Ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in management of pars tensa cholesteatoma.

OBJECTIVE: To compare anatomical and audiological outcomes of ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in patients with pars tensa cholesteatoma. STUDY DESIGN: Prospective clinical study. SETTING: Otolaryngology department, Tanta University Hospital, Egypt. PATIENTS AND METHODS: Over three years, 60 ears in 60 patients underwent surgery for either sinus or tensa retraction cholesteatoma, reconstructed using either a ring-shaped (30 ears) or Mercedes-Benz symbol shaped (30 ears) cartilage-perichondrium graft, with at least two years' follow up. Post-operative drum perforation and retraction, cholesteatoma residue and recurrence, middle-ear effusion, and hearing acuity were monitored. RESULTS: Anatomical outcomes were equivalent in both groups, but slightly better in the Mercedes group. Hearing improved significantly in both groups (pre- vs post-operative results), but significantly more so in the ring group. Within-group hearing outcomes were unaffected by cholesteatoma type or tympanoplasty type. CONCLUSION: The Mercedes-Benz technique may be superior to the ring technique in preventing neodrum retraction. However, the ring graft technique had better hearing outcomes, perhaps due to its more physiological design.

Effect of primary, cross-over, zigzag neopharyngoplasty on acoustic characteristics of alaryngeal, tracheoesophageal voice.

OBJECTIVE: To evaluate the effect of primary, cross-over, zigzag neopharyngeal construction on tracheoesophageal voice, compared with pharyngoesophageal myotomy, following total laryngectomy with partial pharyngectomy. STUDY DESIGN: Prospective clinical trial. SETTING: Otolaryngology department, Tanta University Hospital (tertiary referral centre), Egypt. PATIENTS AND METHODS: Over five years, 30 patients underwent total laryngectomy with partial pharyngectomy to manage stage III or IV laryngeal cancer, followed by primary tracheoesophageal puncture for voice restoration. For neopharyngeal construction, 15 patients underwent pharyngoesophageal myotomy (group one) and 15 cross-over, zigzag neopharyngoplasty (group two). Acoustic parameters of tracheoesophageal voice were compared. RESULTS: Most acoustic parameters were almost equivalent for the two groups, although significant differences were seen for loud intensity, dynamic range, shimmer, loud fundamental frequency, loud jitter, fluency and speaking rate. One post-operative pharyngocutaneous fistula (6.6 per cent) occurred in each group, and resolved with conservative measures. CONCLUSION: The cross-over neopharyngoplasty modification of hypopharyngeal closure may help avoid pharyngoesophageal spasm and assist maintenance of effective voice amplitude, fundamental frequencies, temporal measures and perceptual values.

Comparison between cartilage-perichondrium composite 'ring' graft and temporalis fascia in type one tympanoplasty in children.

OBJECTIVE: This study aimed to evaluate the anatomical and audiological outcomes of primary type one tympanoplasty performed with a modified cartilage-perichondrium composite 'ring' graft, and to compare them with results for primary type one tympanoplasty performed with temporalis fascia, in children. STUDY DESIGN: Retrospective clinical study. SETTING: Otolaryngology department, Tanta University Hospital, Egypt. PATIENTS AND METHODS: Records were evaluated for 82 children with dry tympanic membrane perforation (any size) and intact ossicular chain, and with no history of previous ear surgery except for tympanostomy. Patients of similar age and middle-ear pathology were selected to make the two groups as homogeneous as possible. An underlay type one tympanoplasty, using either a ring graft or temporalis fascia, was performed: 40 children were included in the ring graft group and 42 in the temporalis fascia group. All procedures were performed by the same surgeon. A successful anatomical outcome was considered to comprise full, intact healing of the graft without perforation, retraction, lateralisation or blunting, for at least one year post-operatively. Patients' post-operative pure tone average air-bone gap and speech reception threshold were compared with pre-operative levels, within and between the two groups. RESULTS: Type one tympanoplasty using a ring graft technique resulted in a significantly greater graft acceptance rate (95 per cent) compared with the temporalis fascia technique (76.2 per cent; p < 0.01). Pure tone average air-bone gap and speech reception threshold levels improved significantly in both the ring graft and fascia groups (p < 0.001). There was no significant difference in audiometric results between the two groups (p > 0.05), although there was a trend towards better post-operative results in the ring group. CONCLUSION: In our paediatric patients, type one tympanoplasty with a modified cartilage-perichondrium composite ring graft yielded good anatomical and functional results. The anatomical results obtained using this graft (with its unique appearance and stability during and after surgery) were superior to those for temporalis fascia. The ring graft group had equivalent, if not better, post-operative audiometric results, compared with the temporalis fascia group. Thus, the ring graft is believed to be effective in enabling both tympanic membrane closure and rapid hearing improvement, in the paediatric population.

