|Year : 2015 | Volume
| Issue : 1 | Page : 37-40
Our experience of unsafe ear
Nagendran Navaneethan, Rajprakash Dharmapuri YaadhavaKrishnan, Udhayakumar Muthukumar, Ramasubramaniam Harihara
Department of ENT, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
|Date of Web Publication||10-Mar-2015|
Dr. Nagendran Navaneethan
Department of ENT, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur - 603 319, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the commonest presentation and intraoperative findings and significant post operative challenges in patients who underwent modified radical mastoidectomy in Melmaruvathur adhiparasakthi Institute of medical sciences and research. Design: Retrospective study. Materials and Methods: Fifty six patients who underwent modified radical mastoidectomy for unsafe ear disease were included in this study. The study period was from 2009 to 2012.The commonest presentation was evaluated with the history taken from the patient's records. The intraoperative evaluation of primary pathology and its anatomic extension and ossicular status were identified. Common problems we faced postoperatively were documented. Results: Of the 56 patients,thirty eight(68%) were male and eighteen(32%) were female. The age ranged from nine years -fifty years of age. The commonest presentation in this study was foul smelling scanty discharge (75%) and the primary pathology was isolated cholesteatoma (54%). The involvement of mesotympanum, attic, aditus & antrum with primary disease was more than the isolated involvement of attic,aditus and antrum. Stapes erosion was more common than incus erosion in our study. We faced a very rare postoperative complication of delayed facial palsy in one patient who had no facial nerve dehiscence. Conclusion: Good attention given to patients with infrequent, minimal ear discharge helps to identify unsafe ear. In unsafe ear, otologists should be well prepared to face the stapes erosion during surgery. Even though rare, otologists should be aware of delayed facial palsy and be cautious about the past history of herpes simplex and varizella infection and consider antiviral prophylaxis before surgery.
Keywords: Delayed facial palsy, Modified radical mastoidectomy, Ossicles, Unsafe ear
|How to cite this article:|
Navaneethan N, YaadhavaKrishnan RD, Muthukumar U, Harihara R. Our experience of unsafe ear. Indian J Otol 2015;21:37-40
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a common disease in the specialty of ear, nose, and throat. Unsafe ear disease is dangerous because of the capability of bone erosion.  Surgical treatment, that is, modified radical mastoidectomy is the solution in those patients without intracranial complication. Some authors refer this as Bondy operation  which is performed in unsafe ear with intact ossicles. After recognizing mastoid antrum, removal of superior and posterior canal wall was meticulously done, keeping in mind to retain a thin rim of bone over ossicles. That thin rim was removed carefully to maintain intactness of ossicular chain.
| Materials and Methods|| |
In our medical college hospital, the average census in ENT Department is between 50 and 70 patients daily. Of which 30-40 patients will present with complaints. Compared with safe type, unsafe ear disease will be less. Hence, we were eager to collect records of patients who underwent modified radical mastoidectomy for unsafe ear disease. The study period was from January 2008 to December 2013. Of 72 patients underwent modified radical mastoidectomy during this period, we were able to retrieve data of only 56 patients. We excluded the patient's data, who had not come for regular follow-up postoperatively. For the socioeconomic status, we used modified Prasad scale.  Usually, all patients with the clinical diagnosis of unsafe ear were evaluated under Zeiss microscope for the ear findings.
Patients fit for general anesthesia were admitted 1-day before the surgery and xylocaine test dose was given. They were advised to do hair wash, and their postauricular area was prepared (by shaving 1.5-2 cm hair-bearing area). In modified radical mastoidectomy, the cavity was packed with ribbon gauze soaked in bismuth iodoform paraffin paste. Suture removal was usually done on 7 th postoperative period, and cavity pack was removed was done on the 21 th postoperative period. Follow-up was done every week up to 2-3 months until the cavity had healed well.
| Results|| |
Of the 56 patients, 38 (67.8%) were male and 18 (32.1%) were female. The majority of the patients as mentioned were noted to be males. Extremes of age were involved ranging from 9 to 50 years of age. Right-sided surgery 34 (60.7%) was more than the left-sided surgery 22 (39.3%).
The most common presentation in this study was foul smelling scanty discharge 42 (75%) compared to aural polyp with hearing loss 14 (25%) which was statistically significant with P < 0.02 [Table 1]. Of 56 patients, the most common primary disease removed was pure cholesteatoma. Isolated granulation and cholesteatoma with granulation had almost same incidence in our study [Table 1]a.
By using the revised Prasad scale,  we assessed socioeconomic status in our patients.
Thirty-three patients belongs to V social class (per capita income in rupees per month is < 757) and 23 belongs to social class IV (per capita income in rupees per month is between 767 and 1532). There is statistically significant association in socioeconomic status and foul smelling discharge which is well-described in [Table 1]b. More patients of V social class were having unsafe ear disease than the IV class [Table 1]b.
