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Rahman R, Patel C, Hathaway C, Patel E, Bouldin E, Tey CS, Raol N, Alfonso K. Opioid stewardship and perioperative management of pediatric tympanoplasty. Int J Pediatr Otorhinolaryngol 2023; 173:111713. [PMID: 37696228 DOI: 10.1016/j.ijporl.2023.111713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/14/2023] [Accepted: 08/27/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To provide insight into the intraoperative management, admission course, pain management, and graft success of microscope- and endoscope-assisted tympanoplasty. STUDY DESIGN Retrospective Chart Review. METHODS This study included children 18 years and younger who underwent ambulatory tympanoplasty at a tertiary pediatric hospital between January 2018 and December 2020. Medical records were reviewed and information about intraoperative factors, surgical approach, laterality, complications, and post-operative perforation closure success rates was collected. Multivariate analysis was performed to compare and contrast the two surgical approaches. RESULTS The review included 321 pediatric patients who underwent a tympanoplasty. Endoscopic tympanoplasty accounted for 17.4%, while microscopic tympanoplasty accounted for 82.6%. In both approaches, the rate of intraoperative complications, postoperative complications, audiological improvements, and perforation closure success rates were statistically similar. However, patients who underwent endoscopic tympanoplasty were 3.96 times less likely to require opioids in the post-anesthesia care unit (PACU) and had a shorter post-operative admission length. This pattern emerged regardless of the type of graft used. Obtaining an autograft was not associated with a higher opioid requirement in the PACU. CONCLUSION While both approaches are viable, our findings demonstrate the reduced need for opioids with similar success rates following an endoscopic tympanoplasty. Ultimately, the trade-off for the minimally invasive endoscopic approach appears to be a less painful experience for the child while promoting clinically appropriate opioid stewardship in the perioperative setting.
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Affiliation(s)
- Rahiq Rahman
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chhaya Patel
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Campbell Hathaway
- University of South Carolina School of Medicine, Greenville, SC, USA
| | - Eshan Patel
- Emory University School of Medicine, Atlanta, GA, USA
| | - Emerson Bouldin
- Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ching Siong Tey
- Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristan Alfonso
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Sun WH, Fan JK, Huang TC. The Efficacy of DW and T1-W MRI Combined with CT in the Preoperative Evaluation of Cholesteatoma. J Pers Med 2022; 12:jpm12081349. [PMID: 36013298 PMCID: PMC9409941 DOI: 10.3390/jpm12081349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/20/2022] Open
Abstract
Objective: This study aims to assess the efficacy of diffusion-weighted (DW) and T1-weighted (T1W) magnetic resonance imaging (MRI) combined with high-resolution computed tomography (HRCT) (together as DW-T1W-CT) in the preoperative evaluation of the presence and extent of cholesteatoma, which helps determine whether a patient is suitable for transcanal endoscopic ear surgery (TEES). Methods: This retrospective study included 35 patients (18 male and 17 female) aged from 2 to 81 years diagnosed with chronic otitis media with or without cholesteatoma, who had received surgical treatment and a preoperative MRI and HRCT during the period of December 2015 to December 2020 at Cathay General Hospital. We compared the preoperative DW-T1W-CT findings with the intraoperative findings and final pathologic diagnosis. The accurate predictive value was evaluated using the presence of cholesteatoma and its extent. Results: Regarding the efficacy of detecting cholesteatoma, we found a sensitivity of 92% (23/25 cases with cholesteatoma), a specificity of 90% (9/10 cases without cholesteatoma), and an overall accurate predictive value of 91.4% (32/35) by using combined DW-T1W-CT imaging. With regard to evaluating the extent of cholesteatoma, the combined DW-T1W-CT images obtained an accurate predictive value of 84% (21/25 cases of cholesteatoma). Conclusion: Combined DW-T1W-CT has been proven to be a reliable tool in detecting the presence of cholesteatoma. It is also useful in preoperatively depicting the extent of cholesteatoma, which is crucial for determining whether a patient is suitable for TEES, aiding in surgical planning and patient consultation.
