Evaluation of three cyanoacrylate glues for ossicular reconstruction

Removal of Cyanoacrylate Glue From the External Auditory Canal With Hydrogen Peroxide and Acetic Acid: A Case Report

Ear canal foreign bodies are commonly encountered in the field of otolaryngology. This is especially common in the pediatric otolaryngology discipline. As a foreign body, cyanoacrylate glue (also called "super glue") can be difficult to remove and cause significant patient distress. Multiple solvents can be described as aiding in removing such foreign bodies. Here, a case is described in which hydrogen peroxide and acetic acid were used sequentially to remove cyanoacrylate glue from the external auditory canal. We describe a technique allowing en bloc removal of the cyanoacrylate glue. Thankfully, the patient's hearing returned to baseline post-operatively with minimal complications. Overall, cyanoacrylate glue can be a very difficult foreign body to remove from the ear canal. In this case, the sequential use of hydrogen peroxide and acetic acid to soak the glue was a safe and successful method to facilitate glue removal from the ear canal.

Non-invasive methods for imaging hepatic steatosis and their clinical importance in NAFLD

Hepatic steatosis is a key histological feature of nonalcoholic fatty liver disease (NAFLD). The non-invasive quantification of liver fat is now possible due to advances in imaging modalities. Emerging data suggest that high levels of liver fat and its temporal change, as measured by quantitative non-invasive methods, might be associated with NAFLD progression. Ultrasound-based modalities have moderate diagnostic accuracy for liver fat content and are suitable for screening. However, of the non-invasive imaging modalities, MRI-derived proton density fat fraction (MRI-PDFF) has the highest diagnostic accuracy and is used for trial enrolment and to evaluate therapeutic effects in early-phase clinical trials in nonalcoholic steatohepatitis (NASH). In patients with NAFLD without advanced fibrosis, high levels of liver fat are associated with rapid disease progression. Furthermore, changes on MRI-PDFF (≥30% decline relative to baseline) are associated with NAFLD activity score improvement and fibrosis regression. However, an inverse association exists between liver fat and complications of cirrhosis. Liver fat decreases as liver fibrosis progresses towards cirrhosis, and the clinical importance of quantitative measurements of liver fat differs by NAFLD status. As such, patients with NAFLD should be stratified by fibrosis severity to investigate the utility of quantitative measurements of liver fat for assessing NAFLD progression and prognosis.

Hydroxyapatite bone cement in the reconstruction of defects of the long process of the incus: Personal experience and literature review

OBJECTIVE

Erosion of the long process of the incus is the most common ossicular chain pathology occurring in the course of chronic middle ear disease. The aim of this study was to evaluate our experience in the reconstruction of short-length defects of the long process of the incus using hydroxyapatite bone cement over a period of 15 years.

METHODS

The medical records of all patients treated with hydroxyapatite bone cement for an isolated short-length erosion of the long process of the incus or the lenticular process at an academic tertiary referral center between 2005 and 2019 were studied retrospectively.

RESULTS

48 patients made up our study sample (19 men, 29 women). The mean age at the time of surgery was 38.1 years. The mean preoperative air-bone gap (ABG) was 21.36 dB. The mean postoperative ABG was 15.89 dB within 8 weeks of surgery and 11.81 dB at least 6 months after surgery. The postoperative ABG had significantly improved compared to preoperative ABG values at both the short- and middle-term follow-up (p < 0.001 for both). An ABG ≤ 20 dB was achieved in 68% in the short term and 83% in the middle term. The mean ABG in the long term (< 12 months) was 11.1 dB.

CONCLUSION

Restoration of the anatomic and functional continuity of the ossicular chain using hydroxyapatite cement in defects of the long process of the incus seems to warrant a satisfactory audiologic outcome in the majority of cases.

Clinical Feasibility of Large Gastrotomy Closure Using a Flexible Tissue Glue Based on N-Butyl-2-Cyanoacrylate: Experimental Study in Pigs

BACKGROUND

The use of synthetic adhesives such as cyanoacrylates has been established previously for a wide range of clinical indications. However, more research is necessary to evaluate their use in digestive closures or anastomosis. New chemical formulations developed to achieve more flexibility of synthetic adhesives (i.e., based on n-butyl-2-cyanoacrylate) could be an alternative to achieve this purpose. The aim of this study was to investigate the feasibility of using flexible cyanoacrylate adhesives for large gastric incision closure in an animal model.

