Effects of smoking on otologic surgery outcomes

Toward Improved Detection of Cholesteatoma Recidivism: Exploring the Role of Non-EPI-DWI MRI

Background: Cholesteatoma is a lesion capable of destroying surrounding tissues, which may result in significant complications. Surgical resection is the only effective treatment; however, the presence of cholesteatoma recidivism is common. This study evaluated the effectiveness of the Attic Exposure-Antrum Exclusion (AE-AE) surgical technique in treating cholesteatomas and identifying factors associated with recidivism. Additionally, the study aimed to assess the utility of non-echo-planar diffusion MRI (non-EPI-DWI MRI) in detecting cholesteatoma recidivism in patients undergoing AE-AE surgery. Methods: The study involved 63 patients who underwent AE-AE surgery for primary acquired cholesteatoma and were followed up clinically and radiologically for at least five years. The radiological follow-up included a non-EPI-DWI MRI. Results: Results showed that the AE-AE technique successfully treated cholesteatomas, with a recidivism rate of 5.2%. The study also found that non-EPI-DWI MRI was a useful diagnostic tool for detecting cholesteatoma recidivism, although false positives could occur due to the technique's high sensitivity. As Preoperative Pure-tone average (PTA) increases, there is a higher probability of cholesteatoma recidivism in imaging tests (p = 0.003). Conclusions: Overall, the study highlights the importance of the AE-AE surgical technique and non-EPI-DWI MRI in managing cholesteatoma recidivism in patients, providing valuable insights into associated risk factors and how to manage recidivism. Non-EPI-DWI MRI can assist in patient selection for revision surgery, reducing unnecessary interventions and associated risks while improving treatment outcomes and patient care.

Predictive Patient Factors for Poor Outcomes Following Stapedotomy for Otosclerosis

OBJECTIVE

To assess patient-related risk factors associated with poor outcomes following stapedotomy for otosclerosis.

STUDY DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

METHODS

Retrospective chart review of 107 patients with otosclerosis who underwent stapedotomy between 2013 and 2020. Demographics, comorbidities, and smoking history were obtained. Preoperative and postoperative audiogram data, including air-bone gap (ABG), and complications were collected. Data were analyzed using t test and Fischer's exact test for continuous and categorical variables, respectively.

RESULTS

Among 107 patients, 29.5% were smokers and 70.1% non-smokers. Overall, the average ABG-gain 3-months postoperatively was 20.2 dB, and intraoperative and postoperative complications were 3.74 and 13.1%, respectively. Those with a history of otologic procedures had a lower mean ABG gain at 3 months compared with those without previous otologic surgery (14.4 dB versus 20.4 dB, p = 0.018). The average ABG gain at 3-months was not significantly different between those with current, former, or no smoking history, respectively (13.5 versus 18.1 versus 20.6, p = 0.08). Current smokers had 4.5 times greater odds of complications compared with non-smokers, although not statistically significant (95% CI 0.9-22.8, p = 0.1912).

CONCLUSION

Age and history of otologic procedures as independent risk factors did impact hearing outcomes among our patient cohort; however, smoking history did not. Future prospective studies are required to further investigate complication rates by various modifiable risk factors, such as smoking status, body mass index (BMI), and obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) use, for stapedotomy surgeries.

Effects of cigarette smoke on Haemophilus influenzae-induced otitis media in a rat model

Exposure to cigarette smoke (CS) is a factor that could delay or worsen the recovery of otitis media (OM) by causing inflammatory swelling of the Eustachian tube (ET). However, despite the suggested relationship, little is known about the association between OM and CS. Therefore, we aimed to evaluate the effects of CS on the development, progression, and recovery of OM, as well as the histological and molecular changes caused by CS exposure, by using a rat model of OM infected with non-typeable Haemophilus influenzae (NTHi). Eighty Sprague-Dawley rats with normal middle ears (MEs) were divided into four groups (n = 20 rats/group): control, CS, OM, and CS + OM. The CS and CS + OM groups were exposed to CS for 2 weeks. The inflammatory reaction to NTHi was more intense and lasted longer in the CS + OM group than in the other groups. Goblet cell proliferation and mucus secretion in the ET were more significant in the CS and CS + OM groups than in the other groups. These findings suggested that because CS directly affects the ET and ME mucosa, bacterial OM can become more severe and may resolve more slowly in the presence of CS exposure rather than in its absence.

Tobacco Use and Skin Reactivity in Patients With Percutaneous Auditory Osseointegrated Implants

OBJECTIVES

To determine if there is an association between tobacco use and the development of postoperative skin reactions in patients undergoing percutaneous osseointegrated auditory implant (pOAI) surgery.

STUDY DESIGN

Single surgeon retrospective cohort study.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Retrospective chart review was performed on all patients who underwent pOAI. Smoking status (current and former users versus never-users) was recorded as were numerous demographic and surgical variables. The primary outcome measure was skin reactivity as measured by Holgers score. Secondary outcomes studied included total number of problem visits, minor interventions, and major interventions.

