Revision surgery for chronically discharging mastoid cavities: mastoid obliteration with canal wall reconstruction versus non-obliteration surgery

Ceftazidime Poloxamer Gel: Expanding the Therapeutic Armamentarium for Ciprofloxacin-Resistant Pseudomonas Mastoid Cavity Otorrhea

OBJECTIVE

To present and evaluate the treatment of ciprofloxacin-resistant Pseudomonas mastoid cavity otorrhea with a ceftazidime thermosensitive poloxamer gel.

STUDY DESIGN

A retrospective clinical capsule report.

PATIENTS

Three patients diagnosed with ciprofloxacin-resistant Pseudomonas otorrhea in the setting of a previous canal-wall-down mastoidectomy between March 2019 and June 2023 visiting our tertiary care institution were retrospectively reviewed.

INTERVENTION

Application of a 2% ceftazidime thermosensitive poloxamer gel to mastoid cavity.

MAIN OUTCOME MEASURES

No evidence of disease during microscopic inspection of the ear within a month of initial treatment or bacterial eradication on subsequent culture.

RESULTS

Two patients had complete resolution of symptoms and achieved a safe and dry ear after topical application of the hydrogel. The second patient had pseudomonal eradication on culture, but persistent otorrhea due to other multidrug-resistant bacteria and an anatomically unfavorable mastoid cavity, which ultimately resolved after revision surgery.

CONCLUSIONS

This small case series suggests that topical treatment of mastoid cavity otorrhea with a 2% ceftazidime poloxomer gel is a potential therapeutic avenue in patients with ciprofloxacin-resistant Pseudomonas.

Surgical Treatment for Troublesome Mastoid Cavities: Canal Wall Reconstruction With Bony Obliteration Versus Subtotal Petrosectomy

INTRODUCTION

A chronically discharging modified radical mastoid cavity may require surgical intervention. We aim to explore two techniques.

OBJECTIVE

To compare outcomes of subtotal petrosectomy (STP) and canal wall reconstruction with bony obliteration technique (CWR-BOT).

STUDY DESIGN

Retrospective cohort study.

SETTING

A tertiary referral center.

PATIENTS

All patients with a chronically discharging mastoid cavity surgically treated at the Radboud University Medical Center by STP or CWR-BOT in 2015 to 2020, excluding patients with preoperative cholesteatoma.

MAIN OUTCOME MEASURES

Dry ear rate, audiometry, and rehabilitation.

SECONDARY OUTCOME MEASURES

Healing time, number of postoperative visits, complications, cholesteatoma, and need for revision surgeries.

RESULTS

Thirty-four (58%) patients underwent STP, and 25 (42%) CWR-BOT. A dry ear was established in 100% of patients (STP) and 87% (CWR-BOT). The air-bone gap (ABG) increased by 12 dB in STP, and decreased by 11 dB in CWR-BOT. Postoperative ABG of CWR-BOT patients was better when preoperative computed tomography imaging showed aerated middle ear aeration. ABG improvement was higher when ossicular chain reconstruction took place. Mean follow-up time was 32.5 months (STP) versus 40.5 months (CWR-BOT). Healing time was 1.2 months (STP) versus 4.1 months (CWR-BOT). The number of postoperative visits was 2.5 (STP) versus 5 (CWR-BOT). Cholesteatoma was found in 15% (STP) versus 4% (CWR-BOT) of patients. Complication rate was 18% (STP) and 24% (CWR-BOT) with a need for revision in 21% (STP) and 8% (CWR-BOT), including revisions for cholesteatoma.

CONCLUSION

STP and CWR-BOT are excellent treatment options for obtaining a dry ear in patients with a chronically discharging mastoid cavity. This article outlines essential contributing factors in counseling patients when opting for one or the other. Magnetic resonance imaging with diffusion-weighted imaging follow-up should be conducted at 3 and 5 years postoperatively.

