Search

Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.

Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.

For centuries it has been humankind's instinct to cover the mouth and nose when coughing or sneezing. Common sense would dictate this instinctively reduces the dispersion of aerosol and droplets and thus the spread of contact and airborne infections.

To establish whether criteria can be used to identify patients who do not need high resolution computed tomography (HRCT) scans before cochlear implant operations, by retrospectively applying a preoperative selection pathway, the Cambridge Cochlear Implant Protocol (CCIP).Retrospective case series.Tertiary referral center, Queen Elizabeth Hospital, Birmingham, UK (QEHB).One hundred adult patients receiving primary cochlear implantation (CI) operations from April 2015 to July 2016 performed at the QEHB who received preoperative HRCTs.Etiology of hearing loss and anatomical abnormalities were collected by reanalyzing HRCT scans. Patients were retrospectively grouped according to criteria to restrict HRCT use derived from the Cambridge Cochlear Implant Programme (CCIP). The two main outcomes, recorded management change and significant abnormalities, were compared between the two CCIP groups, scanned and not scanned.Twenty-six patients had significant abnormalities detected on imaging, 16 in the scanned group and 10 in the not scanned group (p = 0.152). Five patients had a recorded management change as a result of HRCT scan, four scanned group, one not scanned group (p = 0.107). Significant abnormalities and recorded management change were seen across all etiological subgroups of hearing loss.The anatomy within the temporal bone is variable amongst CI recipients. Recorded management change and significant abnormalities occurred in both CCIP groups and across many etiologies of hearing loss patients. No specific group, based on the etiology of their hearing loss could be identified that do not require preoperative HRCT. Therefore, it is recommended that all CI patients should continue to receive preoperative HRCT imaging.

To study the effectiveness of Type 1 tympanoplasty for chronic tympanic membrane perforations in the pediatric age group and to investigate factors influencing its success.Searches were conducted of the MEDLINE database and the Cochrane Database of Systematic Reviews using terms focused around tympanoplasty and children. Searches were performed on June 23, 2014 and limited to English language entries since January 1, 1997.Studies reporting tympanoplasty closure rates in children 18 years and younger, with a minimum follow-up of 6 months, were included. Studies focusing on more advanced forms of tympanoplasty and revision surgery were excluded.Five hundred sixty-four articles were screened identifying 2,609 cases from 45 eligible studies. Data were collected by consensus of the first two authors with the third author arbitrating disparities of opinion. Success was taken as the closure rate at 12 months where possible.Forest plots with Mantel-Haenszel analyses were used to compare closure rates with respect to perforation size, adenoidectomy, status of contralateral ear, Eustachian tube function, active infection, and graft position. Linear regression and Fisher's exact were used to analyze closure rate with respect to age.The mean weighted closure rate for pediatric tympanoplasty was 83.4%. Subgroup analysis found age not to be a significant factor affecting the closure rate. Tympanoplasties performed on larger perforations or in children with abnormal contralateral ear findings were more likely to fail. Surgery may be best delayed until contralateral otitis media with effusion has settled.

Objective Cochlear implantation is a clinical and cost-effective treatment for severe hearing loss. Cochlear nerve size assessment by magnetic resonance imaging (MRI) has been investigated for use as a prognostic indicator following cochlear implantation. This study aimed to further that research by assessing nerve size in normal-hearing adults for symmetry. Materials and methods Patients with tinnitus presenting to our center retrospectively had their nerve size assessed by MRI. Results The study found no significant differences between right and left cochlear nerves in normal-hearing adults, supporting our hypothesis of symmetry in these individuals. This was a previously unproven and uninvestigated hypothesis. Conclusion Nerve size assessment should remain an active area of research in otological disease.

Cochlear implantation (CI) has developed from its origins in the 1980s. Initially, CI was for profound bilateral hearing impairment. However, candidacy for CI have become more widespread in recent years with unilateral implantation and an emphasis on hearing preservation. Evidence supports full electrode insertion in an atraumatic fashion into the scala tympani (ST) provides optimal hearing outcomes. The main aim of this systematic review was to elucidate the degree of trauma associated with CI insertion.A systematic literature search was undertaken using PubMed Medline. A grading system described by Eshraghi was used to classify cochlear trauma. Both radiological and histological studies were included.Twenty one papers were identified which were relevant to our search. In total, 653 implants were inserted and 115 (17.6%) showed evidence of trauma. The cochleas with trauma had basilar membrane elevation in 5.2%, ruptured in 5.2%, the electrode passed from the ST to the SV in 84.4% and there was grade 4 trauma in 5.2%. The studies used a variety of histological and radiological methods to assess for evidence of trauma in both cadaveric temporal bones and live recipients.Minimizing cochlear trauma during implant insertion is important to preserve residual hearing and optimize audiological performance. An overall 17.6% trauma rate suggests that CI insertion could be improved with more accurate and consistent electrode insertion such as in the form of robotic guidance. The correlation of cochlea trauma with post-operative hearing has yet to be determined.

