Subtotal Petrosectomy and Cochlear Implantation in Children With Chronic Suppurative Otitis Media: A Single Institutional Experience

BACKGROUND AND OBJECTIVES

Chronic suppurative otitis media (CSOM) with or without cholesteatoma is a frequent chronic inflammatory condition in children, which may lead to severe hearing loss that affects speech development. Treatment of recurrent CSOM associated with unserviceable hearing requires a specialized approach with regard to disease eradication and hearing rehabilitation. In this study, we investigated the advantages of subtotal petrosectomy (SP) combined with cochlear implantation (CI) in children with CSOM associated with unserviceable hearing and describe our experience with regard to the efficacy of this method, together with a literature review.

SUBJECTS AND METHODS

SP with sequential or simultaneous CI was performed in three children (four ears), and postoperative audiometric data were recorded.

RESULTS

The study included two male and one female patient. Mean age at the time of SP was 10.75 years (7-13 years). Sequential implantation was performed in three ears. Facial nerve palsy occurred after SP in one patient. The latest word recognition scores of Cases 1, 2, and 3 were 80% (at 60 dB), 75% (at 60 dB), and 70% (at 50 dB) and 90% (at 50 dB), respectively.

CONCLUSIONS

SP with CI may be safe and reliable in children with CSOM associated with unserviceable hearing.

Quality-of-Life Outcomes After Modified Subtotal Petrosectomy With Ear Canal Closure for Chronic Otitis Media

OBJECTIVE

To assess quality-of-life (QoL) outcomes after modified subtotal petrosectomy with ear canal closure (mSTP) for chronic otitis media.

STUDY DESIGN

Survey study.

SETTING

Tertiary referral center.

PATIENTS

Patients with chronic otitis media.

INTERVENTIONS

mSTP.

MAIN OUTCOME MEASURES

Survey results from enrolled patients on the validated disease-specific Chronic Ear Survey (CES) and Chronic Otitis Media Outcome Test-15 (COMOT-15) regarding their current state of health and, if surgery was performed within 3 years of enrollment, their state of health before mSTP.

RESULTS

A total of 23 patients were studied, including 19 who underwent surgery within 3 years of enrollment. Postoperatively, mean total CES scores were 80 and COMOT-15 scores were 41, with a higher CES and a lower COMOT-15 indicating better QoL. There were statistically significant improvements after mSTP in the CES activity restriction (25% difference; p = 0.008), symptom (17% difference; p = 0.007), and medical resource (13% difference; p = 0.03) domain and total (18% difference; p = 0.006) scores. In addition, there were statistically significant improvements in the COMOT-15 ear symptom (-22% difference; p < 0.001) domain and total (-16% difference; p = 0.01) scores; however, improvements in the hearing function and mental health domains did not achieve statistical significance. Postoperative COMOT-15 total scores were significantly better for patients who underwent aural rehabilitation compared to those who did not (-17% difference; p < 0.001).

CONCLUSION

Modified subtotal petrosectomy with ear canal closure is a useful intervention for patients with recalcitrant chronic otitis media, offering improved QoL in appropriately selected patients. Aural rehabilitation, when feasible, provides the potential for further QoL improvement.

Subtotal petrosectomy and cochlear implantation

Objective

The objective of this study is to analyse surgical outcomes in a series of patients who underwent subtotal petrosectomy in combination with cochlear implantation.

Methods

Retrospective chart review. Thirty patients (32 ears) underwent subtotal petrosectomy and cochlear implantation in one stage. Indications for subtotal petrosectomy included the following: cholesteatoma, chronic otitis media, previous canal wall-down, osteoradionecrosis, revision surgery for clinical reasons, inner ear malformations, middle ear anatomical variations and severe cochlear ossification.

Results

Follow-up ranged from 2 to 54 months. Only 2 complications related to the subtotal petrosectomy (1 subcutaneous abdominal haematoma and 1 subcutaneous abdominal seroma) occurred in this series. Complete electrode insertion was achieved in all but 4 cases.

Conclusions

Subtotal petrosectomy is a safe procedure and can offer technical advantages in some cases of complex cochlear implantation.