Allograft bone vs. bioactive glass in rehabilitation of canal wall-down surgery

Canal wall-down (CWD) mastoidectomy creates a radical cavity that modifies the anatomy and physiology of the middle ear, thus preventing it from being self-cleaning and causing epidermal stagnation in the posterior cavities. Canal wall-down tympanomastoidectomy with reconstruction (CWDTwR) can obliterate such radical cavities. The main objective of this study was to compare postoperative results after CWDTwR by using either bone allografts or 45S5 bioactive glass as a filling tissue with an 18-month follow-up. This was a single-center observational trial including all patients undergoing CWDTwR. Patients were divided into two groups according to the filling material used: allograft bone (AB group) or 45S5 bioactive glass (BG group). Clinical monitoring was performed regularly, with control imaging performed at 18 months (CT scan and DW MRI). The two groups were compared with the t test for quantitative variables and the chi square test for qualitative variables (no revision surgery, audiometric results, complications, mastoid obliteration volume). Thirty-two patients underwent CWDTwR between October 2015 and 2018. The mean age was 48 years, and 71.9% (23/32) were men. A total of 46.9% (15/32) of the patients had undergone at least 3 middle-ear surgeries prior to CWDTwR. The most frequent preoperative symptom was otorrhea (100.0%, 32/32), and only 12.5% (4/32) experienced dizziness. Fifteen and 17 patients underwent surgery with bone allografts and 45S5 bioactive glass, respectively. At 18 months post-operation, 53.3% of the patients (8/15) in the AB group presented with recurrent otorrhea versus 5.9% (1/17) of patients in the BG group (p = 0.005). Seventy-eight percent (7/9) of symptomatic patients had undergone revision surgery at 18 months postoperation: 40.0% (6/15) in the AB group and 5.9% (1/17) in the BG group (p = 0.033). One patient's surgery was cancelled due to the COVID-19 pandemic, and one patient refused surgery. The effects of CWDTwR with bone allografts are disappointing in early follow-up, with significant resorption leading to a 40.0% revision surgery rate. 45S5 BG is a simple solution, with preliminary results that are superior to those of AB. However, prospective controlled studies with longer follow-up times are needed to evaluate the value of BG versus other synthetic materials (such as hydroxyapatite) in surgical management of CWDTwR.Trial registration: retrospectively registered.

Efficacy of S53P4 Bioactive Glass for the Secondary Obliteration of Chronically Discharging Radical Cavities

Objective

Present the results of the secondary obliteration of chronically discharging radical cavities using S53P4 bioactive glass (BAG).

Study Design

Retrospective cohort study.

Setting

Single-center study.

Methods

A single-center retrospective cohort study was conducted of all patients that underwent secondary obliteration of persistently draining radical cavities using S53P4 BAG between 2011 and 2022. Patients with middle ear cholesteatoma were excluded. The main outcome was postoperative otorrhea, as indicated by Merchant grading.

Results

In total, 97 patients were included. The median postoperative follow-up time was 3.9 years (range 0.5-10.4). Average time between the original canal wall down surgery and the secondary obliteration was 25.3 years (SD 11.7, range 2-66). At the most recent follow-up visit, a Merchant grade of 0 to 1 was observed in 95% of the cases. There were no cases of sensorineural hearing loss or facial palsy, one case developed a retro auricular skin defect and 1 patient developed CSF leakage. Minor complications were seen in 10 patients (10%). Ossicular chain reconstruction with a titanium prosthesis was performed in 42 cases, resulting in a median improvement of 11.2 dB in air conduction thresholds. In 9/42 cases (21%), closure of the postoperative air-bone gap to ≤20 dB was achieved. Twenty-five percent of cases could be discharged from out-patient visits.

Conclusion

Revision of persistently draining radical cavities with BAG obliteration is feasible and results in a dry and safe ear in 95% of the patients, thereby enabling wearing of a conventional hearing aid. Out-patient visits could be ceased in 25% of the cases.