Effect of primary neopharyngeal repair on acoustic characteristics of tracheoesophageal voice after total laryngectomy.

OBJECTIVES: The tracheoesophageal puncture technique of voice restoration enables successful voice rehabilitation after total laryngectomy. Because post-operative voice quality can vary significantly, depending on which type of hypopharyngeal repair is chosen, the aim of this study was to evaluate the effect of such repair on tracheoesophageal puncture voice after total laryngectomy. STUDY DESIGN: Prospective, clinical study. SETTING: Otolaryngology department, Tanta University, Egypt. METHODS: Tracheoesophageal puncture voice was quantitatively and qualitatively evaluated in 40 patients using a Provox 2TM prosthesis after standard total laryngectomy. The patients were divided, according to the type of hypopharyngeal repair, into four groups of 10 cases each, as follows: group one, pharyngoesophageal myotomy; group two, pharyngeal plexus neurectomy; group three, non-muscle vertical repair; and group four, transverse repair. These surgical groups were compared with each other with respect to different voice parameters. RESULTS: Patient profiles were almost equivalent in all surgical groups. The mean values of most of the parameters of quantitative tracheoesophageal puncture voice did not differ significantly, comparing the four surgical groups; however, a slightly significant difference was observed regarding loud intensity in the non-muscle repair group, and soft and loud jitter in the transverse repair group. Mean values for qualitative measures of intelligibility and communicative effectiveness did not show significant difference. However, a slightly significant difference was observed regarding fluency, word correctness, speaking rate and wetness, with higher values for all these parameters except wetness in the myotomy group, and higher values for wetness in the non-muscle repair group. CONCLUSION: The four hypopharyngeal repair types--primary pharyngoesophageal myotomy, pharyngeal plexus neurectomy, non-muscle vertical repair and transverse hypopharyngeal repair--were almost equivalent in prevention of pharyngoesophageal spasm in total laryngectomy patients who had undergone primary tracheoesophageal puncture for voice restoration.

Pilot comparison between potassium titanyl phosphate laser and bipolar radiofrequency in paediatric tonsillectomy.

OBJECTIVES: To compare the advantages and disadvantages of potassium titanyl phosphate laser with those of bipolar radiofrequency techniques, in paediatric tonsillectomy. STUDY DESIGN: Prospective, randomised, clinical study. PATIENTS AND METHODS: From July 2004 to April 2006, 80 patients aged between 10 and 15 years, with tonsillectomy planned for chronic tonsillitis, were included in the study. Children were prospectively randomised into two equal groups: potassium titanyl phosphate laser tonsillectomy and bipolar radiofrequency tonsillectomy. Operative time and intra-operative blood loss were recorded. Patients were scheduled for follow up during the first, second and fourth post-operative weeks. They were asked to record their pain and discomfort on a standardised visual analogue scale, from zero (no pain) to 10 (severe pain). Post-operative complications were also recorded and managed. RESULTS: The potassium titanyl phosphate laser group showed a slightly longer operative time (mean 12 minutes) than the bipolar radiofrequency group (mean 10 minutes). Intra-operative blood loss was significantly less in the potassium titanyl phosphate laser group (mean 21 cm3) than in the bipolar radiofrequency group (mean 30 cm3). In the first week, post-operative pain scores were less in the potassium titanyl phosphate laser group than in the bipolar radiofrequency group (means 7.5 and 8.5, respectively). However, in the second week pain scores increased more in the potassium titanyl phosphate laser group than in the bipolar radiofrequency group (means 8.5 and 6, respectively). In the fourth week, both groups showed equal and nearly normal pain scores. No case of reactionary post-tonsillectomy haemorrhage was recorded in either group. Only one case of secondary post-tonsillectomy haemorrhage was recorded, in the potassium titanyl phosphate laser group (2.5 per cent), managed conservatively. CONCLUSION: Both the potassium titanyl phosphate and the bipolar radiofrequency techniques were safe and easy to use for tonsillectomy, with reduced operative time, blood loss and complication rates and better post-operative general patient condition. Potassium titanyl phosphate laser resulted in reduced operative bleeding and immediate post-operative pain, compared with the bipolar radiofrequency technique. However, potassium titanyl phosphate laser required slightly more operative time and caused more late post-operative pain than the bipolar radiofrequency technique. The low rate of recorded complications showed that both techniques cause little damage to the tonsillar bed during dissection, thus minimising complications.