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Affiliation(s)
- Wan-Hsuan Sun
- Department of Otolaryngology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Jiun-Kai Fan
- Department of Radiology, Cathay General Hospital, Taipei 106, Taiwan
| | - Tzu-Chin Huang
- Department of Otolaryngology, Cathay General Hospital, Taipei 106, Taiwan
- Correspondence:
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Review of Transcanal Endoscopic Ear Surgery (TEES) and Bioengineering for Pediatric Otologic Surgery. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00417-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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A Novel Instrument for Endoscopic Ear Surgery With a Steerable Flexible Tip: A Pediatric Anatomical Validation Study. Otol Neurotol 2021; 42:e1683-e1690. [PMID: 34238900 DOI: 10.1097/mao.0000000000003237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS This study compares the reaching ability of two classes of transcanal endoscopic ear surgery (TEES) instruments when operating on difficult to access anatomical targets; two novel instruments with steerable flexible tips (SFT-A and SFT-B) and suction capability are compared with standard commercially available tools. BACKGROUND TEES surgeons identified the need for a new surgical instrument that can enable accessibility of all areas visualized by the endoscope. This motivated the development of the two instrument prototypes. METHODS Six temporal bone models were 3D printed based on CT data from five cholesteatoma patients. Four anatomical targets were marked on each model. Using these targets, the reaching ability while using four standard TEES instruments were compared with the SFT-A and SFT-B prototypes by five surgeon participants. Results were analysed to compare success rates of contacting each target using each tool by fitting four Firth's logistic regression models. This calculated the statistically significant differences (p < 0.05) in tool success rate. RESULTS Using SFT-A to contact the sinus tympani (100%) was significantly more successful than the Panetti suction dissector for atticus (PAT) (77%) and to contact the sinodural angle (0%) was less successful than the PAT (10%) and SFT-B (93%). Using SFT-B to contact the lateral semicircular canal (90%) was significantly more successful than all current tools and to contact the sinodural angle (93%) was significantly more successful than all tools. CONCLUSION Using SFT-B enables enhanced accessibility of anatomical structures during TEES which may lead to less extensive bone removal to facilitate minimally invasive TEES.
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Ridge SE, Shetty KR, Lee DJ. Current trends and applications in endoscopy for otology and neurotology. World J Otorhinolaryngol Head Neck Surg 2021; 7:101-108. [PMID: 33997719 PMCID: PMC8103526 DOI: 10.1016/j.wjorl.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 09/28/2020] [Indexed: 01/03/2023] Open
Abstract
There has been a rapid increase in endoscopic ear surgery for the management of middle ear and lateral skull base disease in children and adults over the last decade. In this review paper, we discuss the current trends and applications of the endoscope in the field of otology and neurotology. Advantages of the endoscope include excellent ergonomics, compatibility with pediatric anatomy, and improved access to the middle ear through the external auditory canal. Transcanal endoscopic ear surgery has demonstrated comparable outcomes in the management of cholesteatoma, tympanic membrane perforations, and otosclerosis as compared to microscopic approaches, while utilizing less invasive surgical corridors and reducing the need for postauricular incisions. When a postauricular approach is required, the endoscopic-assisted transmastoid approach can avoid a canal wall down mastoidectomy in cases of cholesteatoma. The endoscope also has utility in treatment of superior canal dehiscence and various skull base lesions including glomus tumors, meningiomas, and vestibular schwannomas. Outside of the operating room, the endoscope can be used during examination of the outer and middle ear and for debridement of complex mastoid cavities. For these reasons, the endoscope is currently poised to transform the field of otology and neurotology.