Subtotal Petrosectomy and Cochlear Implantation: A Systematic Review and Meta-analysis

IMPORTANCE

Subtotal petrosectomy (STP) has been more frequently performed to prepare ears with unfavorable conditions for cochlear implantation.

OBJECTIVES

To provide an overview of indications for and complications of STP and cochlear implantation and to compare outcomes between single vs multistage procedures and between pediatric vs adult populations.

DATA SOURCES

A search of PubMed, Scopus, Ovid, and the Cochrane Library was performed from the databases' inception to January 23, 2020, for studies evaluating STP for cochlear implantation.

STUDY SELECTION

Studies with a minimum follow-up of 3 months and no missing data regarding postoperative outcomes were included. Of the initial 570 studies identified, 27 (4.7%) met selection criteria.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently assessed study eligibility according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines; discrepancies were resolved by a third reviewer. Extracted data included patient demographics, indications for STP, rates of complications, and cholesteatoma recidivism when applicable. Data were pooled using a random- or a fixed-effects model when appropriate.

MAIN OUTCOMES AND MEASURES

The primary study outcome was rate of global complications stratified by patient- and surgery-level characteristics.

RESULTS

Twenty-seven unique studies with 377 unique patients (54.2% male; mean age, 50.6 [range, 1-99] years) undergoing 397 STP procedures and cochlear implantation were included. Of these procedures, 299 of 394 cases with the information reported (75.9%) were single procedures and 95 (24.1%) were multistage procedures. Of the total 397 STP procedures, most common indications included chronic otitis media (220 cases [55.4%]), previous open mastoid cavity (141 [35.5%]), cholesteatoma (74 [18.6%]), and cochlear ossification (29 [7.3%]). The overall complication rate was 12.4% (95% CI, 9.4%-15.9%); overall cholesteatoma recidivism rate was 9.3% (95% CI, 4.3%-17.1%). Complication rates did not significantly differ based on stage or age of patients. Cases with cholesteatoma more often underwent multistage vs single-stage procedures (23 of 54 [42.6%] vs 35 of 174 [20.1%]).

CONCLUSIONS AND RELEVANCE

Across all age groups, STP has been shown to be an effective surgical operation in preparing an ear with unfavorable conditions for cochlear implantation. The potential indications for which cochlear implantation can be performed have expanded with the use of STP. Presence of cholesteatoma might indicate that a multistage procedure should be performed. Lastly, with complication rates comparable to those in adult patients, STP can be considered in children requiring cochlear implantation to minimize ear-related issues and allow benefit from cochlear implantation.

The Value of Diffusion-Weighted MRI in the Long-term follow-up After Subtotal Petrosectomy for Extensive Cholesteatoma and Chronic Suppurative Otitis Media

OBJECTIVE

To report the long-term follow-up with diffusion-weighted magnetic resonance imaging (DW MRI) after subtotal petrosectomy (SP) with blind sac closure of the external auditory canal for extensive cholesteatoma and chronic suppurative otitis media.

STUDY DESIGN

Retrospective clinical record study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-one patients (31 ears) with extensive cholesteatoma and 17 patients (19 ears) with chronic suppurative otitis media without cholesteatoma who underwent SP between July 1995 and December 2015.

INTERVENTIONS

All 48 patients were followed clinically and with DW MRI to rule out residual cholesteatoma.

MAIN OUTCOME MEASURE

Residual cholesteatoma, indicated by a marked hyperintensity on non-echoplanar (non-EP) DW MRI.

RESULTS

In the cholesteatoma group the mean interval between surgery and the latest DW MRI was 3.9 years. Seven patients presented with a residual cholesteatoma pearl. The mean interval between surgery and detection of residual disease was 3.7 years. In the chronic suppurative otitis media group the mean interval between surgery and the latest DW MRI was 5.3 years. Residual cholesteatoma was found in three patients. Mean interval between surgery and the detection of disease was 4.5 years.

CONCLUSIONS

This study shows the importance of DW MRI in the follow-up after SP for cholesteatoma and chronic suppurative otitis media. A little higher residual cholesteatoma rate was found compared with earlier studies, where patients were followed only clinically. One may wonder whether reintervention is always needed or whether in selected cases with small pearls, one may still observe these by a watchful waiting policy with DW MRI.

