Petros V. Vlastarakos

Grommets in otitis media with effusion : the most frequent operation in children. But is it associated with significant complications?

IntroductionOtitis media with effusion is one of the most frequent diseases in children, and its management requires the attention of general practitioners, pediatricians and ear, nose and throat (ENT) surgeons. The main complications associated with tympanostomy tube insertion, are: (1) purulent otorrhea (10–26% of cases), in which local otic preparations might be effective, and biofilm-resistant tubes may decrease this complication in the future; (2) myringosclerosis (39–65% of operated ears), with usually no serious sequelae; (3) segmental atrophy (16–75% of cases); (4) atrophic scars and pars flaccida retraction pockets (28 and 21% of operated ears, respectively); (5) tympanic membrane perforations (3% of cases, although with T-tubes, the incidence may be as high as 24%); (6) cholesteatoma (1% of cases), although tympanostomy tubes may sometimes prevent, rather than contribute to its development; (7) granulation tissue (5–40% of instances), when the duration of tube retention is prolonged.ConclusionIt would appear that the complications associated with tympanostomy tube insertion are more frequent than anticipated, reaching 80% of operated ears under specific circumstances and in certain subgroups of children. These complications may resolve with conservative management, but in persistent cases surgical removal of the tubes is mandatory.

Cochlear implantation under the first year of age—The outcomes. A critical systematic review and meta-analysis

OBJECTIVEnTo review the current knowledge on cochlear implantation in infancy, regarding auditory perception/speech production outcomes.nnnSTUDY-DESIGNnMeta-analysis. EBM level: II.nnnMETHODSnLiterature-review from Medline and database sources. Related books were also included.nnnRESULTSnThe number of cohort-studies comparing implanted infants with under 2-year-old children was five; three represented type-III and two type-II evidence. No study was supported by type I evidence. Overall, 125 implanted infants were identified. Precise follow-up period was reported in 82. Median follow-up duration ranged between 6 and 12 months; only 17 children had follow-up duration equal or longer than 2 years. Reliable outcome measures were reported for 42 infants; 15 had been assessed with open/closed-set testing, 14 with developmental rating scales, and 13 with prelexical speech discrimination tools. Ten implanted infants assessed with open/closed-set measures had been compared with under 2-year-old implanted children; 4 had shown better performance, despite the accelerated rate of improvement after the first postoperative year.nnnCONCLUSIONnNeuroplasticity/neurolinguistic issues have led cochlear implant centers to implant deaf children in infancy; however, widespread policies regarding the aforementioned issue are still not justified. Evidence of these childrens outperformance regarding auditory perception/speech production outcomes is limited. Wide-range comparisons between infant implantees and under 2-year-old implanted children are lacking. Longer-term follow-up outcomes should be also made available. There is a need to develop and validate robust measures of monitoring implanted infants. Potential factors of suboptimal outcomes (e.g. misdiagnosis, additional disorders, device tuning, parental expectations) should also be weighted, when considering cochlear implantation in infancy.

Diagnostic challenges and safety considerations in cochlear implantation under the age of 12 months

AIMnTo review the current knowledge on cochlear implantation in infancy, regarding diagnostic, surgical and anesthetic challenges.nnnSTUDY-DESIGNnMeta-analysis. EBM level: II.nnnMATERIALS/METHODSnLiterature-review from Medline and database sources. Related books were also included.nnnSTUDY SELECTIONnMeta-analyses, prospective controlled studies, prospective/retrospective cohort studies, guidelines, review articles.nnnDATA SYNTHESISnThe diagnosis of profound hearing loss in infancy, although challenging, can be confirmed with acceptable certainty when objective measures (ABR, ASSR, OAEs) and behavioural assessments are combined in experienced centres. Reliable assessment of the prelexical domains of infant development is also important and feasible using appropriate evaluation techniques. Overall, 125 implanted infants were identified in the present meta-analysis; no major anesthetic complication was reported. The rate of surgical complications was found to be 8.8% (3.2% major complications) quite similar to the respective percentages in older implanted children (major complications ranging from 2.3% to 4.1%).nnnCONCLUSIONnAssessment of hearing in infancy is feasible with adequate reliability. If parental expectations are realistic and hearing aid trial unsuccessful, cochlear implantation can be performed in otherwise healthy infants, provided that the attending pediatric anesthesiologist is considerably experienced and appropriate facilities of pediatric perioperative care are readily available. A number of concerns, with regard to anatomic constraints, existing co-morbidities or additional disorders, tuning difficulties, and special phases of the developing child should be also taken into account. The present meta-analysis did not find an increased rate of anesthetic or surgical complications in infant implantees, although long-term follow-up and large numbers are lacking.