METHODS

Twelve farm pigs were divided in two groups depending on the type of closure method applied. In all cases, extra-large seven centimeters gastrostomies were performed. Braided absorbable hand-sewn interrupted suture versus n-butyl-2-cyanoacrylate with softener closure were compared during a 3-week follow-up period. Histopathological aspects, hematologic and inflammatory biomarkers, and endoluminal pressure tolerated until leakage were assessed. The time spent on both closing procedures was compared.

RESULTS

No differences between the two groups were found in any of the histopathological and inflammatory variables evaluated. The glued group tolerated a significantly higher pressure than the manual suture group. A reduction of surgery time was also observed.

CONCLUSIONS

Our results suggest that flexible cyanoacrylates could be a feasible alternative to improve the clinical outcome of the closure of hollow viscera through more efficient sutureless procedures.

The effect of increased stiffness of the incudostapedial joint on the transmission of air-conducted sound by the human middle ear

OBJECTIVE

To study the possible effects of increased stiffness at the incudostapedial joint (ISJ) on sound transmission in the human middle ear.

BACKGROUND

The physiologic role played by the IS joint in the mechanics of human middle ear function is unclear. It is also unclear how fixation of this joint might manifest itself and what the implications are of fixing this joint during surgical reconstruction.

HYPOTHESIS

Increased stiffness of the ISJ will affect sound transmission through the middle ear.

METHODS

Cyanoacrylate adhesive was instilled around the ISJ joint in 5 fresh human cadaveric temporal bones to increase ISJ stiffness. Laser Doppler vibrometry measurements of sound-induced peak-to-peak displacement of the umbo and stapes footplate were made before and after stiffening the ISJ.

RESULTS

At baseline, the measurements at the stapes footplate followed those at the umbo but were approximately 12 dB lower in the speech frequencies. We found that stiffening the ISJ produced an almost equal decrease in peak-to-peak displacement at both the umbo and the stapes footplate, with little change in their relative motion, consistent with an increase in ossicular impedance. The decrease was mainly between 400 and 1,000 Hz with a statistically significant mean magnitude loss of 6 dB at 740 Hz.

CONCLUSION

Increased stiffness at the ISJ results in a small, probably clinically insignificant decrease of 3 to 6 dB in middle ear sound transmission in the lower frequencies between 400 and 1,000 Hz.

Efficacy of octyl-2-cyanoacrylate in type I tympanoplasty

OBJECTIVE

To evaluate the safety and efficacy of octyl-2-cyanoacrylate for type I tympanoplasty.

METHODS

This study involved 23 patients (14 females and 9 males) with chronic otitis media who underwent type I tympanoplasty. During surgery, the temporal fascia is placed underlying the eardrum remnant, and octyl-2-cyanoacrylate was dropped over the temporal fascia. The mean air-bone gap (ABG) at the 4 frequencies (500, 1000, 2000, and 4000) was calculated for each patient before and after surgery. These data were compared by Student t test.

RESULTS

The mean follow-up was 10 months (range, 6-12 mo). Successful tympanic membrane grafting occurred in 21 patients (91.3%). Graft failure was seen in 2 patients. The mean preoperative ABG of the 23 patients was 19.3 (SD, 5.7) dB, and the postoperative ABG improved to a mean value of 8.2 (SD, 5.9) dB (P ≤ 0.0001).

CONCLUSIONS

Octyl-2-cyanoacrylate is effective and safe in using as a compound on temporalis muscle fascia in type I tympanoplasty and can be used more widely in tympanoplasty.

Use of Mimix hydroxyapatite bone cement for difficult ossicular reconstruction

OBJECTIVE

To describe the advantages of using Mimix hydroxyapatite (HA) bone cement in reconstructing a variety of ossicular chain abnormalities.

STUDY DESIGN AND SETTING

Case series at a tertiary medical center.

RESULTS

Twenty-five cases of HA reconstruction are included in this series (ages 23-74; mean, 47 years). The examples presented include (1) HA as the sole reconstructive material for incus erosion, (2) HA for securing a total or partial ossicular replacement prosthesis, (3) incus augmentation after crimping for revision stapedotomy with incus erosion, (4) HA in primary stapedotomy to fix the crimped prosthesis to an intact incus, and (5) other unique situations. Preoperative and postoperative audiograms were evaluated for 4-tone pure tone average (PTA), speech reception thresholds, word recognition scores, and air-bone gaps (AB gaps). Mean follow-up was 11 months (range 2 to 22 months). The mean PTA improved from 57 dB to 37 dB, whereas the mean AB gaps decreased from 33 dB to 16 dB. There were no cases of infection or extrusion.

CONCLUSIONS

Hydroxyapatite bone cement is an excellent adjunct or alternative to ossiculoplasty with preformed prostheses. Easily malleable, rapidly setting, and rapidly hardening, Mimix is particularly well suited for middle ear work.

