The surgical management of chronic otitis media is ever evolving. This is also the
case at the Chris Hani Baragwanath Academic Hospital where in recent times,
certain new techniques were adopted and other older ones revisited. This changed
surgical approach was deemed to be necessary not only in view of the limited
resources available to deal with a large patient load, but also to improve surgical
outcomes in the local environment. The focus was mainly on the implementation of
internationally accepted surgical techniques that have been shown to not only be
effective and safe, but also simple and time-saving. Changes were mostly seen in the
management of patients presenting with simple perforations and cholesteatoma.
It is the objective of this study to formally assess the outcome and feasibility of this
changed surgical approach, as well as to assess the outcomes of surgery as a whole.
A retrospective clinical chart review was undertaken over an eighteen-month period
from July 2009 to December 2010. All patients undergoing single stage surgery for
chronic otitis media in this period were included, and grouped in terms of procedure
performed, viz. Tympanoplasty, Tympanomastoidectomy and Canal wall down
CWD mastoidectomy. All data were collected from an otological database, each
case independently evaluated in terms of surgical and audiological outcomes after at
least a 2 month follow up period. Only data acquired at the latest follow-up date
were used. The follow up period ranged from 2 to 18 months.
The Butterfly Cartilage Inlay Graft (BCIG) tympanoplasty technique was the
predominant technique used for simple perforations of any size and location, and
showed superior surgical outcomes to the more traditional Fascia underlay graft
(FUG) technique. Surgical success (i.e. healed / intact tympanic membrane) in the
FUG tympanoplasty group was 75%, compared to 93% in the BCIG group. One
hundred percent of cases subjected to BCIG tympanoplasty achieved sociable
hearing (ACT< 30dB) in the early post-operative period. We found the hearing improvement post-surgery to be directly related to the size of perforation
(p= 0, 0195), and pre-operative hearing loss (p= 0, 0001 r= 0.93). None of the other
variables studied influenced the audiological outcome achieved.
In the study period, surgical techniques used for more severe Noncholesteatomatous
chronic otitis media (NCCOM) were little changed from before.
An evaluation of these cases focused on those with actively discharging ears to
assess the outcome of Tympanomastoidectomy to achieve not only a dry ear, but
also an intact tympanic membrane (TM) and hearing improvement (HI). Eighty-six
percent of patients with discharging ears had dry ears post-operatively, 50% of
which achieved an intact tympanic membrane and sociable hearing (ACT< 30dB).
Graft failures in the tympanomastoidectomy group as a whole were mostly related to
size of perforation (p= 0,047) and to the presence of discharge pre-operatively (p=
0,012).
In the CWD mastoidectomy group, although evaluating both the large (completely
exenterated mastoid)- and small cavity techniques, the focus was on the latter. With
this technique, disease is surgically approached from its site of origin, and followed
into the attic and mastoid. The resultant defect in the medial canal wall and mastoid
is kept as small as possible, to avoid obliteration and the morbidity of an
unnecessarily large cavity. Dry ears were achieved in 93% of patients. In cases
where the TM was grafted, an intact tympanic membrane was achieved in 85% of
patients. Significant hearing improvement (>10dB in two consecutive frequencies)
was achieved in 33% of patients who had the tympanic membrane grafted to an
intact stapes suprastructure (Type 3 tympanoplasty with or without a cartilage
columella). These results compared favourably to the large cavity CWD technique
in this series where obliteration and middle ear grafting were not performed on a
regular basis. In this group, only 16% of patients had an intact tympanic membrane
post-operatively, and 63% of ears were dry at latest follow up. Although statistical
analysis did not show one technique to be superior to the other in achieving a dry ear
post-operatively (p= 0,39), the results with the small cavity technique were very
encouraging. Hearing improvement in both groups were variable and hearing preservation rather than augmentation was achieved in most. The lack of hearing
improvement may not only have been related to the extensive disease encountered
(80% extending beyond attic, 50 % stapes suprastructure erosion), but also to
inadequate and infrequent reconstruction of the middle ear.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/12532 |
| Date | 18 March 2013 |
| Creators | Joubert, Wynand |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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