Treating options for deaf children

BACKGROUND/AIMnAlthough already established for metabolic diseases, universal screening programs for hearing have not been widely applied, despite the high incidence of profound congenital hearing loss. The present paper aims to review the current knowledge on the available treatment options for deaf infants.nnnDATA SYNTHESISnThe acquisition of spoken language is a time-dependent process. For a child to become linguistically competent, some form of linguistic input should be present as early as possible in his/her life. Although objective audiological methods have certain weaknesses, their combination can give an accurate diagnosis in most of the cases. Later on, behavioural audiometry should confirm the diagnosis. Additional disabilities also need to be considered, although such assessments may be difficult in very young children. Congenital deafness should be managed by a multidisciplinary team (MDT). Affected infants should be bilaterally fitted with hearing aids, no later than three months after birth. They should be monitored and if they are not progressing linguistically, cochlear implantation (CI) should be considered after thorough preoperative assessment. Following CI, the vast majority of congenitally deaf children develop significant speech perception and production abilities over time. Age-at-intervention and oral communication, are the most important determinants of outcomes. Realistic parental expectations are also essential. The continuous support of a dedicated pediatric CI program, in collaboration with local professionals, and community members, are also necessary to achieve a successful outcome.nnnCONCLUSIONnCongenitally deaf children should be detected early, and referred timely for the process of auditory rehabilitation to be initiated. Strong support by community members, and professional bodies, can maximize the future earnings of pediatric auditory rehabilitation with hearing aids and cochlear implants.

CT scan versus surgery: how reliable is the preoperative radiological assessment in patients with chronic otitis media?

The objective of the study was to evaluate the accuracy of the preoperative radiological assessment regarding 10 different middle ear structures in patients with chronic otitis media (COM). The setting of the prospective study was in a Tertiary university hospital. Fifty patients scheduled for a primary operation for COM. All patients underwent preoperative temporal bone high-resolution CT-scan (HRCT). AC1-statistics between the radiological report and the intra-operative findings were calculated. There was no correlation between the radiological assessment and the surgical findings in the scutum, attic area, and oval window. There was a poor or fair agreement on the condition of the malleus–incus complex, the status of the tympanic cavity, and the round window. There was a moderately strong agreement regarding the status of the lateral semicircular canal (LSCC) and tegmen tympani. This agreement was primarily observed, when no erosion/exposure was present in the LSCC or the dura. There was a very strong agreement in the mastoid air-cell complex and the sigmoid sinus, especially when the former was abnormal and the latter had no pathology. There are significant difficulties in radiological imaging for reliably assessing the middle ear in patients with chronic otitis media, using HRCT. The preoperative CT scan generally underestimates the actual pathology found by the surgeon in certain middle ear areas. The decision for surgical intervention should not be based on the radiological interpretation of certain middle ear structures, and ENT surgeons should be prepared to encounter conditions which are not reported by the radiologist preoperatively, and modify the operating strategy accordingly. EBM level: 2c.

Cochlear implantation update: contemporary preoperative imaging and future prospects – the dual modality approach as a standard of care

The selection of cochlear implant (CI) candidates requires consideration of a variety of clinical and radiographic factors. The present article reviews the current knowledge regarding the preoperative imaging of CI candidates and explores emerging developments in different imaging modalities. Preoperative radiologic assessment should evaluate the status of the middle/inner ear, auditory nerve and central acoustic pathways. Preoperative computed tomography displays anatomic middle ear variations of surgical importance. MRI can demonstrate fluid/obliteration in the inner ear and depict the retrocochlear auditory pathways. Dual modality imaging with high-resolution computed tomography and MRI of the petrous bone and brain can provide the maximum information regarding surgical landmarks and detect deafness-related abnormalities. Cost–effectiveness issues also justify its use. New systems are now becoming available, offering improved soft-tissue delineation, sophisticated segmentation techniques, volumetric measurements, semitransparent views and superior surface resolution, thus significantly advancing our diagnostic acumen and making the preoperative evaluation of CI candidates more accurate and reliable.

Surgical versus percutaneous tracheostomy: an evidence-based approach

The choice between surgical (ST) and percutaneous tracheostomy (PT) is not often based on evidence. The aim is to evaluate the quality of evidence in published articles comparing the two methods. A MEDLINE search was done. From 298 articles found, 37 fulfilled the inclusion criteria and 35 were further analyzed. No study was based on type I evidence, 13 (37%) represented type II, in 1 (3%) a clear-cut definition between type II or III was not possible and 21 (60%) represented type III or IV evidence. Taking into account the complication rate of the 13 type II evidence studies, 7 are in favor of PT and 3 in favor of ST. The majority of studies comparing PT with ST are of type III or IV level of evidence. Even if only type II studies are analyzed, outcomes are controversial. Any claims by clinicians in favor of a particular treatment are still debatable.

