Mao-Che Wang

Ear Problems in Swimmers

&NA; Acute diffuse otitis externa (swimmers ear), otomycosis, exostoses, traumatic eardrum perforation, middle ear infection, and barotraumas of the inner ear are common problems in swimmers and people engaged in aqua activities. The most common ear problem in swimmers is acute diffuse otitis externa, with Pseudomonas aeruginosa being the most common pathogen. The symptoms are itching, otalgia, otorrhea, and conductive hearing loss. The treatment includes frequent cleansing of the ear canal, pain control, oral or topical medications, acidification of the ear canal, and control of predisposing factors. Swimming in polluted waters and ear‐canal cleaning with cotton‐tip applicators should be avoided. Exostoses are usually seen in people who swim in cold water and present with symptoms of accumulated debris, otorrhea and conductive hearing loss. The treatment for exostoses is transmeatal surgical removal of the tumors. Traumatic eardrum perforations may occur during water skiing or scuba diving and present with symptoms of hearing loss, otalgia, otorrhea, tinnitus and vertigo. Tympanoplasty might be needed if the perforations do not heal spontaneously. Patients with chronic otitis media with active drainage should avoid swimming, while patients who have undergone mastoidectomy and who have no cavity problems may swim. For children with ventilation tubes, surface swimming is safe in a clean, chlorinated swimming pool. Sudden sensorineural hearing loss and some degree of vertigo may occur after diving because of rupture of the round or oval window membrane.

The effects of Vaseline gauze strip, Merocel, and Nasopore on the formation of synechiae and excessive granulation tissue in the middle meatus and the incidence of major postoperative bleeding after endoscopic sinus surgery

Background: Endoscopic sinus surgery (ESS) has become the widely accepted procedure for the treatment of medically refractory chronic rhinosinusitis and nasal polyps. Nasal packing is usually placed after ESS to prevent synechia formation and postoperative bleeding and to support wound healing. The aim of this study was to evaluate the effects of three different nasal packing materials [Vaseline gauze strip, Merocel (Metronic Xomed, Jacksonville, FL, USA), and Nasopore (Polyganics, Rozenburglaan, Groningen, The Netherlands)] on the formation of synechiae and excessive granulation tissue in the middle meatus and incidence of major postoperative bleeding in patients who had undergone ESS. Methods: A total of 626 patients (1,018 sides) who had undergone ESS were studied retrospectively. Each patient chose one of the three different nasal packing materials according to his or her own preference. The outcome variable was the formation of synechiae and excessive granulation tissue in the middle meatus, which was identified from the medical records of endoscopic evaluations performed 3–4 weeks and 10–12 weeks after surgery. Major postoperative bleeding within 2 weeks after the operation was also documented for analysis. Finally, multiple logistic regression models were used to confirm the results of this study. Results: We did not observe significant intergroup differences in the effect on the formation of synechiae in the middle meatus. Nasopore packing showed a trend toward causing the formation of excessive granulation tissue during the early stages of wound healing (p = 0.004). Patients who had received packing with Nasopore had a greater chance of undergoing readmission or additional packing because of major nasal bleeding within the first 2 weeks after the operation (p = 0.03). Multivariable logistic regression models showed that Nasopore was a significant factor for the formation of excessive granulation tissue at 3–4 weeks after the operation (p = 0.022) and for major postoperative nasal bleeding within the first 2 weeks after the operation (p = 0.023). Conclusion: Among patients who had undergone ESS for rhinosinusitis with or without polyps, the incidence of synechiae and excessive granulation tissue in the middle meatus and major postoperative bleeding in the patients who received Vaseline gauze packing was equivalent to the incidence of these complications in the patients who received Merocel. Nasopore was not superior to the other two nonabsorbable packing materials.

New therapeutic strategy for treating otitis media with effusion in postirradiated nasopharyngeal carcinoma patients