RESULTS

126 patients, 73 with no tobacco history (NT) and 53 with a positive smoking tobacco history (T) underwent pOAI surgery in this study. The T group was found to have higher rates of first postoperative visit soft tissue reactions compared with the NT group (24.5% versus 6.8%, p 1/4 0.011, odds ratio [OR] 4.42, 95% confidence interval [CI]: 1.5, 13.3), but not at long-term follow-up. When former smokers were eliminated from analysis, differences were also found at long- term follow-up (40.9% versus 19.2%, p 1/4 0.037, OR 2.92, 95% CI [1.0 - 8.1]). There were no differences in total number of problem visits or total number of minor or major interventions.

CONCLUSIONS

Patients with a history of tobacco use have a significantly higher rates of skin reactivity compared with patients without, though smoking cessation may partially mitigate long-term risks. Surgeons should be aware of the risks of early skin reactivity and should counsel patients accordingly.

A systematic review of the impact of cigarettes and electronic cigarettes in otology

BACKGROUND

The detrimental systemic effects of cigarette smoking are well established. Though less pronounced in the field of otology, they are proposed to contribute to the global burden of unaddressed hearing loss. Recently, in efforts to stop smoking, individuals have used electronic cigarettes of which the long-term safety data are largely unknown. This study aimed to conduct a systematic review of cigarette smoking and electronic cigarette effects in the field of otology.

METHOD

Relevant articles were identified by a National Institute for Health and Care Excellence healthcare database literature search and by scanning the references of relevant articles and reviews.

RESULTS

A total of 473 articles were identified, with 43 articles included in the review after trials were excluded.

CONCLUSION

Cigarette smoking is associated with recurrent otitis media, otitis media with effusion and sensorineural hearing loss in children exposed to second-hand smoke. In adults, it is associated with active and aggressive chronic suppurative otitis media, worse tympanoplasty success rates, increased post-operative complications and sensorineural hearing loss that is more pronounced in the long term and at high frequencies. The effects of e-cigarettes in otology are largely unknown.

Association between Smoking and 30-Day Outcomes in Otologic Surgery

Objective

To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery.

Study Design

Retrospective cohort study.

Setting

Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016.

Subjects and Methods

Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated.

Results

A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%.

Conclusions

In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events—in particular, wound infections, wound dehiscence, and readmission to hospital.

Long-term Outcomes After Secondary Mastoid Obliteration

OBJECTIVES

To assess long-term outcomes after secondary mastoid obliteration.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

PATIENTS

Adult patients (20-80 yr of age) undergoing secondary mastoid obliteration.

OUTCOME MEASURES

Hearing results (improvement in pure-tone average air-bone gap [PTA-ABG] from baseline) at the time of postoperative audiometry and at least 5 years after surgery, anatomic outcomes (rate of successful tympanic membrane graft healing), and the incidences of observed complications.

RESULTS

An average improvement in PTA-ABG by 16.9 dB (p = 1.8 × 10) was noted. Postoperatively, the PTA-ABG was successfully closed to ≤20 dB in 39.5% (17/43) of patients. The average final PTA-ABG (obtained at least 5 years after surgery) was 25.3 dB, which was also a significant improvement over the preoperative baseline PTA-ABG (p <<< 0.01). Significant complications were observed in 14.0% (6/43) of patients, with 9.3% (4/43) requiring a subsequent surgery. Although 69.8% (30/43) of patients experienced otorrhea preoperatively, otorrhea was only observed in 4.7% (2/43) at any point in time postoperatively.

CONCLUSION

Secondary mastoid obliteration with reconstruction of a more natural posterior canal wall, cartilage tympanoplasty, and ossicular chain reconstruction is a hybrid technique that allows for creation of a safe, dry ear with significant, long-term improvement in hearing and functional outcomes in patients with unstable mastoid cavities.

The Impact of Smoking on Ossiculoplasty Outcomes

OBJECTIVES

To assess the impact of tobacco smoking on outcomes after ossiculoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

PATIENTS

Adult patients (16-88 yr of age) undergoing ossiculoplasty with cartilage tympanoplasty.

OUTCOME MEASURES

Patients were classified as smokers (TOB) or nonsmokers (TOB). Comparisons were then made between these two groups with regard to early and late audiometric outcomes, rate of cure of conductive hearing loss, rate of successful graft healing, and incidence of complications after surgery.

RESULTS

There was no significant difference between the two groups with regard to postoperative ΔPTA-ABG (change in pure-tone average air-bone gap) (-14.4 dB vs. -14.6 dB for TOB vs. TOB, respectively, p = 0.946) or final audiometric outcome (ΔPTA-ABGfinal) (-13.6 dB vs. -11.7 dB for TOB vs. TOB, respectively, p = 0.315), cure of conductive hearing loss, defined as closure of the PTA-ABG to ≤20 dB HL, at postoperative audiometry (75.0% [129/172] for the TOB group vs. 69.3% [52/75] for the TOB group, p = 0.355), late audiometry (71.4% [105/147] for the TOB group vs. 66.7% [44/66] for the TOB group, p = 0.483), or successful graft healing (99.4% in the TOB group vs. 98.7% in the TOB group, p = 0.544). However, complications were observed significantly (p = 0.0003) more often in the TOB group (34.7% [26/75]) than the TOB group (14.5% [25/172]).