Middle Ear Obliteration with Blind-Sac Closure of the External Auditory Canal for Spontaneous CSF Otorrhea

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.

Systematic Review and Meta-analysis of Surgical Complications following Cochlear Implantation in Canal Wall Down Mastoid Cavities

Objective

We sought to assess the complication rates following cochlear implantation in canal wall down mastoid cavities in adults and children.

Data Sources

A systematic review of English articles from PubMed, Web of Science, EMBASE, and the Cochrane Library. Additional studies were identified by reviewing the reference lists of the originally identified studies.

Review Methods

Studies were included that reported on surgical outcomes following cochlear implantation in canal wall down mastoid cavities. Two authors, using predefined data fields, independently reviewed all articles while tabulating study quality indicators. A meta-analysis of proportions was conducted on select cohorts to determine weighted complication rates.

Results

Forty-two articles were included that accounted for 424 patients and described surgical outcomes following cochlear implantation in canal wall down mastoid cavities. In a comparison of the postoperative complication rates, overclosing the external auditory meatus had significantly fewer global complications than did maintaining a canal wall down mastoid cavity ( P = .027). In a comparison of the complication rates (1) between staging the cochlear implantation and performing external auditory meatus overclosure simultaneously with cochlear implantation and (2) between pediatric and adult cochlear implantation recipients with external auditory meatus overclosure, there were no significant differences ( P = .085 and P = .92, respectively).

Conclusion

Overclosing the external auditory meatus at the same time of cochlear implantation leads to significantly fewer complications when compared with maintaining a canal wall down mastoid cavity with soft tissue coverage of the electrode array.

Cochlear Implantation in Canal Wall Down Mastoid Cavities

Cochlear implantation in canal wall down mastoid (CWD) cavities is fraught with the issue of how best to manage the mastoid cavity. Decision points include whether the external auditory meatus should be overclosed, whether the implantation should be staged, or even if the eustachian tube should be plugged. Given these options, we sought to describe our experience of cochlear implantation in CWD cavities. Among evaluation of subjects ≥18 years of age, 9 had cochlear implants placed in CWD mastoid cavities, 7 of which had the external auditory meatus overclosed, while 2 maintained open cavities following implantation. With an average follow-up of 36.7 months (median, 22.8 months), 2 subjects who had overclosure developed meatal dehiscences requiring further intervention, while no complications were observed in the 2 patients who maintained open cavities.

The use of subtotal petrosectomy in cochlear implant candidates with chronic otitis media

Cochlear implants (CI) candidates with chronic otitis media require special attention and management. The need of opening of the inner ear creates potential routes of spread of infection to subarachnoid spaces and lead to meningitis. The aim of the study was to analyse the technique and complications of subtotal petrosectomy (SP) in cochlear implant candidates with chronic otitis media at three different CI centres. A retrospective study was carried out in three Territory Referral Hospitals. The centres follow Fisch's philosophy and surgical techniques of SP. The study group consisted of 19 patients, 4 men and 15 women, aged 12-82 years. All patients underwent SP with either primary or staged CI implantation. Indications for single or a staged management, difficulties during surgery and complications were analysed. Skin and muscle flap design in primary and revision cases as well as imaging follow-up strategy are discussed. In 14 patients implantation was performed in a single stage and in 5 cases in two stages. Follow-up ranged from 8 months to 10 years. All the patients use their implants and there were no major nor minor complications. The use of subtotal petrosectomy with cochlear implants is a safe and efficient technique when strict surgical steps and rules are applied. Closure of the external ear canal after previous meatoplasty can be challenging and extreme care dissecting the skin flaps is required. In patients with extensive cholesteatoma, active discharge from the ear with resistant bacteria or an "unstable" situation, the procedure can be staged.

