The Impact of Smoking on Ossiculoplasty Outcomes

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.

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.

The Utility of Numeric Grading Scales of Middle Ear Risk in Predicting Ossiculoplasty Hearing Outcomes

OBJECTIVE

To assess the usefulness of numeric grading scales of middle ear risk in predicting ossiculoplasty hearing outcomes.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care, academic medical center.

PATIENTS

Adults and children undergoing ossiculoplasty between May 2013 and May 2019 including: synthetic ossicular replacement prosthesis, autograft interposition, bone cement repair, and mobilization of lateral chain fixation.

INTERVENTION

Cases were scored via middle ear risk index (MERI), surgical prosthetic infection tissue eustachian tube (SPITE) method, and ossiculoplasty outcome scoring parameter (OOPS) scale. Preoperative and postoperative hearing outcomes were recorded.

MAIN OUTCOME MEASURE

Statistical correlation between risk score and postoperative pure-tone average air-bone gap (PTA-ABG).

RESULTS

The 179 included cases had average pre and postoperative PTA-ABGs of 30.3dB (standard deviation [SD] 12.7) and 20.3dB (SD 11.1), respectively. Mean MERI, SPITE, and OOPS scores were 4.5 (SD 2.3), 2.8 (SD 1.7), and 3.1 (SD 1.8), respectively. Statistically significant correlations with hearing outcome were noted for all three methods (MERI r = 0.22, p = 0.003; OOPS r = 0.19, p = 0.012; SPITE r = 0.27, p < 0.001). No scale predicted poor (PTA-ABG > 30dB) outcomes; only low SPITE scores predicted excellent (PTA-ABG < 10dB) outcomes (odds ratio [OR] 0.74 [Confidence Interval: 0.57 - 0.97], p = 0.032).

CONCLUSIONS

Significant weak correlations between each middle ear risk score and hearing outcomes were encountered. Although only the SPITE method predicted postoperative PTA-ABG, it was not overwhelmingly superior. Current grading scale selection may be justified by familiarity or ease of use.

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.

Long-Term Hearing Results After Ossiculoplasty

OBJECTIVES

To determine if the OOPS index is predictive of long-term hearing results after ossiculoplasty.

STUDY DESIGN

Case series with retrospective chart review.

SETTING

Tertiary care otology practice.

PATIENTS

Adult and pediatric patients (3-88 years of age).

INTERVENTIONS

Ossiculoplasty with cartilage tympanoplasty, with or without mastoidectomy.

OUTCOME MEASURES

Primary outcome measures included short-term hearing results (pure-tone average air-bone gap [PTA-ABG] measured between 60 days and 1 year after surgery), long-term hearing results (PTA-ABG measured ≥5 years after surgery), and the rate of successful ABG closure to ≤20 dB. Secondary measures included the need for revision surgery, delayed tympanic membrane graft failure, worsening conductive hearing loss (after an initially satisfactory hearing result), and recurrence of cholesteatoma.

RESULTS

There was no significant difference between adults and children for short-term hearing results (average post-op PTA-ABG was 18.9 dB vs. 19.8 dB, respectively; p = 0.544), long-term hearing results (average final PTA-ABG was 19.3 dB vs. 19.4 dB, respectively; p = 0.922), or rate of ABG closure to less than 20 dB (63.1% vs. 58.0%, p = 0.282). Spearman's rank-order correlation (ρ) identified a strong positive correlation between OOPS index score and average post-operative PTA-ABG (ρ = 0.983; p < 0.001; 2-tailed), as well as average long-term PTA-ABG (ρ = 0.950, p < 0.001; 2-tailed).

CONCLUSIONS

The OOPS index makes it possible to accurately prognosticate hearing outcomes in adult and pediatric patients undergoing ossiculoplasty in both the short term and the long term.