Outcomes Following Revision Stapes Surgery in Children: A Single-Surgeon, Single-Center 15-Year Experience.

OBJECTIVE: To review a single surgeon experience with revision pediatric stapes surgery for congenital stapes fixation (CSF) and tympanosclerosis (TS). Secondly, to determine whether hearing outcomes following revision surgery may be predicted by a thorough work-up aimed at assessing whether an extruded or malpositioned prosthesis is likely to be encountered intraoperatively. SETTING: Tertiary referral center. STUDY DESIGN: Retrospective chart review. PATIENTS: Fifteen patients having revision surgery for fixation of the stapes footplate over a 15-year period. MAIN OUTCOME MEASURES: Hearing results based on pre- and post-revision pure-tone average air-bone gap (PTA-ABG) and speech recognition threshold testing (SRT). RESULTS: Overall, the mean improvement of PTA-ABG following revision surgery was 11.9 dB (standard deviation [SD] 15.2) while SRTs improved by a mean of 12.3 (SD 19.9). Outcomes were significantly better in patients who reported a history of trauma following their initial surgery, when there was otoscopic evidence of an extruding or extruded prosthesis and/or a pre-revision CT (where performed) suggested an extruded or malpositioned prosthesis. No patients had a significant postoperative sensorineural hearing loss. CONCLUSION: Revision stapes surgery in children is a safe procedure in experienced hands which nonetheless should only be contemplated in patients in whom preoperative work-up suggests an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.

Quality of life outcomes after transmastoid plugging of superior semicircular canal dehiscence.

PURPOSE: This study was performed to evaluate the effectiveness and impact on quality of life in patients undergoing plugging of superior semicircular canal dehiscence using the transmastoid approach. MATERIALS AND METHODS: Retrospective chart review with prospective outcomes assessment, using validated quantitative scoring systems, was performed on 10 patients (23-76 years) who underwent transmastoid plugging of superior semicircular canal dehiscence between February 2014 and February 2018 at a tertiary referral center. Pre-operative and post-operative autophony and vertigo were measured by The Autophony Index and the Dizziness Handicap Index. Overall quality of life following intervention was measured by the Glasgow Benefit Inventory. Subjective improvement, audiological changes, and subjective quality of life changes were also recorded. RESULTS: A significant reduction in the total Dizziness Handicap Index was seen following transmastoid repair of superior semicircular canal dehiscence (p = 0.0078). This was also evident when subgroup analysis of the Dizziness Handicap Index was performed, as physical (p = 0.0273), emotional (p = 0.0078), and functional subgroups were all significantly reduced (p = 0.0117). Autophony was also significantly reduced following intervention (p = 0.0312). Overall quality of life was seen to be improved following surgery as measured by the Glasgow Benefit Inventory (p = 0.0345). CONCLUSION: Our data suggest that transmastoid plugging of a dehiscence in the superior semicircular canal is a safe and effective means of improving autophony, dizziness and overall quality of life in these patients. We believe that these results should be taken into consideration in discussions regarding surgical approach for patients who are contemplating this procedure.

Outcomes of Primary Pediatric Stapedotomy.

OBJECTIVE: To review a single institution experience with pediatric stapedotomy for juvenile otosclerosis (JO), congenital stapes footplate fixation (CSFF), or tympanosclerosis. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Pediatric patients undergoing surgery for stapes fixation from 2001 to 2017. MAIN OUTCOME MEASURES: Hearing result based on preoperative, first postoperative, and final postoperative pure-tone average air-bone gap (PTA-ABG). Age, sex, diagnosis, procedure performed, prosthesis, and ossicular anomalies were considered. RESULTS: A total of 59 children (4-16 years of age) underwent surgery for stapes fixation (67 ears), with an average postoperative audiogram out to 2.88 years. Final postoperative ABG for tympanosclerosis (30.4 dB ±â€Š10.9 dB) showed some improvement but the outcome was significantly worse than in CSFF (21.0 dB ±â€Š11.4 dB) (p = 0.020) and JO (22.8 dB ±â€Š14.9 dB). CONCLUSION: Our data suggest, that in our clinic, surgery for stapes fixation is safe to perform in children. While we achieved desirable results for JO and CSFF, patients with tympanosclerosis showed a statistically worse hearing outcome. Tympanosclerosis deserves special consideration and may be better served with a malleovestibulopexy, total ossicular replacement prosthesis (TORP), or amplification in lieu of traditional stapes surgery.

