Alan G. Kerr

Realities in ossiculoplasty

The results of ossiculoplasty are frequently reported in terms of closure of the air-bone gap. This parameter is a reliable indicator of the degree of technical success, and is useful in comparing different materials and types of reconstructions. However, assessment of the operated ear alone does not evaluate the effect of surgery on binaural hearing ability, leading to the situation where sub-optimal advice may be given to patients pre-operatively. This article advocates a more patient orientated method of assessing the results of ossiculoplasty. Previous studies have indicated that the operated ear must reach an air conduction level of 30 dB for the speech frequencies, or be within 15 dB of the other ear, to ensure that the patient will gain significant benefit. A graphical method for the prediction of patient benefit is presented, and compared to the rule of thumb quoted above. The implications for surgeons and patients considering ossiculoplasty are obvious. Many statements routinely made to patients prior to surgery for conductive hearing loss are unduly optimistic and unrelated to the realities of reported results. There is a need to determine what types of such hearing losses can be helped surgically, and more importantly to what extent the patients hearing disability can be relieved.

Second ear stapedectomy—a continued controversy

This paper presents the results of an investigation into the effects of stapedectomy on vestibular function. We detected a disturbingly high incidence of vestibular abnormality in the results of caloric tests at three months postoperatively. Surprisingly, this was not usually accompanied by concurrent vestibular symptoms and there was no evidence of cochlear dysfunction in most cases. Although the caloric response at 12 months postoperatively showed an improvement in most instances, the responses rarely became symmetrical. We believe that a long-term alteration in vestibular response is not uncommon following stapedectomy. Although most patients will compensate quite quickly after unilateral stapedectomy we suspect that this occurs much less readily after bilateral stapedectomy and not at all should bilateral impairment of vestibular function occur. On the basis of this evidence, we submit that bilateral stapedectomy is justified only when vestibular function can be shown to be normal prior to the second ear operation.

Role and results of cortical mastoidectomy and endolymphatic sac surgery in Menière's disease

It is almost impossible to establish the natural history of Menières disease and, by the same token, it is difficult to confirm the efficacy of endolymphatic sac surgery. The authors doubt the logic of sac operations. Only two controlled trials of sac surgery have been found and both cast doubt upon its value. There do not appear to be any controlled trials indicating that it works. In 14 cases of incapacitating Menières disease, where vestibular nerve section was indicated, cortical mastoidectomy was offered and accepted in the expectation that two-thirds might be spared the more major procedure. In the event, the vertigo was controlled in eight out of 14 (57 per cent), the remaining six (43 per cent) requiring more major surgery. A surgical model illustrates that, of themselves, these results are essentially meaningless in assessing the efficacy of cortical mastoidectomy in Menières disease. Until all cases in a community are considered and followed-up, we shall be in doubt about the value of sac surgery and most other treatments of Menières disease.

Emotional investments in surgical decision making

Gordon Smyth had a deep emotional investment in closed cavity surgery for cholesteatoma but, nonetheless, later acknowledged that he believed that he had been mistaken. Emotional investments create problems for all surgeons. Sometimes they have difficulty in recognizing that they need to change what they are doing. This is especially important in the management of Ménières disease where unproven surgical procedures are often perpetuated. Surgery on the endolymphatic sac is of doubtful value but still continues to be the most frequently performed operation for this condition. Surgeons need to reconsider the evidence and question the appropriateness of these operations.

Disability after labyrinthectomy

A labyrinthectomy is known to relieve vertigo successfully in the majority of patients who suffer from Menières disease and have non-serviceable hearing in the affected ear. It is assumed that the procedure reduces disability, helps the patient to return to work and improves the quality of life. Eighteen patients who underwent a transmastoid drill-out labyrinthectomy between 1980 and 1990 were interviewed and an attempt was made to evaluate the success of the operation in accordance with the guidelines set out by the AAO-HNS 1985. In the present series it was noted that although vertigo was relieved in 89 per cent of patients after labyrinthectomy, only 50 per cent of them returned to work. In this study, the age and occupation of the patient at the time of surgery and the relief of vertigo did not accurately predict whether or not a patient returned to work.

Are the media manipulating the GMC

EDITOR—Smiths review of media coverage of the General Medical Council draws attention to the fact that regardless of the outcome of the case in Bristol (in which two cardiothoracic surgeons and a manager are accused of operating on children despite high mortality) the GMC will lose.1 It is important that the GMC acts appropriately in this case; the GMC is on trial as much as, if not more than, the doctors from Bristol. Because this trial has been driven by the media …