CONCLUSION

Smoking is not a significant risk factor for anatomic failure of cartilage tympanic membrane graft or worsened audiometric outcome after ossiculoplasty. However, complications were significantly more common in smokers, supporting the practice of primary tympanostomy tube placement at the time of ossiculoplasty.

Associations between cardiovascular disease and its risk factors with hearing loss-A cross-sectional analysis

OBJECTIVES

To investigate the relationship between hearing loss and cardiovascular disease risk factors.

DESIGN

Cross-sectional study.

METHODS

Participants were recruited between May 2010 and December 2015 and answered a health and risk factor questionnaire. Physical and biochemical assessments were performed.

SETTING

A community-based population.

PARTICIPANTS

A total of 5107 participants born within the years 1946-1964 enrolled in the Busselton Healthy Ageing Study.

MAIN OUTCOME MEASURES

Hearing was assessed behaviourally through the best ear pure-tone average (500, 1000, 2000, 4000 Hz), low-frequency average (250, 500, 1000 Hz) and high-frequency average (4000, 8000 Hz). Self-reported hearing loss, tinnitus and hyperacusis were assessed via questionnaire. Cardiovascular risk factors were assessed via a patient-completed questionnaire and objective measurements including blood pressure, body mass index, waist circumference, lipid profile and glycated haemoglobin.

RESULTS

Of the participants, 54% were female, with the mean age of 58 years (range 45-69 years). Age, sex and family history of hearing loss were consistently strong determinants of hearing loss outcomes. After adjusting for these, obesity, current smoking, peripheral arterial disease and history of cardiovascular disease were significantly associated with pure-tone, low-frequency and high-frequency hearing loss. In addition, high blood pressure, triglyceride and glycated haemoglobin were significantly associated with low-frequency hearing loss. There was a graded association between hearing loss and Framingham Risk Score for cardiovascular risk (P<0.001).

CONCLUSIONS

Established cardiovascular disease and individual and combined cardiovascular disease risk factors were found to be associated with hearing loss. Future research should prospectively investigate whether targeting cardiovascular disease can prevent hearing loss.

Panel 8

Background and Objectives

Although serious complications of otitis media (OM) such as brain abscess are rare, sequelae of OM such as tympanic membrane perforation and atelectatic tympanic membrane are quite common. Inner ear sequelae can cause hearing loss and speech and language problems. The objectives of this article are to provide a state-of-the-art review on recent articles on complications and sequelae of OM in different anatomic locations, from the tympanic membrane to intracranial sites, as well as hearing loss and speech and language development.

Data Sources

Primarily PubMed supplemented by Ovid MEDLINE and the Cochrane Database.

Review Methods

All types of articles related to OM complications and sequelae published in English between January 2007 and June 2011 were identified. A total of 127 relevant quality articles are summarized and included in this report.

Results

Key findings are summarized based on the following major anatomic locations and categories: tympanic membrane; cholesteatoma; ossicular problems; mucosal sequelae; inner ear sequelae; speech and language development; extracranial areas, including mastoiditis and facial nerve paralysis; intracranial complications; and future research goals. New information and insights were gained to prevent complications and sequelae.

Conclusion and Implications for Practice

Over the past 4 years, progress has been made in advancing the knowledge on the complications and sequelae of OM, which can be used to prevent and treat them effectively. Areas of potential future research have been identified and outlined.

Cartilage tympanoplasty in smokers

OBJECTIVES

We compared the outcomes of cartilage tympanoplasty in nonsmokers and smokers.

METHODS

We performed a retrospective chart review of patients who underwent cartilage tympanoplasty in a tertiary academic medical center from 1991 to 2010. There were 129 operations in 118 patients; 84 operations were performed in nonsmokers and 45 operations were performed in smokers. The primary outcome measure was the tympanic membrane graft take rate at the interval and most recent follow-up visits. Secondary measures included recurrence, the need for revision surgery, and hearing outcomes.

RESULTS

Nonsmokers and smokers had comparable long-term rates of intact eardrums (90.6% versus 92.9%; p = 0.99). There was a trend toward a higher rate of recurrent or persistent disease requiring further operation for smokers (13.3% versus 4.7%; p = 0.09). Both groups had improvement in pure tone averages (12.1 dB in nonsmokers and 12.8 dB in smokers) and air-bone gaps (9.6 dB in nonsmokers and 5.1 dB in smokers), although the rates were not statistically significantly different from each other. The rates of success of cartilage tympanoplasty in smokers appear superior to previously published rates of noncartilage tympanoplasty.

CONCLUSIONS

Cartilage tympanoplasty has success rates and postoperative audiological measures that are comparable between smokers and nonsmokers. In smokers, cartilage grafting is superior to noncartilage grafting and is recommended for any patient who smokes and is undergoing tympanoplasty.