Prevention of postlaryngectomy pharyngocutaneous fistula using a sternocleidomastoid muscle collar flap.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of a sternocleidomastoid muscle collar flap in the prevention of pharyngocutaneous fistula in patients who had undergone total laryngectomy. STUDY DESIGN: Retrospective clinical study. SETTING: Otolaryngology department, Tanta University, Egypt. METHODS: Sixty-five consecutive total laryngectomy procedures performed between October 1999 and October 2005 were reviewed. The fistula rate in laryngectomy patients operated on prior to 2002, without sternocleidomastoid collar flap creation (group A) was compared with that of patients operated on after October 2002, at which time this flap was introduced for routine use during primary surgery (group B). RESULTS: In group A, the incidence of pharyngocutaneous fistula was 12 in 35 (34 per cent) while its incidence in group B was 1 in 30 (3.3 per cent). On analysis, the risk factors within both the groups were essentially similar. CONCLUSION: The routine addition of a superiorly based sternal head of sternocleidomastoid muscle flap on one or both sides to cover the repaired pharynx during surgery reduced the incidence of postlaryngectomy pharyngocutaneous fistula, patient morbidity and mortality, and hospital stay; voice rehabilitation and swallowing were also improved.

Repair of tympanic membrane perforation using a modified cartilage-perichondrium composite ring graft.

Ring graft is a modified cartilage-perichondrium composite graft (CPCG) with only a peripheral ring shaped cartilage. In this series, tympanic membrane perforations were repaired using (ring graft) during treatment of 18 cases of non-cholesteatomatous chronic suppurative otitis media (CSOM). This study showed that ring graft has the advantages of both CPCG and perichondrial graft but without their disadvantages. Complete closure of the perforations was achieved in all cases without delay in hearing improvement. It is recommended to use the ring graft whenever needed to repair central tympanic membrane perforations even with difficult anterior or total perforations.

Managing problems with tracheoesophageal puncture for alaryngeal voice rehabilitation.

OBJECTIVES: The tracheoesophageal puncture (TEP) technique and the insertion of its associated voice prostheses may give rise to adverse events. We present our experience with this technique, paying special attention to the incidence and management of these adverse events. STUDY DESIGN: A retrospective clinical analysis was undertaken. METHODS: Seventy-five laryngectomized patients underwent TEP for voice restoration. They were divided into two groups: group one, 43 patients with secondary TEP; and group two, 32 patients with primary TEP. Patient medical records were reviewed for data on the incidence, management and outcome of adverse events encountered during patients' follow up. RESULTS: Problems that arose in the patients were itemized as either early or late. The same patient could develop one or more problems in either group. The management of these problems, concerning the creation and maintenance of the TEP and associated prostheses, was noted. In group one, results were initially favourable in 91 per cent of patients and still positive in 81.4 per cent after three years. In group two, early results were favourable in all patients, and only two patients asked for late elective closure of the TEP (with a success rate of 93.7 per cent). CONCLUSIONS: Via an intensive and multidisciplinary approach to problems, most of the inevitable adverse events could be solved adequately, minimizing the discomfort of patients who had undergone laryngectomy and indwelling voice prosthesis insertion.