0.0309). CONCLUSION: The present study clearly shows that endonasal endoscopic laser DCR is an effective procedure, well tolerated and recommended by the patients. Discomfort during the procedure is not a major problem. Younger patients, with no previous surgical intervention and with short duration of symptoms are likely to be benefited the most. Though success rates are higher with external DCR, endonasal endoscopic laser DCR offers certain advantages over the external approach while keeping the option of external DCR open, if needed at a later date.

B-cell lymphoma of the external auditory meatus.

A 53-year-old female presented with a painful swelling within her external auditory meatus. Biopsies revealed this to be a B-cell lymphoma and she underwent surgical treatment followed by chemotherapy. This is the first reported case of non-Hodgkin's lymphoma of the external auditory meatus in an human immunodeficiency virus (HIV)-negative patient.