Long-term Outcomes of Ossiculoplasty With and Without an Intact Malleus.

OBJECTIVE: To compare long-term hearing outcomes following ossiculoplasty with cartilage tympanoplasty with (M) and without (M) the malleus present. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: One twenty-six patients (18-88 yr of age) undergoing ossiculoplasty with tympanoplasty or tympanomastoidectomy using cartilage tympanic membrane grafts from 1998 to 2012 with at least 5 years of documented postoperative follow-up. MAIN OUTCOME MEASURES: Short-term hearing results (pure-tone average air-bone gap [PTA-ABG] measured between 60 d and 1 yr after surgery), long-term hearing results (PTA-ABG measured ≥5 yr after surgery), Ossiculoplasty Outcome Parameter Staging (OOPS) index, and complications. RESULTS: There were 46 patients in the M group and 80 in the M group. Preoperative PTA-ABG was 23.8 dB for M and 34.5 dB for M (p = 0.00001). Short-term postoperative PTA-ABG was 19.3 dB for M and 18.5 dB for M (p = 0.727). Long-term postoperative PTA-ABG was 18.2 dB for M and 19.6 dB for M (p = 0.500). The OOPS index was 4.11 and 6.41 for M and M, respectively, (p = 0.00001). Thirteen patients (10.3%) experienced complications. CONCLUSION: Our data suggest that the malleus is not statistically significant with regard to its impact on final audiometric outcome following ossiculoplasty. This has implications in our clinic, particularly in our use of the OOPS index as a prognostic tool, and will likely lead to its revision. These data may further support the coupling theory of acoustic gain and weaken the catenary lever theory.

Evaluation of Intraoperative Testing During Cochlear Implantation From a Time and Cost Perspective: A Single-Center Experience in the United States.

OBJECTIVE: To measure the time spent performing intraoperative testing during cochlear implantation (CI) and determine the impact on hospital charges. STUDY DESIGN: Prospective study. SETTING: Tertiary referral hospital. PATIENTS: Twenty-two children (7 mo-18 yr) who underwent a total of 22 consecutive primary and/or revision CIs by a single surgeon from December 2016 to July 2017. INTERVENTION: The time spent performing intraoperative testing, including evoked compound action potentials (ECAP) and electrical impedances (EI), was recorded for each case. The audiologist performing the testing was unaware of the time measurement and subsequent evaluations with regard to cost data. Billing information was used to determine if the testing contributed to increased operative charges to the patient. OUTCOME MEASURES: Whether intraoperative testing had an impact on operative charges to the patient. RESULTS: The average time spent in testing (ECAPs/EIs in all cases) was 6.7 minutes (range, 2-26 min). No correlation was found between testing time and preoperative computed tomography findings, the audiologist performing testing, or the electrode type used (p > 0.05). Based on billing data, including time spent in the operating room (OR), 5/22 (23%) cases incurred greater charges than if intraoperative testing had not been performed. CONCLUSION: Our data suggest that intraoperative testing increases time in the OR and can contribute to increased hospital charges for CI patients. By using testing selectively, costs incurred by patients and hospitals may be reduced. This is of interest in a healthcare environment that is increasingly focused on cost, quality, and outcomes.

Paradoxical role of 3-methyladenine in pyocyanin-induced toxicity in 1321N1 astrocytoma and SH-SY5Y neuroblastoma cells.

