Comparison of methods of evaluating hearing benefit of middle ear surgery.

The objective of this paper is to compare two methods of predicting the level of subjective patient benefit following reconstructive middle ear surgery. This should have always been an important consideration in advising patients regarding surgery, but assumes even more relevance in these days of clinical audit and cost benefit analysis. The two methods studied were the '15/30 dB rule of thumb' (Smyth and Patterson, 1985) and the 'Glasgow plot' (Browning et al., 1991). The predictions of benefit for each of the two methods were compared to the assessment of actual benefits by the patient post-operatively. The results of this comparison in 153 patients were analysed, the rule of thumb was found to be somewhat more sensitive in predicting patient benefit.

Non-surgical management of acoustic neuromas.

Watchful waiting is one of the options available in the management of acoustic neuromas and this article deals with 13 patients who were so managed. Non-operative management was advised because of age, poor general health, small size of tumour, only hearing ear, or in patients unwilling to undergo surgery for various reasons. This group was followed up at 6-12-monthly intervals and the follow-up period ranged from 1 to 18 years (mean 5.3 years). Ten patients had small tumours and only in 2 of these was increase in tumour size demonstrated on follow-up CT scan. In one this increase was later followed by regression. Two patients required partial removal of tumour because of increasing symptoms after 3 and 7 years of follow-up; one of them died on the twelfth post-operative day. There appears to be a small group of patients for whom delay is worth while rather than to subject all patients with acoustic neuroma to surgery from which full recovery cannot be guaranteed.

Toynbee Memorial Lecture 1992: facts and fantasies in modern otology: the ear doctor's dilemma.

Until it is accepted that many of the recommendations for surgical treatment of middle ear disease, based on impressions formed twenty years ago, are misleading, attempts to rationalize the use of hospital resources will be little more than cosmesis. Responsibility for the initiation of cost-effective reform is primarily that of surgeons and requires urgent self-audit and the provision of realistic advice to patients (and administrators) as to what benefits microsurgery of the ear can offer.

Management of posterior mesotympanic cholesteatoma.

Contrary to previous practice, the eradication of posterior mesotympanic cholesteatoma can frequently be achieved using a transcanal approach and without the need for more major surgery. For success, certain specific steps are necessary. These are described and the results reported.

Small cavity mastoidectomy.

Disappointment with the long-term results of closed operations for ears with extensive cholesteatoma has led to a renewed preference for open techniques. Although the technical advantages provided by magnification and hypotensive anaesthesia have reduced the numbers of unstable post-operative open mastoidectomy cavities, when large, they are still frequently troublesome. Frequently, surgical cavities have been much larger than necessary because of adherence to a traditional approach to the pathologic lesion from its posterior aspect, and the inevitable removal of much normal bone. It is proposed herein that if, instead, bone removal were commenced from the area proximate to the origin of the disease and extended only as far as necessary in order to achieve adequate and effective exteriorization of the disease, fewer large cavities would result and the proportion of stable post-operative ears would be increased. To test this, 100 patients have been treated by atticoantrotomy in which bone lateral to the cholesteatoma sac was removed from anterior to posterior. The 5-year status of the first 43 patients thus treated supports the view that atticoantrotomy provides a logical, safe and successful means of treating extensive cholesteatoma.

Realities in ossiculoplasty.

The results of ossiculoplasty are frequently reported in terms of closure of the air-bone gap. This parameter is a reliable indicator of the degree of technical success, and is useful in comparing different materials and types of reconstructions. However, assessment of the operated ear alone does not evaluate the effect of surgery on binaural hearing ability, leading to the situation where sub-optimal advice may be given to patients pre-operatively. This article advocates a more patient orientated method of assessing the results of ossiculoplasty. Previous studies have indicated that the operated ear must reach an air conduction level of 30 dB for the speech frequencies, or be within 15 dB of the other ear, to ensure that the patient will gain significant benefit. A graphical method for the prediction of patient benefit is presented, and compared to the rule of thumb quoted above. The implications for surgeons and patients considering ossiculoplasty are obvious. Many statements routinely made to patients prior to surgery for conductive hearing loss are unduly optimistic and unrelated to the realities of reported results. There is a need to determine what types of such hearing losses can be helped surgically, and more importantly to what extent the patients hearing disability can be relieved.