SIGNIFICANCE

Definitive fixation with bone cements during difficult ossicular chain reconstruction may ensure a more enduring successful outcome.

Cyanoacrylate in myringoplasty - an office based procedure

Graft failure continues to be a problem for surgery of the perforated eardrum. We present our experience of six cases managed using commercially available superglue (cyanoacrylate) for myringoplasty. This method is simple, office based, less time consuming and cost effective. An insulin syringe was used to deliver the glue after a temporalis fascia graft was tucked under the edges of the perforation.

The use of Indermil (n-butyl cyanoacrylate) in otorhinolaryngology and head and neck surgery. A preliminary report on the first 33 patients

The authors present their initial experience of a new sterile medical grade cyanoacrylate adhesive (Indermil) in otolaryngeal and head and neck surgery. Thirty-three patients who underwent a variety of head and neck operations consented to have their skin incisions closed using the adhesive and 10 of those also underwent repair of the tympanic membrane, either as part of tympanoplasty or mastoid surgery. The history of the use of this class of adhesive is presented with an explanation of the chemical properties of these compounds. Advantages of using cyanoacrylate adhesives and future possible applications in otolaryngology and head and neck surgery are discussed.

Prothrombotic cytotoxicity of cyanoacrylate tissue adhesive

Alkyl-2-cyanoacrylates exhibit properties suggestive of their use as surgical adhesives; however, their cytotoxic and proinflammatory properties have prevented their widespread application. The question of whether cyanoacrylate cytotoxicity may be due to eicosanoid production was investigated. Endothelial cells from rats were exposed to increased concentrations of isobutyl-2-cyanoacrylate. The products from this exposure promoted enhanced, concentration-dependent thromboxane biosynthesis as detected by platelet aggregation. When platelets were pretreated with 1-carboxyheptylimidazole (2.0 mM), an inhibitor of thromboxane biosynthesis, up to 80% less aggregation was observed. Such aggregation was inhibited using 1-carboxyheptylimidazole in a dose-dependent manner. Treatment of endothelial cells with isobutyl-2-cyanoacrylate and 1-carboxyheptylimidazole did not significantly alter the amount of platelet aggregation. A soluble metabolite of isobutyl-2-cyanoacrylate appeared to activate platelet aggregation. The cytotoxicity associated with the surgical use of alkyl-2-cyanoacrylates may be mediated by enhanced local thromboxane production.

Viscous isoamyl 2-cyanoacrylate as an osseous adhesive in the repair of osteochondral osteotomies in rabbits

An in vivo study of viscous isoamyl 2-cyanoacrylate used in limited amounts as an osseous adhesive was performed to evaluate the ability of the monomer to maintain the reduction of an unstable intra-articular osteochondral osteotomy as well as to allow for healing around the sites of adhesive placement. A histologic evaluation of any inflammatory reaction involving adjacent bone, cartilage, or synovium was also performed. Osteochondral fragments were created in 48 rabbit knees. In 24 knees, reduction of the fragment was secured with one small drop of adhesive at either end of the osteotomy surface. In 24 control knees, no adhesive was used. Ninety-six percent of the osteotomies in the adhesive treated group healed versus 50% of the control group. This difference is statistically significant (p less than 0.05). Osseous and cartilaginous healing was noted to proceed in an apparently unimpaired fashion around the sites of adhesive placement, and no inflammatory reaction involving adjacent viable tissue was evident.

A new autologous fibrinogen-based adhesive for otologic surgery

Many middle ear reconstructive procedures would be facilitated by use of a relatively safe surgical adhesive. A fibrinogen-based adhesive (Tisseel) has been effective in otologic surgery in Europe, but because it is derived from pooled human blood, it carries a risk of transmitting hepatitis, acquired immune deficiency syndrome, and other illnesses. This report details a new procedure for creating an autologous fibrinogen-based adhesive, obviating these risks. The fibrinogen and factor XIII component of the adhesive was isolated by polyethylene glycol precipitation from human plasma within a few hours, and was used either immediately or frozen for use up to 3 weeks later. Fifteen chinchillas had either the single donor adhesive, the commercial European adhesive, or saline placed on the oval and round windows, and no evidence of cochlear, mucosal, or ossicular damage was seen by light microscopy 30 days later. Auditory brain stem response thresholds remained stable, except in three animals that developed otitis media. Based on this investigation, autologous fibrinogen-based adhesive appears promising as a relatively safe, biological bonding material for otologic surgery, and is worthy of further study.