The role of autophagy in pyocyanin (PCN)-induced toxicity in the central nervous system (CNS) remains unclear, with only evidence from our group identifying it as a mechanism underlying toxicity in 1321N1 astrocytoma cells. Therefore, the aim of this study was to further examine the role of autophagy in PCN-induced toxicity in the CNS. To achieve this, we exposed 1321N1 astrocytoma and SH-SY5Y neuroblastoma cells to PCN (0-100 µmol/L) and tested the contribution of autophagy by measuring the impact of the autophagy inhibitor 3-methyladenine (3-MA) using a series of biochemical and molecular markers. Pretreatment of 1321N1 astrocytoma cells with 3-MA (5 mmol/L) decreased the PCN-induced acidic vesicular organelle and autophagosome formation as measured using acridine orange and green fluorescent protein-LC3 -LC3 fluorescence, respectively. Furthermore, 3-MA (5 mmol/L) significantly protected 1321N1 astrocytoma cells against PCN-induced toxicity. In contrast pretreatment with 3-MA (5 mmol/L) increased PCN-induced toxicity in SH-SY5Y neuroblastoma cells. Given the influence of autophagy in inflammatory responses, we investigated whether the observed effects in this study involved inflammatory mediators. The PCN (100 µmol/L) significantly increased the production of interleukin-8 (IL-8), prostaglandin E2 (PGE2), and leukotriene B4 (LTB4) in both cell lines. Consistent with its paradoxical role in modulating PCN-induced toxicity, 3-MA (5 mmol/L) significantly reduced the PCN-induced production of IL-8, PGE2, and LTB4 in 1321N1 astrocytoma cells but augmented their production in SH-SY5Y neuroblastoma cells. In conclusion, we show here for the first time the paradoxical role of autophagy in mediating PCN-induced toxicity in 1321N1 astrocytoma and SH-SY5Y neuroblastoma cells and provide novel evidence that these actions may be mediated by effects on IL-8, PGE2, and LTB4 production.

Maintenance of quality in a small cardiac surgical unit.

BACKGROUND: The purpose of this study was to evaluate the outcome of cardiac surgery at Allamanda Hospital which is a small private hospital carrying out less than 100 operations per year. METHODS: Data on patients undergoing cardiac surgery since 2002 were prospectively entered into a database. An analysis of this data is presented and compared with national and international benchmarks for results from larger national and international cardiac surgery units. RESULTS: From October 2002 to March 2007, there were 360 patients who underwent cardiac surgery in a small private cardiothoracic surgical unit (average of 80 patients per year). The average logistic EuroSCORE, Cleveland Clinic and Parsonnet Scores for the patients were 13%, 5.7 and 13.4, respectively. The mean logistic EuroSCORE observed in this study of 13% was substantially higher than those of other published series and institutions. The Allamanda results were compared with those from the European database (EuroSCORE), the STS and the Victorian National Cardiac Surgery Database. The overall observed mortality at Allamanda of 7.5% was lower than predicted by the mean logistic EuroSCORE of 13%. In comparison with the Victorian database, there was no significant difference in mortality for low-risk (additive EuroSCORE 0-3) and medium-risk (4-6) groups. Patients in the high-risk group with additive EuroSCOREs>or=7 were similarly divided into categories of three additive EuroSCOREs. There was no significant difference in any of the categories in the high-risk group. There was a greater proportion of high-risk (additive EuroSCORE>or=7) patients in the Allamanda series (P<0.0001). Patients in the Allamanda series were older (mean age 70.1) than the other published series (P<0.0001). The mean logistic EuroSCORE for the mortality group was 35.9+/-29.4% (6.4-65.3%). CONCLUSION: Low volume cardiac surgery can be undertaken safely in a small Australian private cardiothoracic unit with acceptable results. The trend towards improved outcomes for high-risk patients in larger institutions suggests that such patients undergoing elective procedures should be given the option of doing so in a larger centre. Ongoing quality assurance programs are equally important for large and small cardiac surgical units with participation in a national or international cardiac surgery database.