Juha Silvola

Balloon Dilation of the Cartilaginous Eustachian Tube

Objectives. (1) To translate techniques developed in a previous cadaver study of balloon dilation of the cartilaginous eustachian tube (ET) into clinical treatment for refractory dilatory dysfunction and (2) to study the safety/efficacy of the technique in a pilot clinical trial. Study Design. Prospective with subjects as their own historical controls since June 2009. Setting. Regional academic center. Subjects and Methods. Eleven consecutive adult patients with longstanding otitis media with effusion (OME) who were unable to autoinsufflate their ET by Valsalva, swallow, or yawn and who had previous tympanostomies (average, 4.7). At the time of intervention, 5 of 11 had a tube; 2 of 11 had a tympanic membrane (TM) perforation. Four of 11 had intact TMs, 2 with OME and tympanogram type B and 2 with TM retraction and tympanogram types B and C. Balloon dilation of the cartilaginous ET was performed with sinus dilation instruments via transnasal endoscopic approach under general anesthesia in a day surgery setting. Inflation was to a maximum of 12 atm for 1 minute. Outcome measures: ability to Valsalva, rating of ET mucosal inflammation, tympanogram, and otomicroscopy findings. Results. All cases successfully dilated. Eleven of 11 could self-insufflate by Valsalva (P < .001); tympanograms were A (4/11), C (1/11), or open (6/11). All atelectases resolved. Procedures were well tolerated, without pain or complications related to dilation. Conclusion. Dilation of the cartilaginous ET appeared to be beneficial and without significant adverse effects in the treatment of ET dilatory dysfunction. Larger controlled trials with long-term results are now justified and needed.

Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis.

A recent systematic review of treatments of Eustachian tube dysfunction commissioned by the UK NIHR Health Technology Assessment (HTA) Programme revealed that an important limitation with the available evidence is a lack of consensus on the definition and diagnosis of this disorder.1 The HTA report recommended that key to advancing research in this field is achieving consensus on diagnostic criteria for Eustachian tube dysfunction (to identify eligible patients for future trials) and on important clinical outcomes. To address this need, an international forum of scientists and physicians with expertise in the field of Eustachian tube disorders met at a workshop in Amsterdam on 21 June 2014 and was tasked to come to an agreement on the definition, clinical presentation and diagnosis of Eustachian tube dysfunction, and areas for future research. This study summarises the outcomes of that meeting.

Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube

Objective Studies of balloon Eustachian tuboplasty (BET) have shown encouraging results in small series with short follow-ups. Our pilot study suggested that patients with protracted otitis media with effusion (OME) or atelectasis of the tympanic membrane (TM) could benefit from BET. Study Design A prospective study where subjects act as their own controls. Patients from the pilot study and additional cases were enrolled in this cohort with long-term follow-up. Setting Regional Academic Center. Subjects and Methods Out of 80 patients who underwent BET, 41 consecutive Eustachian tube (ET) operations were included. Subjects’ inclusion criteria were OME and/or TM atelectasis, type B or C tympanograms, and inability to inflate their middle ears by Valsalva maneuver. All patients had longstanding ET dysfunction relieved only by repeated tympanostomies. Outcomes included ability to perform a Valsalva maneuver, audiometry, tympanometry, videoendoscopy of the ET with mucosal inflammation rating scores, and otomicroscopy. Results All cases were dilated successfully, without significant complications. Mean follow-up was 2.5 years (range, 1.5-4.2 years). Eighty percent (33/41) could do a Valsalva maneuver postoperatively; none of these ears required new tympanostomy tubes and subjective symptoms were relieved. Tympanometry results showed overall improvement. Nine patients had persistent perforations and 3 declined removal of the tube. Subjective symptoms were not relieved for 10% (4/41). Conclusion The results show that BET can effectively improve ET function in ears with OME or atelectasis. The procedure is well tolerated and without significant complications. The follow-up continues and we are investigating possible reasons for failures.