Cholesteatoma is a condition describing the accumulation of squamous epithelium and keratinocytes within the middle ear space. There is conflicting evidence regarding the influence of socioeconomical status on the prevalence of cholesteatoma. Hospital episode statistics (HES) data detailing the numbers of cholesteatoma surgeries performed per area were compared with the Index of Multiple Deprivation 2010 (IMD 2010) data that give a statistical measure of deprivation per local health authority in the UK. Statistical analysis of this data was performed to identify correlations between prevalence of cholesteatoma and deprivation. A trend was identified showing that health authorities associated with an overall low IMD 2010 value indicating more deprived, had higher numbers of mastoid operations. Our results have found that increasing levels of deprivation are associated with greater numbers of mastoid operations and thus greater numbers of cholesteatomas. Our work suggests that there is a need for additional input in deprived areas to accommodate the increased numbers of mastoid operations and chronic middle ear disease.

Fungal malignant otitis externa (FMOE) is a serious and potentially life-threatening condition that is challenging to manage. Diagnosis is often delayed due to the low sensitivity of aural swabs and many antifungal drugs have significant side effects. We present a case of FMOE, where formal tissue sampling revealed the diagnosis and the patient was successfully treated with voriconazole, in addition to an up to date review of the current literature. We would recommend tissue biopsy of the external auditory canal in all patients with suspected FMOE in addition to routine microbiology swabs.

Copyright © 2014 Tom Williamson et al. Robotic assistance in the context of lateral skull base surgery, particularly during cochlear implantation procedures, has been the subject of considerable research over the last decade. The use of robotics during these procedures has the potential to provide significant benefits to the patient by reducing invasiveness when gaining access to the cochlea, as well as reducing intracochlear trauma when performing a cochleostomy. Presented herein is preliminary work on the combination of two robotic systems for reducing invasiveness and trauma in cochlear implantation procedures. A robotic system for minimally invasive inner ear access was combined with a smart drilling tool for robust and safe cochleostomy; evaluation was completed on a single human cadaver specimen. Access to the middle ear was successfully achieved through the facial recess without damage to surrounding anatomical structures; cochleostomy was completed at the planned position with the endosteum remaining intact after drilling as confirmed by microscope evaluation.

Conventional computed tomography (CT) imaging is the standard imaging technique for temporal bone diseases, whereas cone-beam CT (CBCT) imaging is a very fast imaging tool with a significant less radiation dose compared with conventional CT. We hypothesize that a system for intraoperative cone-beam CT provides comparable image quality to diagnostic CT for identifying temporal bone anatomical landmarks in cadaveric specimens.Cross-sectional study.University tertiary care facility.Twenty cadaveric temporal bones were affixed into a head phantom and scanned with both a prototype cone-beam CT C-arm and multislice helical CT. Imaging performance was evaluated by 3 otologic surgeons and 1 head and neck radiologist. Participants were presented images in a randomized order and completed landmark identification questionnaires covering 21 structures.CBCT and multislice CT have comparable performance in identifying temporal structures. Three otologic surgeons indicated that CBCT provided statistically equivalent performance for 19 of 21 landmarks, with CBCT superior to CT for the chorda tympani and inferior for the crura of the stapes. Subgroup analysis showed that CBCT performed superiorly for temporal bone structures compared with CT. The radiologist rated CBCT and CT as statistically equivalent for 18 of 21 landmarks, with CT superior to CBCT for the crura of stapes, chorda tympani, and sigmoid sinus.CBCT provides comparable image quality to conventional CT for temporal bone anatomical sites in cadaveric specimens. Clinical applications of low-dose CBCT imaging in surgical planning, intraoperative guidance, and postoperative assessment are promising but require further investigation.

OBJECTIVE Evaluate the type, content, and quality of information available via the Internet for patients with common otological conditions. METHODS The Google search engine was used to generate responses for the following search terms: glue ear, otitis media, otosclerosis, Meniere's disease, cholesteatoma, and ear perforation. The first 10 websites for each search term were selected for analysis. Websites were evaluated with the validated DISCERN instrument (Institute of Health Sciences, University of Oxford, UK), the LIDA tool (Minervation Ltd, Oxford, UK), the Flesch Readability Formula, the Simple Measure Of Gobbledygook (SMOG) readability score, and against the Journal of the American Medical Association (JAMA) criteria. Comparisons were made with a similar study assessing quality of information in nonotological conditions. RESULTS Mean SMOG score was 12.19 years of education (range, 6.2-22.8). The health on the net (HON) symbol appeared on 15 of 49 websites (30.61%). Pearson's r was used to identify interactions between variables and demonstrated a significant correlation between LIDA score and Google ranking (R = -0.1195, p = 0.002); between university/hospital affiliation and JAMA score (R = -1.7889, p = 0.0182) and commercial affiliation and JAMA score (R = 1.0561; p = 0.01). Multivariate linear regression analysis showed LIDA to be the strongest predictor of Google ranking (Page rank decreasing by 0.10572 per LIDA score; p = 0.01). CONCLUSION As websites with better Google ranking were only weakly associated with higher quality rankings patients would benefit from being directed to reliable websites by clinicians. There is currently a gap in the available resources for a high quality repository of otological information aimed at patients.

