Cholesteatoma: "second look" procedures

Educational Objectives

The goal of this program is to improve the management of patients with cholesteatomas. After hearing and assimilating this program, the clinician will be better able to, discuss the pros and cons of second-look surgery after surgery for cholesteatoma and review the evidence.

Summary

Preoperative considerations for chronic ear disease: discuss risk-benefit ratio; explain to patient less risk associated with surgery than with not doing surgery; explain second look; discuss need for possible canal wall down surgery; speaker uses video of himself explaining phases of chronic ear disease, etiology, preoperative and intraoperative considerations, and postoperative course; documents informed consent process, saves time, and improves understanding of patients; new symptoms reported on day of surgery important in preoperative decision making; speaker recommends surgical time-out in every case, just before incision, after patient prepped and draped; imaging not required in every case; if studies done, ensure availability; CT for sensorineural hearing loss, vertigo, facial nerve symptoms, and anatomic variances

Adjunctive techniques: CO2 laser scalpel (OmniGuide) — no need for filter in scope or for micromanipulator; speaker does not use often; used for granulation tissue and erosion of stapes superstructure; intraoperative CT scanner — on wheels; used for suspicion of intracranial disease, petrous apex disease, facial nerve anomalies, cochlear anomalies, and cochlear implant surgeries; speaker prefers wide prep with povidone iodine (Betadine); chlorhexidine contraindicated because of ototoxicity; speaker uses preoperative, intraoperative, and postoperative antibiotics; prefers ciprofloxacin over bacitracin; ciprofloxacin not ototoxic and effective against Pseudomonas and Staphylococcus species; dose 500 mg intravenous (IV); speaker puts into sterile saline to irrigate field; ensure sterile technique; speaker uses facial nerve monitoring in all cases; hemostasis key to preventing complications; 3 strengths of adrenaline in premixed carpules of dental syringes; 1:100,000, 1:50,000, and undiluted in gel foam (for topical use)

Second look: reliance on anatomic landmarks makes otologic surgery difficult; some surgeons never second look, while others always do; speaker decides intraoperatively; some surgeons more aggressive about second look in pediatric population; speaker treats pediatric and adult patients similarly; advantages — discovery of residual disease; avoidance of catastrophic disease; better hearing result; disadvantages — second operation may be unnecessary; cost of procedure to patient, eg, copayment, incidental expenses; missed days at school or work (≥1 wk); emotional impact; diffusion-weighted magnetic resonance imaging (MRI) can demonstrate residual cholesteatoma

Second look for pediatric cholesteatomas (2011): 517 pediatric patients; second look in ≈47%; of these, recurrent cholesteatoma in 48%; in ≈5%, severity of disease required canal wall down procedure; age, sex, side, presence of perforation, otorrhea, degree of conductive hearing loss, and timing of second look (4, 6, 8, or 12 mo) not associated with recurrent disease; high correlation of facial recess, sinus tympani disease, or incus destruction with recurrent disease; in group without second look, recurrent disease in only 4.4%; components of speaker’s second-look operation — transcanal tympanomeatal flap; look at middle ear, ossicular chain, attic, facial nerve, and sinus tympani; ossicular chain reconstruction; no postauricular incision

Intracranial complications of otitis media (2010): no cholesteatoma or previous otologic surgery in cases of lateral sinus thrombosis; treatment — IV antibiotics; surgical decompression; anticoagulation; intracranial abscess — only 2 patients with previous mastoidectomy for cholesteatoma; second look in 1 of these; all responded to IV antibiotics; subdural empyema — catastrophic disease; no cholesteatoma or previous surgery in 1 patient; questionable whether second look prevents catastrophic complications

Readings

Cremers CW et al: Congenital aural atresia. a new subclassification and surgical management. Clin Otolaryngol Allied Sci 9:119, 1984; Cremers CW et al: International consensus on Vibrant Soundbridge implantation in children and adolescents. Int J Pediatr Otorhinolaryngol 74:1267, 2010; Greenberg JS, Manolidis S: High incidence of complications encountered in chronic otitis media surgery in a U.S. metropolitan public hospital. Otolaryngol Head Neck Surg 125:623, 2001; Jahrsdoerfer RA et al: Grading system for the selection of patients with congenital aural atresia. Am J Otol 13:6, 1992; Kochkin S: MarkeTrak VII: Customer Satisfaction with hearing instruments in the digital age. Hear J 58:30, 2005; Lin FR et al: Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci 66:582, 2011; Mandalà M et al: Treatment of the atretic ear with round window Vibrant Soundbridge implantation in infants and children: electrocochleography and audiologic outcomes. Otol Neurotol 32:1250, 2011; McRackan TR et al: Evaluation of second look procedures for pediatric cholesteatomas. Otolaryngol Head Neck Surg 145:154, 2011; Service GJ, Roberson JB Jr: Current concepts in repair of aural atresia. Curr Opin Otolaryngol Head Neck Surg 18:536, 2010; Snik AF et al: Consensus statements on the BAHA system: where do we stand at present? Ann Otol Rhinol Laryngol Suppl 195:2, 2005; Tak S et al: Exposure to hazardous workplace noise and use of hearing protection devices among US workers – NHANES, 1999-200 4.Am J Ind Med 52:358, 2009; Tyler RS, Baker LJ: Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 48:150, 1983; Venail F et al: New perspectives for middle ear implants: first results in otosclerosis with mixed hearing loss. Laryngoscope 117:552, 2007; Wanna GB et al: Contemporary management of intracranial complications of otitis media. Otol Neurotol 31:111, 2010; Yellon RF, Branstetter BF 4th: Prospective blinded study of computed tomography in congenital aural atresia. Int J Pediatr Otorhinolaryngol 74:1286, 2010; Zöger S et al: Relationship between tinnitus severity and psychiatric disorders. Psychosomatics 47:282, 2006.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Haynes is a consultant for Advanced Bionics, Anspach, Cochlear Limited, and Grace Medical (an Enteroptyx company). In his lecture, Drs Haynes presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Haynes was recorded at UCSF Otolaryngology Update 2011, held in San Francisco, CA, on November 10-12, 2011, and sponsored by University of California, San Francisco, School of Medicine, Office of Continuing Medical Education. Information about upcoming events from University of California, San Francisco, School of Medicine can be found at cme.ucsf.edu. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT451202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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