Background: Postirradiation otitis media with effusion (OME) is the most common radiotherapy‐associated otologic complication associated with nasopharyngeal carcinoma (NPC). This studys aim was to evaluate the efficacy of laser myringotomy followed by intratympanic steroid injection (LMIS) for treating OME in postirradiated NPC patients. Methods: From August 2002 to January 2006, 27 newly diagnosed NPC patients who developed OME after a full course of radiotherapy were enrolled. Laser myringotomy was performed followed by once‐weekly administration of steroids (0.5 mL dexamethasone at a concentration of 5.0 mg/mL) into the middle ear for 3 consecutive weeks. The success rate of dry eardrum perforation and the prognostic factors associated with OME resolution were analyzed. Results: The procedure was performed on 44 ears of 27 patients. The mean follow‐up period was 37 weeks. Of the 44 ears, 23 (52.3%) developed persistent eardrum perforation, 18 (40.9%) developed recurrent OME, and three (6.8%) were disease‐free on follow‐up. Of the 23 ears with persistent eardrum perforation, 18 (78.3%) were diagnosed as dry perforation. The absence of pretreatment mastoiditis was an independent factor associated with OME resolution (p < 0.001). Conclusion: LMIS is a quick, minimally invasive, office‐based technique that can be repeatedly performed to treat highly recurrent postirradiation OME, and it results in relatively slight pain to NPC patients. Long‐lasting dry eardrum perforation allows for adequate middle ear ventilation and drainage and guarantees sustained relief from symptoms. The absence of preoperative mastoiditis is a favorable prognostic factor associated with OME resolution.

The protective effect of adenoidectomy on pediatric tympanostomy tube re-insertions: a population-based birth cohort study.

Objectives Adenoidectomy in conjunction with tympanostomy tube insertion for treating pediatric otitis media with effusion and recurrent acute otitis media has been debated for decades. Practice differed surgeon from surgeon. This study used population-based data to determine the protective effect of adenoidectomy in preventing tympanostomy tube re-insertion and tried to provide more evidence based information for surgeons when they do decision making. Study Design Retrospective birth cohort study. Methods This study used the National Health Insurance Research Database for the period 2000–2009 in Taiwan. The tube reinsertion rate and time to tube re-insertion among children who received tympanostomy tubes with or without adenoidectomy were compared. Age stratification analysis was also done to explore the effects of age. Results Adenoidectomy showed protective effects on preventing tube re-insertion compared to tympanostomy tubes alone in children who needed tubes for the first time (tube re-insertion rate 9% versus 5.1%, p = 0.002 and longer time to re-insertions, p = 0.01), especially those aged over 4 years when they had their first tube surgery. After controlling the effect of age, adenoidectomy reduced the rate of re-insertion by 40% compared to tympanostomy tubes alone (aHR: 0.60; 95% CI: 0.41–0.89). However, the protective effect of conjunction adenoidectomy was not obvious among children with a second tympanostomy tube insertion. Children who needed their first tube surgery at the age 2–4 years were most prone to have tube re-insertions, followed by the age group of 4–6 years. Conclusions Adenoidectomy has protective effect in preventing tympanostomy tube re-insertions compared to tympanostomy tubes alone, especially for children older than 4 years old and who needed tubes for the first time. Nonetheless, clinicians should still weigh the pros and cons of the procedure for their pediatric patients.

Decision making in the choice of surgical management for preauricular sinuses with different severities.

Objectives The preauricular sinus is a common congenital abnormality of the preauricular soft tissues. Here, we demonstrate the decision making in the choice of surgical management of preauricular sinuses based on disease severity. In addition, a method termed figure 8 incision with extended fistulectomy is introduced. Study Design Case series with chart review. Setting Tertiary care center. Subjects Between January 2003 and February 2010, a total of 90 patients (109 ears) underwent surgery for preauricular sinuses in our hospital. Methods After controlling the infection, the patients received definite surgery. They were classified into 3 groups according to the operative methods. We recorded the clinical conditions and any recurrences during the follow-up period. Results Group I patients (48 ears) had a trace inflammatory condition and underwent a simple sinusectomy. The recurrence rate was 2.08%. Group II (31 ears) and group III (30 ears) patients had more highly inflamed tissue and underwent a local wide excision and a figure 8 incision with extended fistulectomy, respectively. The recurrence rate in group II was 22.58%. Meanwhile, none of the group III cases showed a recurrence. In our study, there were 8 recurrent cases in 109 ears, yielding a recurrence rate of 7.34%. Conclusion Simple sinusectomy is an adequate surgical technique for preauricular sinuses with a mild inflammatory condition. For more severe cases, the figure 8 incision with extended fistulectomy can achieve adequate wound exposure for radical excision of the inflamed tissue and a satisfactory surgical outcome.