Intraoperative evaluation of extent of the disease in the middle ear cleft revealed that involvement of mesotympanum along with attic, aditus, and antrum (38 patients) was more than isolated involvement of attic, aditus, and antrum (18 patients). During the surgery under microscopic magnification, we were able to appreciate intact malleus in majority of the cases, incus was eroded in 27 patients and stapes suprastructure was absent in 40 patients. Ossicular status of unsafe ear disease in our study is completely described in [Table 2].
Of 56 patients, 6 (11%) had low-lying dura, 6 (11%) had anterior placed sinus plate, and four patients had dehiscent facial nerve in the tympanic segment [Table 3]. Though lateral semicircular canal is well-preserved during surgery, we had an opportunity to notice a fistula in one patient on separating the cholesteatoma sac from aditus. We anticipated lateral semicircular canal fistula in that patient since he had profound nerve deafness before the surgery itself. He had severe vertigo during his postoperative period.
Postoperative challenges as shown in [Table 4], six had delayed postoperative wound gaping after suture removal on the 7 th postoperative day. Those patients were treated with parentral amoxicillin with clavulanic acid for 7 days along with loosening of pack in the mastoid cavity. All six patients recovered well.
One patient with lateral semicircular canal fistula had severe giddiness postoperatively, and he was treated with oral betahistine, cinnarizine, and parenteral Stemetil for 10 days and patient recovered well.
One patient developed delayed facial nerve palsy (DFP) on the 5 th postoperative day and was managed with oral prednisolone and physiotherapy along with loosing of pack in the cavity. After knowing the relationship of viral reactivation and DFP, which was expressed by Salvinelli et al. in his study. We were also able to elicit the history of recurrent attacks of herpes labialis in our patient. He recovered very well with 3 months of physiotherapy.
| Discussion|| |
The most common clinical presentation of our patients was foul smelling scanty discharge 42 (75%) which is more than that of Varshney et al.  (35.19%). Improvement of socioeconomic status can reduce the incidence of unsafe ear disease since we had more number of patients in V social class compared to the IV social class. Baig et al.  also stated that improvement of socioeconomic status of people, early recognition and treatment of CSOM can reduce the number of cases and complications of the disease.
The susceptibility for the ossicular destruction is much greater in cases of unsafe CSOM, which was due to the presence of cholesteatoma and/or granulations.  In our study, intact malleus was found in 58.9%, eroded malleus was in 35.7% and 3.5% of patients had absent malleus which correlates with the study of Varshney et al.  in unsafe CSOM, the malleus was found intact in 33 (55.00%), necrosed in 21 (35.00%) and absent in 6 (10.00%) cases. In our study, one patient (1.7%) had a malformed malleus and incus which were fused to form a bony mass.
In our study, eroded incus is in 48.2% using Student's t-test statistically significant at P < 0.05 which is more than that of both Varshney et al.  (45.00%) and Udaipurwala et al.  (41.00%). In our study, 75% had suprastructure involvement which is more than that of Udaipurwala et al. study (21.00%) which is statistically significant (P < 0.01) by using Student's t-test. Comparison of various studies about the involvement of stapes suprastructure is as shown in [Table 5].
Sensorineural hearing loss in preoperative patients indicates involvement of the inner ear either due to toxins or direct invasion.  In our study, one patient who had profound nerve deafness preoperatively, had a quite big fistula in the dome of lateral semicircular canal.
Safdar et al.  documented the incidence of delayed onset facial nerve palsy following tympanomastoid surgery as 0.91%. It is comparatively lesser than that of our experience (1.8%). The difference may be because of selection of bigger sample size in Safdar et al. study. Safdar et al.  elicited facial weakness in 8 th and 14 th postoperative day in two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection.
In our study, DFP occurs in 5 th postoperative day. Bonkowsky et al. defined DFP occurs 3 days after the otological procedure. Though it is usually reversible, it causes dissatisfaction for both the patient and the surgeon. He also quoted that the viral reactivation is induced by facial nerve irritation during the surgical procedure.
To avoid the incidence of DFP in patients with a history of recurrent attacks of herpes labialis or immunodepression status, Vrabec et al.  insisted to start oral valacyclovir 1-day before the procedure and continue for 10 days postoperatively in all otological and neurotological procedure.
| Conclusion|| |
Careful and systematic approach is mandatory for patients with infrequent, minimal ear discharge. It helps a lot to identify unsafe ear. In unsafe ear, incus is the most commonly eroded bone in which ossiculoplasty will be done with reconstructed incus itself. Stapes erosion is also more than incus erosion; we should be ready to face the reconstruction of sound transportation and middle ear augmentation. It is always advisable to evaluate history of herpes simplex and varicella infection preoperatively to avoid a rare complication of DFP.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]