Middle ear ventilation status postoperatively after translabyrinthine resection of vestibular schwannoma with mastoid obliteration and Eustachian tube occlusion: is the Eustachian tube enough to ventilate the middle ear without the mastoid air cell system?

BACKGROUND

Gas pressure balance is essential for maintaining normal middle ear function. The mucosal surfaces of the middle ear, the mastoid air cell system (MACS), and the Eustachian tube (ET) play a critical role in this process; however, the extent that each of these factors contributes to overall middle ear ventilation is unknown. The objective of this study was to determine if the ET alone can maintain normal middle ear pressure without the MACS. To do this, we reviewed subjects who had their MACS completely removed with translabyrinthine (TL) surgery for vestibular schwannoma.

METHODS

A retrospective chart review was done to collect pre and postoperative tympanometry data from patients who underwent resection of vestibular schwannoma. Data from the operative side was compared to the non-operative side at 2 years post-op.

RESULTS

Twenty-four patients were included in this study. Of these, 63 % achieved a type A tympanogram at 2 years post-op in the TL resection group, implying an ability to maintain middle ear pressure in the absence of a mastoid cavity. Because some had negative pressures post TL resection, the average change in pre and postoperative pressure was -37.5 daPa for the operative side and 7.8 daPa for the non-operative side. This was significantly different.

DISCUSSION

The difference for change in pre and postoperative pressure and compliance between operative and non-operative side might be expected from the ET plugging during TL resection. However, more interesting are those patients in whom the ET presumably reopens, and in these subjects, despite having no mastoid compartment at all, and the space obliterated with fat, they were still able to maintain normal ventilation of the middle ear space.

CONCLUSION

Our findings imply that the ET alone is adequate to ventilate at least the reduced middle ear space following TL surgery in most subjects, and perhaps in 100 % if the ET hadn't been plugged during surgery. Hence, the mastoid air cell system, even when healthy, is not needed to maintain air in the middle year cleft.

The effectiveness of nurse-led outpatient referral triage decision making in pediatric otolaryngology

OBJECTIVES

To assess the effectiveness of nurse-led triage of outpatient referrals in an academic pediatric otolaryngology practice.

METHODS

Three hundred consecutive outpatient referrals were reviewed and triaged by two otolaryngology registered nurses and two attending pediatric otolaryngologists. The nurses received triage training. The referrals were triaged as 'routine' (to be seen within 2-3 months), 'semi-urgent' (to be seen within 6 weeks), or 'urgent' (to be seen within 2 weeks). Weighted Kappa statistics (correcting for chance agreement) were performed to assess for the degree of agreement. After the consultation visits, patient records were reviewed to determine whether any referrals had been inappropriately triaged by the nurses.

RESULTS

Overall, there was substantial agreement between all raters. Specifically, weighted Kappa statistics were as follows: surgeon 1, nurse 1: 0.708; surgeon 1, nurse 2: 0.670; surgeon 2, nurse 1: 0.762; surgeon 2, nurse 2: 0.647; nurse 1, nurse 2: 0.756; and surgeon 1, surgeon 2: 0.784. Review of patient charts after consultation showed that no referrals were deemed to be inappropriately triaged and no urgent cases had been missed.

CONCLUSIONS

Our model of nurse-led triage of outpatient referrals was found to be effective and safe. Similar systems may be considered in other areas of medicine as a viable and acceptable alternative to the traditional physician-led triage practice.

Post-tonsillectomy complications in children less than three years of age: a case-control study

OBJECTIVES

To assess the need for post-tonsillectomy admission in children under the age of three years.

DESIGN

A retrospective case-control study.

METHOD

Medical records of 127 children under the age of three years who underwent tonsillectomy with or without adenoidectomy were reviewed for complications and compared to 127 gender-matched controls between three to four years of age.

RESULTS

Overall complication rate in the study group was 9.4% (12 of 127). Early complications (3.1%) were respiratory related, while late complications (6.3%) were due to dehydration and hemorrhage. Comparable complication rate was observed in the control group (8.7%, P>0.05); early complication rate of 3.1% and late complication rate of 5.5% was ascertained. Similar types of complications occurred in the control group.

CONCLUSIONS

Post-tonsillectomy complication rates were low and no significant difference was observed between the study and control groups. This suggests that postoperative admission for children younger than three years of age may not be necessary in all cases.

Wait times for head and neck cancer patients in the Maritime provinces

OBJECTIVE

To assess wait times for surgery and radiotherapy in head and neck cancer patients from the Maritime provinces.

METHODS

A retrospective chart review of 275 Maritime head and neck cancer patients treated between 2007 and 2009 by the tertiary Otolaryngology-Head and Neck Surgery Service at the Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax, Nova Scotia, was conducted to assess surgical and radiotherapy wait times.

RESULTS

The mean wait time from referral to assessment by a head and neck surgeon was 15 days. The mean wait time from the initial consultation with a head and neck surgeon to surgery was 33 days, with 42% waiting more than 28 days and 18% waiting more than 42 days for surgery. The mean wait time from surgery to postoperative radiotherapy was 74 days, with 94% of patients waiting more than 42 days. The mean wait time from referral to Radiation Oncology to assessment by a radiation oncologist was 10 days. The mean wait time from ready to treat to radiotherapy was 21 days, with 74% of patients waiting more than 14 days.

CONCLUSION

Maritime head and neck cancer patients wait longer than established guidelines for both surgery and radiotherapy and may be at increased risk for negative outcomes because of delayed treatment.

A Case of Autologous Microfat Grafting in Lip Reconstruction of a Whistle Deformity Following Cancer Treatment

A whistle deformity is defined as a deficiency in the vertical length of the lip so that the free margins of the upper and lower lips do not meet normally, giving the appearance of whistling. This is a common secondary deformity of the vermilion in patients with cleft lip. A case involving a 61-year-old man who developed a whistle deformity as a result of two wedge resections and postoperative radiotherapy for treatment of squamous cell carcinoma of the lower lip is presented. Hyaluronic acid-based tissue filler and autologous microfat transplantation to the lower lip were used for definitive management of the patient's whistle deformity. After one year of follow-up, the patient was pleased with the overall result and noted marked improvement of his oral competence and overall appearance of the lip. The present case demonstrates that microfat transplantation is a viable option for correcting a whistle deformity, not only after surgery, but also following adjuvant radiotherapy – both of which potentially reduce graft viability secondary to decreased vascularity of the recipient site.

A case of autologous microfat grafting in lip reconstruction of a whistle deformity following cancer treatment

A whistle deformity is defined as a deficiency in the vertical length of the lip so that the free margins of the upper and lower lips do not meet normally, giving the appearance of whistling. This is a common secondary deformity of the vermilion in patients with cleft lip. A case involving a 61-year-old man who developed a whistle deformity as a result of two wedge resections and postoperative radiotherapy for treatment of squamous cell carcinoma of the lower lip is presented. Hyaluronic acid-based tissue filler and autologous microfat transplantation to the lower lip were used for definitive management of the patient's whistle deformity. After one year of follow-up, the patient was pleased with the overall result and noted marked improvement of his oral competence and overall appearance of the lip. The present case demonstrates that microfat transplantation is a viable option for correcting a whistle deformity, not only after surgery, but also following adjuvant radiotherapy - both of which potentially reduce graft viability secondary to decreased vascularity of the recipient site.