Canal wall reconstruction in cholesteatoma surgeries: rate of residual

To evaluate the rates of residual and recurrent cholesteatoma following canal wall reconstruction (CWR) tympano-mastoidectomy with mastoid obliteration, for the treatment of chronic otitis with cholesteatoma. Consecutive cohort study. We included patients following surgical cholesteatoma removal by CWR tympano-mastoidectomy with hydroxyapatite mastoid obliteration from 2008 to 2012. We analyzed audiometric and postoperative radiologic data. We determined the rates of residual disease and recurrence, and evaluated postoperative complications. Thirty-six ears were included in this study. The mean follow-up after surgery was 24 months (range 12.3-51.4 months). The recurrence rate was 3.1% (one case) and the rate of residual disease was 6.2% (two cases including one of iatrogenic cholesteatoma). No canal-wall-down tympanoplasty was required. Local infection was detected in 33% of cases and was successfully treated with appropriate antibiotics. Postoperative audiometry showed no impairment of the cochlear reserve. No postoperative facial palsy or deafness was observed. CWR permits well exposure of the lesion, making complete excision of the cholesteatoma possible. This study showed a decreasing of the rate of residual cholesteatoma and must be confirmed with further studies. CWR makes it possible to use hearing aids for auditory rehabilitation.

Blind sac closure of the external auditory canal for chronic middle ear disease

OBJECTIVE

To determine the rate of complications in patients who underwent blind sac closure of the external auditory canal for chronic middle ear disease.

STUDY DESIGN AND SETTING

Retrospective case review of 29 patients from combined public tertiary and private centers who underwent blind sac closure between 2000 and 2011.

PATIENTS

All patients undergoing blind sac closure with minimum follow-up period of 1 year were included. There were 14 male and 15 female subjects with a mean age of 54 years at time of surgery.

MAIN OUTCOME MEASURE

Complications were identified as major and minor complications, with particular attention to the rate of residual cholesteatoma.

RESULTS

Thirty-two cases of blind sac closure were identified in 29 patients, with 3 patients undergoing bilateral procedures. We identified 8 major and 6 minor complications. Of the major complications, 3 were infections, and 5 involved residual cholesteatoma. Recurrent cholesteatoma was identified between 2 years 8 months and 6 years 6 months.

CONCLUSION

Although blind sac closure of the external ear canal is a functionally useful procedure, it is associated with a significant rate of complications. In particular, we noted a higher rate of residual cholesteatoma in our series, when compared with the published literature. Appropriate patient selection to ensure long-term follow-up compliance for at least 8 years is essential for the detection of recurrent cholesteatoma.

Mastoid cavity obliteration and Vibrant Soundbridge implantation for patients with mixed hearing loss

OBJECTIVES/HYPOTHESIS

To review the results of obliteration of a preexisting mastoid cavity with abdominal fat and Vibrant Soundbridge implantation in patients with mixed hearing loss (MHL) and to compare the data with results of Vibrant Soundbridge implantation in patients with MHL without mastoid cavity and with pure sensorineural hearing loss (SNHL).

STUDY DESIGN

Retrospective chart analysis of 10 patients (10 ears) with MHL and preexisting mastoid cavity, 18 patients (19 ears) with MHL alone and nine patients (10 ears) with SNHL treated in one tertiary referral center.

METHODS

Vibrant Soundbridge implantation and obliteration in case a mastoid cavity existed previously. Pure tone audiometry (average air-bone gap, average functional gain), speech audiometry (Freiburg Monosyllabic Test) and complication rate were main outcome measures.

RESULTS

Postoperative average air-bone gap was -15.1 ± 21.2 dB in patients with MHL with mastoid cavity obliteration, -7.2 ± 11.4 dB in patients with MHL without mastoid cavity, and -5.7 ± 11.2 dB in patients with SNHL. Average functional gain was 40.0 ± 23.5 dB, 39.7 ± 12.1 dB, and 9.5 ± 10.6 dB. Postoperative speech discrimination rate was 77.9 ± 20.8%, 83.3 ± 13.6%, and 83.6 ± 6.3%. No severe intraoperative or postoperative complications were noted.

CONCLUSIONS

Mastoid cavity obliteration during Vibrant Soundbridge implantation in patients with MHL and preexisting mastoid cavity is a safe procedure. The audiometric results are satisfying and comparable to those of other patient groups implanted with the same device.

LEVEL OF EVIDENCE

4.