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Affiliation(s)
- Sarah E Ridge
- Eaton-Peabody Laboratories, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Kunal R Shetty
- Eaton-Peabody Laboratories, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Daniel J Lee
- Eaton-Peabody Laboratories, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Rusetsky YY, Meitel IY, Anikin AV, Pashkova AE, Arutyunyan SK, Rozmanov EO, Krasivicheva OV. [External ear canal parameters and endoscopic otosurgery in children]. Vestn Otorinolaringol 2020; 85:24-29. [PMID: 32885632 DOI: 10.17116/otorino20208504124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Main difficulties of endoscopic ear surgery in children could be connected with width of external ear canal (EEC) and endoscope diameter discrepancy. OBJECTIVE To investigate EEC parameters in children, to determine cross section and to develop the recommendations whenever possible of endootosurgery performance in children. MATERIAL AND METHODS Research included two stages. First - average values determination of narrowest site EEC in children according to computer tomograms. Second - determination of age of the patient and the amount of acoustical pass at which there are specifications for performance of interventions endoscopic. RESULTS EEC square: 1-3 years - 12.6±1.91 mm2, diameter is 4.01±0.59 mm; 4-7 years - 16.8±1.34 mm2, diameter is 5.34±0.43 mm; 8-11 years - 21.7±1.38 mm2, diameter is 6.9±0.45 mm; 12-18 years - 31.3±4.27 mm2, diameter is 9.96±1.4 mm. The difference between parameters at each of age groups was statistically reliable. Comfortable work endoscopically is possible with EEC square 20.4±3.19 mm2 and more. This corresponds to average value of EEC in 8-18 years. CONCLUSIONS Endoscopic ear surgery is inexpedient in children up to 4 years. It is necessary to expect that intervention will be exigeant and transition to the microscopic equipment is required in case of 4-7 years old patients. Endoscopic ear surgery can be used with success to performance of various manipulations and surgical interventions on a middle ear in patients 8-18 years old.
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Affiliation(s)
- Yu Yu Rusetsky
- National Medical Research Center for Children's Health, Moscow, Russia
| | - I Yu Meitel
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A V Anikin
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A E Pashkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - S K Arutyunyan
- National Medical Research Center for Children's Health, Moscow, Russia
| | - E O Rozmanov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O V Krasivicheva
- National Medical Research Center for Children's Health, Moscow, Russia
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Miller KA, Fina M, Lee DJ. Principles of Pediatric Endoscopic Ear Surgery. Otolaryngol Clin North Am 2019; 52:825-845. [DOI: 10.1016/j.otc.2019.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Contribution of the Use of a Pen-Type Endoscope to Evaluate and Treat Ears Simultaneously During Cleft Palate Surgery in Late Presented Cases. J Craniofac Surg 2019; 30:1211-1213. [PMID: 30865113 DOI: 10.1097/scs.0000000000005272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The prevalence of secretory otitis media is very high among the nonoperated cleft palate patients. METHODS Ninety-one cleft palate operations were performed on late presented cases in Sudan, Africa. The surgeries were performed according to the Veau-Wardill-Kilner push-back technique. A laptop connected pen-type endoscopic camera was used to evaluate the tympanic membrane and address middle ear disease in all patients simultaneously. The procedure was performed after removing wax from the external auditory canal. A small incision was made with a myringotomy knife through the layers of the tympanic membrane if any sign of fluid collection was observed, after which the middle ear effusion was evacuated and the ventilation tube was inserted. RESULTS This procedure was undertaken in 182 ears; 41 ears (22.5%) were healthy, 19 ears (10.5%) had chronic perforations, 122 ears (67%) underwent myringotomy procedures, and 54 (44.2%) were treated by inserting a ventilation tube. Despite the challenging work environment, standard monitoring facilities were available and all operations were completed with no early complications. CONCLUSION The pen-type camera instead of an operating microscope was a tremendous contribution, as it was easy to handle and contributed to the good outcomes. The use of this technique is strongly recommended in surgical camps. LEVEL OF EVIDENCE III.
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