Diagnosis and treatment of HIV-associated manifestations in otolaryngology

Almost 30 years after its first description, HIV still remains a global pandemic. The present paper aims to review the current knowledge on the ear, nose and throat (ENT) manifestations of HIV infection, and present the available diagnostic and treatment options. A literature review was conducted in Medline and other available database sources. Information from related books was also included in the data analysis. It is well acknowledged that up to 80% of HIV-infected patients eventually develop ENT manifestations; among which, oral disease appears to be the most common. Oro-pharyngeal manifestations include candidiasis, periodontal and gingival disease, HSV and HPV infection, oral hairy leucoplakia, Kaposis sarcoma, and non-Hodgkins lymphoma. ENT manifestations in the neck can present as cervical lymphadenopathy or parotid gland enlargement. Respective nasal manifestations include sinusitis (often due to atypical bacteria), and allergic rhinitis. Finally, otological manifestations include otitis (externa, or media), inner ear involvement (sensorineural hearing loss, disequilibrium), and facial nerve palsy (up to 100 times more frequently compared to the general population). Although ENT symptoms are not diagnostic of the disease, they might be suggestive of HIV infection, or related to its progression and the respective treatment failure. ENT doctors should be aware of the ENT manifestations associated with HIV disease, and the respective diagnosis and treatment. A multi-disciplinary approach may be required to provide the appropriate level of care to HIV patients.

Are intra-tympanically administered steroids effective in patients with sudden deafness? Implications for current clinical practice

Over 60xa0years since its first report, sudden sensorineural hearing loss (SSNHL) still represents an ill-explained condition, with potentially devastating effects for the quality of life of previously well patients. The present study critically reviewed the available evidence regarding the efficacy of intra-tympanic steroid administration in the treatment of SSNHL. Factors affecting that efficacy were also explored. The literature was systematically reviewed in Medline and other database sources until July 2011, and analyzed through critical analysis of pooled data. The study selection included multi-center prospective randomized control trials, prospective randomized comparative, prospective comparative and prospective studies, retrospective comparative and retrospective studies. The total number of analyzed studies was 43. Intra-tympanic steroids appear to be effective as primary (strength of recommendation A), or salvage treatment (strength of recommendation B) in SSNHL. It is difficult to draw definite conclusions regarding the efficacy of combination therapy. The identification of a time window for effective treatment in the former two approaches yields a grade C strength of recommendation. Primary intra-tympanic treatment is the most effective modality in terms of complete hearing recovery (34.4% cure rate). There is not enough evidence to attribute treatment failures to impaired permeability of the round window membrane. Most complications of intra-tympanic treatment are minor, temporary, and conservatively managed. Intra-tympanic steroids can theoretically provide a more organ-specific treatment in patients with SSNHL. The observation that they seem effective both as primary and salvage treatment modalities with a very low complication rate may have serious implications for current clinical practice.

Meniere's disease: Still a mystery disease with difficult differential diagnosis

One hundred and forty-six years after its first description, the differential diagnosis of Meniere’s disease remains very challenging. The aim of the present study is to review the current knowledge on the advantages and disadvantages of the new diagnostic methods for Meniere’s disease. The importance of accurate diagnosis for primary healthcare systems is also discussed. An extensive search of the literature was performed in Medline and other available database sources. Information from electronic links and related books were also included. Controlled clinical studies, prospective cohort studies, retrospective cohort studies, cross-sectional studies, case reports, written guidelines, systematic reviews, and books were selected. The typical clinical triad of symptoms from the vestibular and cochlear systems (recurrent vertigo, fluctuating sensorineural hearing loss and tinnitus) is usually the key for clinical diagnosis. Glycerol dehydration test and electrocochleography are the main diagnostic tests in current practice, while vestibular evoked myogenic potentials may be used in disease staging. Imagine techniques are not specific enough to set alone the diagnosis of Meniere’s disease, although they may be necessary to exclude other pathologies. Recently developed 3D MRI protocols can delineate the perilymphatic/endolymphatic spaces of the inner ear and aid diagnosis. Meniere’s disease is a continuous problem for the patients and affects their quality of life. Taking into account the frequent nature of the disease in certain countries, efforts for reliable diagnosis, prompt referral, and successful management are undoubtedly cost-effective for healthcare systems.