The authors wish to acknowledge financial support by Cochlear Ltd., Australia, and clinical support from Queen Elizabeth Hospital, Birmingham, UK in this work and the advice and enthusiasm of Mechtron Design Ltd, UK.

Aim:(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).Materials and methods:All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.Results:Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.Conclusion:Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

There has been a reduction in the number of modified radical mastoidectomy and revision mastoidectomy surgeries per head of population in Ontario between 1987 and 2007, we believe that this represents a true reduction in prevalence of cholesteatoma. The increase of cases performed at the University Hospital Network, Toronto (UHN) may represent a shift to subspecialization in the treatment of chronic ear disease.To analyze the trends in mastoid operations for chronic middle ear disease in the Canadian province of Ontario between 1987 and 2007 and to determine whether an increasing proportion of these procedures are being performed in tertiary referral centres.The year on year population and number of mastoid procedures performed per year in Ontario and at the UHN between 1987 and 2007 were obtained from Statistics Canada and the Ministry of Health and Long-Term Care, Ontario, respectively. Population-adjusted rates of mastoid surgery for Ontario and the UHN. These data were collated and graphically represented for trend analysis.The population-adjusted number of mastoid procedures for Ontario declined from 7.1 cases per 100,000 in 1986 to 4.1 cases per 100,000 in 2006. During this time the number of both modified radical mastoidectomies and revision mastoid surgeries at UHN increased.

The standard current treatment of an otogenic brain abscess is drainage via neurosurgical burr hole or complete excision, followed by an otological procedure to eradicate the primary pathology – often at a later date. We describe the drainage of otogenic brain abscess via a transtemporal approach. We present a retrospective study of six cases, five children and one adult. All the children had acute middle ear disease while the adult patient had a petrous apex cholesteatoma. All cases had an otogenic intracranial abscess either in the posterior cranial fossa or in both posterior and middle cranial fossae. Diagnosis was confirmed by computed axial tomography (CT) scan. All the patients were treated by mastoidectomy and needle aspiration to drain the abscesses. In all cases the brain abscess and the ear pathology were successfully treated by a single stage transmastoid approach. The five paediatric patients had an extended cortical mastoidectomy approach to both intracranial pathology and ear disease except one patient who required a burr hole to drain a posteriorly located subdural posterior fossa abscess. The adult patient underwent petrosectomy, followed by transtemporal abscess drainage. There was postoperative pus recollection in one patient who required further aspiration. We conclude that transtemporal drainage of an otogenic brain abscess can successfully treat otological and intracranial pathology in a single operation. It has a low complication rate and avoids the need for a craniotomy or subsequent operations.

Background In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. Methods The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. Results Three robotic systems were identified with potential usage in ENT: the Pathfinder™ neurosurgical robot, the Acrobot® knee replacement system and the autonomous smart drill for drilling a cochleostomy. Conclusions The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results. Copyright © 2007 John Wiley & Sons, Ltd.

The concept of a hand guided robotic drill has been inspired by an automated, arm supported robotic drill recently applied in clinical practice to produce cochleostomies without penetrating the endosteum ready for inserting cochlear electrodes. The smart tactile sensing scheme within the drill enables precise control of the state of interaction between tissues and tools in real-time. This paper reports development studies of the hand guided robotic drill where the same consistent outcomes, augmentation of surgeon control and skill, and similar reduction of induced disturbances on the hearing organ are achieved. The device operates with differing presentation of tissues resulting from variation in anatomy and demonstrates the ability to control or avoid penetration of tissue layers as required and to respond to intended rather than involuntary motion of the surgeon operator. The advantage of hand guided over an arm supported system is that it offers flexibility in adjusting the drilling trajectory. This can be important to initiate cutting on a hard convex tissue surface without slipping and then to proceed on the desired trajectory after cutting has commenced. The results for trials on phantoms show that drill unit compliance is an important factor in the design.

An inflammatory pseudotumour of the temporal bone is a rare, idiopathic, fibro-inflammatory lesion which mimics malignancy. Although such a lesion is known to occur elsewhere in the body such as the liver, abdominal viscera, pelvis, thorax and the upper respiratory tract, the involvement of the temporal bone is extremely unusual. We present such a case in a 60-year-old man, which provided a great diagnostic challenge. We review the key radiological and histological results that confirmed the diagnosis and demonstrated for the first time that oral steroids alone may completely resolve the condition.

A single-stage fitting of a bone-anchored hearing aid (BAHA) implant and abutment with mastoid obliteration both obviates the need for two separate procedures and utilises the BAHA soft tissue reduction in the mastoid obliteration. Such a procedure has good outcomes in terms of osseointegration and achieving a dry ear. We present a 6-patient case series report highlighting the technique of combined BAHA insertion and mastoid obliteration in six patients. All patients at twelve-month followup have a good degree of sound localisation and hearing thresholds with their BAHA and are free from the social stigma associated with a foul smelling discharging ear.