The costs and quality of operative training for residents in tympanoplasty type I

Conclusion. A teaching hospital would incur more operation room costs on training surgical residents. Objective. To evaluate the increased operation time and the increased operation room costs of operations performed by surgical residents. As a model we used a very common surgical otology procedure – tympanoplasty type I. Subjects and methods. From January 1, 2004 to December 31, 2004, we included in this study 100 patients who received tympanoplasty type I in Taipei Veterans General Hospital. Fifty-six procedures were performed by a single board-certified surgeon and 44 procedures were performed by residents. We analyzed the operation time and surgical outcomes in these two groups of patients. The operation room cost per minute was obtained by dividing the total operation room expenses by total operation time in the year 2004. Results. The average operation time of residents was 116.47 min, which was significantly longer (p<0.0001) than that of the board-certified surgeon (average 81.07 min). It cost USD

Learning curve of tympanoplasty type I

40.36 more for each operation performed by residents in terms of operation room costs. The surgical success rate of residents was 81.82%, which was significantly lower (p=0.016) than that of the board-certified surgeon (96.43%).

Conversion Deafness Presenting as Sudden Hearing Loss

OBJECTIVE To determine the time required to train a surgeon to skillfully perform tympanoplasty type I. MATERIALS AND METHODS From July 1, 2001 to December 31, 2006, 75 patients who underwent tympanoplasty type I were enrolled in this study. All of the procedures were performed by two surgeons trained in the same tertiary referral center. We stratified the patients into groups according to the surgeon level at the time of their surgery. We analyzed the operation time and surgical outcomes of these patients. RESULTS The average operation time of resident physicians was 116.36 min, which was significantly longer (p<0.0001) than that of the attending physicians (average 83.11 min). There was no statistical difference in surgical success rate and post-operative complication between the resident year and attending year groups. We stratified the patients according to surgeon years, from year 3 to year 7. The operation time of the 4th and the 5th year surgeons was not statistically different from that of 3rd year surgeons. However, the operation time of the 6th and 7th year surgeons was statistically shorter than that of 3rd year surgeons. There was no difference on surgical success rate and complications among all year groups. CONCLUSION A surgeons years of experience could make the difference in terms of speed of operation. It takes 5 years for surgeons to reach a plateau in learning curve on the speed of performing tympanoplasty type I. We therefore conclude that it takes 5 years to train a surgeon for tympanoplasty type I.

Tonsillectomy and the Risk for Deep Neck Infection—A Nationwide Cohort Study

Conversion deafness is a somatoform disorder characterized by hearing loss without an anatomic or pathophysiologic lesion. Clinically, discrepancies between behavior hearing thresholds and objective electrophysiologic examinations, such as impedance audiometry, otoacoustic emissions (OAE), and auditory brainstem response (ABR), will raise the suspicion of this disorder. It is judged to be due to psychological factors and that patients do not intentionally produce the symptom. Conversion deafness is sometimes reported in children but is extremely rare among adults. Two young adults with this disease are presented. These 2 patients were both under enormous stress from the national entrance examinations for universities. Pure tone audiometry showed bilateral hearing deterioration, but OAE and ABR were normal. The hearing of both patients recovered after treatment. The diagnosis, prognosis and treatment of this disorder are also discussed. It is important to discover the psychological stress in patients with conversion deafness. This report aims to increase awareness of this condition and avoid unnecessary steroid use in its treatment.

The Impact of Prior Tonsillitis and Treatment Modality on the Recurrence of Peritonsillar Abscess: A Nationwide Cohort Study

Background Although the tonsils contribute to first line immunity against foreign pathogens in the upper aero-digestive tract, the association of tonsillectomy with the risk of deep neck infection remains unclear. The aim of this study was to assess the incidence rate and risk of deep neck infection among patients who had undergone a tonsillectomy. Methods This retrospective cohort study evaluated all patients who had undergone tonsillectomy between 2001 and 2009 as identified from the Taiwan National Health Insurance Research Database. For each post-tonsillectomy patient, 10 age-, sex-, and index date-matched controls without a history of tonsillectomy were randomly selected. Cox Proportional hazard model and propensity score model were performed to evaluate the association between tonsillectomy and deep neck infection after adjusting for demographic and clinical data. Results There were 34 (71.6 cases per 100,000 person-years) and 174 (36.6 cases per 100,000 person-years) patients that developed deep neck infection in the tonsillectomized and comparison cohorts, respectively. After adjusting for covariates, patients who had undergone a tonsillectomy had a 1.71-fold greater risk of deep neck infection by both Cox proportional hazard model (95% confidence interval, 1.13-2.59) and propensity score model (95% confidence interval, 1.10-2.66). This association was not altered regardless of the indication for tonsillectomy (i.e. chronic/recurrent tonsillitis or sleep apnea/hypertrophy of tonsil) (p = 0.9797). Conclusions Based on our review of a nationwide cohort study we identified that the risk of deep neck infection is significantly increased among patients who have undergone a tonsillectomy. Additional research is needed to explore the possible mechanisms behind these findings.