Otological manifestations of a new familial polyostotic bone disorder.

Fifty members of a family with a unique autosomal dominant bone disease were investigated. Nineteen of the family members were either known to have, or were strongly suspected of having the disease. All but one of these had a hearing loss which was conductive in the younger age group and mixed in the older members. The common finding in those who had middle ear surgery was replacement of the long process of incus by a fibrous band. The histological features were similar to those found in Paget's disease. The age of onset, distribution of lesions and radiographic findings, however, were not typical of this disorder.

Realities in ossiculoplasty.

The results of ossiculoplasty are frequently reported in terms of closure of the air-bone gap. This parameter is a reliable indicator of the degree of technical success, and is useful in comparing different materials and types of reconstructions. However assessment of the operated ear alone does not evaluate the effect of surgery on binaural hearing ability, leading to the situation where sub-optimal advice may be given to patients pre-operatively. This article advocates a more patient orientated method of assessing the results of ossiculoplasty. Previous studies have indicated that the operated ear must reach an air conduction level of 30dB for the speech frequencies or be within 15dB of the other ear to ensure that the patient will gain significant benefit. A graphical method for the prediction of patient benefit is presented, and compared to the rule of thumb quoted above. The implications for surgeons and patients considering ossiculoplasty are obvious.

Comparison of the Goode T-tube with the Armstrong tube in children with chronic otitis media with effusion.

Treatment of otitis media with effusion is focused on reaeration of the middle ear cavity. In achieving long-term aeration, the insertion of ventilation tubes that have a long duration of stay can be beneficial. The results are presented of a trial in which the Goode T-tube was compared with the Armstrong tube. Fifteen children were treated between 1981 and 1986 with a T-tube in one ear and a conventional tube in the other. The results are different with regard to duration of stay in the tympanic membrane. Re-insertions were necessary in 47 per cent in the Armstrong group and in 20 per cent in the T-tube group. Otorrhoea occurred in 20 per cent of the Armstrong and 13 per cent of the T-tube intubated ears. A persistent perforation was present in 6 per cent of the ears in both groups. It is concluded that the Goode T-tube is indicated primarily in cases when long-term ventilation is needed.

Surgical treatment of cholesteatoma: a comparison of three techniques.

The debate regarding the surgical technique for the management of cholesteatoma still continues. The resolution of this issue will only come with the study of the long term results of well controlled series. In this paper long term follow-up on three groups of patients is reported. The groups underwent combined approach tympanoplasty (CAT), mastoid tympanoplasty with obliteration (MOT), and modified radical mastoidectomy (MRM) respectively for cholesteatoma. The factors studied included frequency of required review, condition of the external canal/cavity, and hearing status. The meatal cross-sectional areas and cavity volumes were also measured for the MRM and MOT groups. Analysis of the data showed no significant difference between the groups in either frequency of review or cavity status. The hearing results showed an initial improvement in all groups, however, over the prolonged follow-up period the air conduction threshold gradually increased. In conclusion this data supports the view that a one-stage canal wall down procedure provides maximum long term patient benefit.

Role and results of cortical mastoidectomy and endolymphatic sac surgery in Menière's disease.