Mastoidectomy Cavity Obliteration with Bioactive Glass: A Pilot Study

Objective To show that mastoid cavities with continuous infections and cleaning problems can be obliterated with bioactive glass (BG) and to present results of a pilot study for 16 operations on adults. Study Design Case series with planned data collection. Setting Päijät-Häme Central Hospital, Finland—a single ear, nose, and throat (ENT) hospital department serving a population of 216,000. Subjects and Methods Fourteen patients had a large open radical cavity with recurrent infections. Two ears had discharge and pain after simple mastoidectomy. A re-mastoidectomy included support of the cavity skin and obliteration with BG. The mean follow-up time was 2.2 years. Results All ears became dry. One reoperation was needed as the fascia support to the ear canal (EC) skin was too weak, and part of the BG leaked into the EC. The ear stayed dry, and the missing BG was replaced in a reoperation. A slightly short musculoperiosteal flap supported the EC skin in 1 ear. A minor amount of BG leaked into the EC. The ear stayed dry. The aim was an ample ear canal. One ear was overfilled and required meatoplasty. Simple mastoid cavities were isolated from the middle ear and become asymptomatic. Conclusions In this pilot study, BG works safely and with success as an obliteration material in problematic open radical cavities. Bioactive glass seems to tolerate chronic infection in the mastoid and prevent postoperative infections.

Histopathology of balloon-dilation eustachian tuboplasty

Surgical intervention of the Eustachian tube (ET) has become increasingly common in the past decade, and balloon dilation has shown promising results in recent studies. It is unclear how balloon dilation enhances ET function. Our aim was to evaluate histological changes in the ETs mucosal lumen comparing before balloon dilation, immediately after, and postoperatively.

Local bupivacaine-epinephrine infiltration combined with general anesthesia for adult tonsillectomy.

Conclusion. Use of a solution of bupivacaine (5 mg/ml)–epinephrine (5 µg/ml) (BE) is beneficial in reducing intraoperative bleeding and decreasing the operation time in adult (adeno)tonsillectomy patients. Objective. Pain and intra- and postoperative bleeding are problems associated with tonsillectomy/adenotonsillectomy. In order to make tonsillectomy/adenotonsillectomy better suited to outpatient surgery, solutions to these problems should be found. One possibility may be the combination of local and general anesthesia. The aim of this study was to find out if such a combination is beneficial in tonsillectomy/adenotonsillectomy. Material and methods. We performed a prospective, randomized, double-blind, controlled study on 64 adult (adeno)tonsillectomy patients to investigate the possible benefits of infiltrating the peritonsillar space with a BE solution. Results. In the recovery room, the BE group experienced less pain than a control group infiltrated with saline; subsequently there was no significant difference between the groups concerning pain. The average volume of intraoperative bleeding and the operation time were significantly smaller in the BE group. Postoperative bleeding from the tonsillar fossae occurred in 19% (6/31) of the patients in the BE group and in 18% (6/33) in the saline group.

Endoscopic sinus surgery might reduce exacerbations and symptoms more than balloon sinuplasty.

Background Endoscopic sinus surgery (ESS) is considered after medical therapy failure of chronic rhinosinusitis (CRS). The balloon sinuplasty dilates the natural ostium without moving mucosa or bone. It still lacks evidence from randomized controlled trials. The aim of this retrospective controlled study was to compare the symptom outcomes after maxillary sinus surgery with either the ESS or the balloon sinuplasty technique. No previous or additional sinonasal operations were accepted. Methods Two hundred eight patients with CRS without nasal polyps underwent either balloon sinuplasty or ESS. The patients who met with the inclusion criteria (n = 45 in ESS group and n = 40 in balloon group) replied to a questionnaire of history factors, exacerbations, and a visual analog scale (VAS) scoring of the change in symptoms, on average 28 ± 6 (mean ± SD) months postoperatively. Results The groups were identical in the response rate (64%), patient characteristics, and the improvement in all of the asked symptoms. Patients with CRS-related comorbidity and/or present occupational exposure had a statistically significantly better symptom reduction after ESS than after balloon sinusotomy. Moreover, the balloon sinusotomy group reported a statistically significant higher number of maxillary sinus punctures and antibiotic courses during the last 12 months. Conclusion ESS might be superior to balloon sinuplasty, especially in patients with risk factors. There is a need to perform more controlled studies on the treatment choices of CRS.