It is almost impossible to establish the natural history of Menière's disease and, by the same token, it is difficult to confirm the efficacy of endolymphatic sac surgery. The authors doubt the logic of sac operations. Only two controlled trials of sac surgery have been found and both cast doubt upon its value. There do not appear to be any controlled trials indicating that it works. In 14 cases of incapacitating Menière's disease, where vestibular nerve section was indicated, cortical mastoidectomy was offered and accepted in the expectation that two-thirds might be spared the more major procedure. In the event, the vertigo was controlled in eight out of 14 (57 per cent), the remaining six (43 per cent) requiring more major surgery. A surgical model illustrates that, of themselves, these results are essentially meaningless in assessing the efficacy of cortical mastoidectomy in Menière's disease. Until all cases in a community are considered and followed-up, we shall be in doubt about the value of sac surgery and most other treatments of Menière's disease.

Long-term results of sacculotomy in older patients.

In patients with Meniere's disease with incapacitating vertiginous complaints in whom medical treatment has failed, sacculotomies by both the Fick and tack operations are relatively simple surgical procedures, whose short duration of anesthesia and hospitalization of patients minimizes the risks of morbidity in older patients appropriately to their general health, with good results in controlling vertigo. With respect to preservation of hearing, the tack operation is superior to the Fick operation.

Transplanted ossicles after two decades.

The authors now report on the histological appearance of two very long-term ossicles, an autologous incus removed from the middle ear at revision surgery 21 years after repositioning and a homologous incus removed from the middle ear after 20 years. Having been placed in formalin immediately after removal from the ear, both specimens were later decalcified by ethylene diamine tetra-acetic acid, embedded in paraffin wax, serially sectioned and stained with haematoxylin and eosin.

Surgical treatment of cholesteatoma: the role of staging in closed operations.

It has been proposed that closed operations on cholesteatomatous ears should be performed on a two-stage basis in order to detect disease left behind at the first operation and to correct developing retraction pockets. Two groups of patients who had closed operations performed in two stages, 100 combined approach tympanoplasties and 100 mastoid obliterations with tympanoplasty, were observed for 10 years after the second stage. A much greater than expected incidence of eventual cholesteatoma recurrence suggests that even with staging, closed techniques may provide a less than reliable outcome in surgical control of the disease, and long-term observation of ears thus treated is desirable.

Acoustic neuroma surgery in Northern Ireland 1976-1986.

Forty acoustic neuromas have been removed surgically between 1976 and 1986. The condition was unilateral in 32 and bilateral in four. There were 31 large, four medium and five small tumours. Excision was complete in 16 and incomplete in 24. Of the incomplete removals 14 were subtotal leaving microscopic remnants, eight were partial capsular and two were intracapsular. Follow-up ranged from two months to ten years (median 3.5 years).There was one early death in an 83-year-old. The overall incidence of post-operative complete facial paralysis was 20% but reached 55% for large tumours when excision was complete. Twenty-eight patients had hearing before operation and in eleven patients some preservation of hearing was possible (39%). In these, the excision was complete in three, subtotal in four, partial capsular in three and intracapsular in one.Of the unilateral tumours, there have been three recurrences requiring repeat surgery. All were initially incompletely excised. Two were of an invasive nature causing considerable erosion of the petrous temporal bone making complete excision impossible. For the bilateral tumours a deliberate incomplete excision was first performed on one side to ensure preservation of hearing. Further excision on this side was then left until such time as hearing was lost. Complications included CSF otorhinorrhoea (5%), persistent but temporary nausea and vomiting (10%), meningitis (5%), facial numbness (5%) and hoarseness and dysphagia (3%).

Long-term results of tympanic membrane repair.

Long-term results of tympanic membrane repair were analyzed in 605 patients operated upon from 1970 to 1975. By survival life table analysis, 81% closure of perforations was found at 11 years, and only 74% of patients had normally healed tympanic membranes. Children less than 10 years of age and with anterior perforations healed more poorly. A second group of patients--all with anterior perforations operated upon from 1982 to 1984-showed autologous temporalis fascia to be superior to homograft dura as the graft material. Analysis of results also showed a 60% chance of perforation closure at revision operation. These results are believed to represent an accurate and realistic assessment of tympanic membrane repair by use of survival life table analysis.