Pediatric one-stage cholesteatoma surgery: long term results

The long-term results of pediatric cholesteatoma are dispersed and there is no consensus on operation methods and on factors affecting outcome of surgery. We analyzed the independently evaluated long-term results and possible reasons for recholesteatoma. Eighty-four consecutive pediatric (age < 16 years) cholesteatoma operations were undertaken in the Helsinki University Central Hospital ENT Department. The operations were not staged; all mastoids were obliterated and bony ear canals reconstructed without open cavities. The pre- and perioperative and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.8 years and 87% attendance. The total recholesteatoma rate was 29% (24/84), and it was not dependent on the size of cholesteatoma, mastoid status, cholesteatoma in the window niches or stapedial erosion. A retraction process developed in 25% (21/84) of the ears and 42% (9/21) of these turned into retraction pocket cholesteatomas as late as 13 years postoperatively. Retractions and postoperative discharge, especially in combination, predisposed to recholesteatoma. Of the healed ears, 37% became atelectatic. Hearing was maintained on the preoperative level. Reduced middle ear and attic ventilation led to retractions, and atelectasis and a tendency to discharge accelerated the process. Pitfalls in mastoid obliteration and attic reconstruction and the failure to create new ventilation routes were important reasons for recholesteatoma.

Insertion Depth in Cochlear Implantation and Outcome in Residual Hearing and Vestibular Function.

Objectives: It has long been known that cochlear implantation may cause loss of residual hearing and vestibular function. Different insertion depths may cause varying degrees of intracochlear trauma in the apical region of the cochlea. The present study investigated the correlation between the insertion depth and postoperative loss of residual hearing and vestibular function. Design: Thirty-nine adults underwent unilateral cochlear implantation. One group received a Med-El +Flex24 electrode array (24 mm; n = 4), 1 group received a Med-El +Flex28 electrode array (28 mm; n = 18), and 1 group received a Med-El +FlexSOFT electrode array (31.5 mm; n = 17). Residual hearing, cervical vestibular-evoked myogenic potentials, videonystagmography, and subjective visual vertical/horizontal were explored before and after surgery. The electrode insertion depth and scalar position were examined with high-resolution rotational tomography after implantation in 29 subjects. Results: There was no observed relationship between the angular insertion depth (405° to 708°) and loss of low-frequency pure-tone average. Frequency-specific analysis revealed a weak relationship between the angular insertion depth and loss of hearing at 250 Hz (R2= 0.20; p = 0.02). There was no statistically significant difference in the residual hearing and vestibular function between the +Flex28 and the +FlexSOFT electrode array. Eight percent of the cases had vertigo after surgery. The electrode arrays were positioned inside the scala tympani and not scala vestibuli in all subjects. In 18% of the cases, the +FlexSOFT electrode array was not fully inserted. Conclusions: The final outcome in residual hearing correlates very weakly with the angular insertion depth for depths above 405°. Postoperative loss of vestibular function did not correlate with the angular insertion depth or age at implantation. The surgical protocol used in this study seems to minimize the risk of postoperative vertigo symptoms.

Mastoidectomy Cavity Obliteration with Bioactive Glass

Objective: 1) Show that mastoid cavities with continuous infections and cleaning problems can be obliterated with bioactive glass (BG). Bioactive glass S53P4 inhibits bacterial growth, turns slowly into bone, and activates new bone formation. 2) Present results of a pilot study for 16 operations on adults. Method: A prospective follow-up of mastoid obliterations started in 2007. The mean follow-up time is 1.16 years. Fourteen ears had a large open radical cavity with recurrent infections. Two ears had discharge and pain after simple mastoidectomy. A re-mastoidectomy included support of the cavity skin and obliteration with BG. Results: All ears become dry. One reoperation was needed, as the fascia support to the EC skin was too weak and part of the BG leaked into the EC. The ear stayed dry, and the missing BG was replaced in a reoperation. A slightly short musculoperiosteal flap supported the EC skin in one ear. A minor amount of BG leaked into the EC. The ear stayed dry. The aim was an ample ear canal (EC). One ear was overfilled and waits for meatoplasty. Simple mastoid cavities were isolated from the middle ear and became asymptomatic. Conclusion: BG works as obliteration material in problematic open radical cavities safely and with success. BG seems to tolerate chronic infection in the mastoid and prevent postoperative infections.