ᅟThe three well recognized tympanoplasty approaches: permeatal, postaural, and endaural, each have advantages and disadvantages. The permeatal approach is suitable only for ears with adequate canal size. The postaural approach limits visualization of the posterior eardrum margin. The endaural approach limits the view of the eardrum's anterior margin.This study describes a modified endaural approach, developed to overcome these limitations. A retrospective case series review and collection of a prospective cohort of patient reported outcome data were undertaken to assess the technique.MethodStandard incisions as used in an endaural approach are placed within the ear canal. The novel incision extends from the superior canal incision into the conchal cavum. This allows a flap of the thick, hairbearing skin from both the bony and cartilaginous portions of the canal to be raised, and everted, to provide an excellent view of the entire drum. Perichondrium can be harvested for grafting from the conchal cavum.The clinical charts of all patients operated on by the first author using this technique from 2010–2012 were retrospectively reviewed. The size and position of the perforation, size of the canal, whether primary or revision surgery, graft take rate, hearing results and the occurrence of chondritis/perichondritis were recorded.To investigate the morbidities and the acceptance by the patients of the incision/scar in the conchal cavum, all patients undergoing the procedure in the 8 months up to the end of August 2013 were prospectively recruited to complete a self-assessment Likert scale questionnaire recording postoperative pain, and satisfaction with the cosmesis of the operative site. The clinician recorded if there was any evidence of chondritis/perichondritis.ResultsA 100 % graft take rate was achieved in the 75 adults treated by the first author from 2010 to 2012 regardless of the size and position of the perforation, configuration of the canal, primary or revision surgery.Preoperative Pure Tone Audiometric (PTA) Air Bone Gap (ABG) averaged over 3 frequencies (0.5, 1 and 2 K Hz) was 19.4dB (standard deviation = 9.6, range 2 to 50). Postoperative PTA ABG average was 6.2 dB (standard deviation = 8.3, range -7 to 37), demonstrating a statistically significant post-surgery mean improvement of 13.2 dB (paired T-test, p < 0.001).Twenty-one patients who underwent the procedure in 2013, reported minimal postoperative analgesic use, and scored the acceptability of the incision scar highly (4.8 out of a maximum of 5). There was no case of chondritis/perichondritis in the 96 cases.ConclusionWhilst it is the surgeon’s decision to use a permeatal, postaural or endaural approach, the endaural approach with the conchal cavum modification is an excellent alternative to the traditionally described approaches.Trial RegistrationClinical trial number: NCT02000843 at ClinicalTrials.gov
Revascularized iliac bone has advantages over other revascularized bone grafts for the reconstruction of large mandibular defects. This is a detailed anatomical study of the blood supply to the iliac bone using microfil and Batson injection methods. It confirms and extends Taylor's study. Clinical results are reported for six cases of extensive mandibular defects which were reconstructed using this method.
Objectives: Most acute low-tone sensorineural hearing loss without vertigo (ALHL) improves over time; however, some cases develop into typical Ménière's disease (MD), suggesting an association between ALHL and MD. This study aimed to investigate associations between ALHL and MD from the perspective of development of the vestibular aqueduct.Methods: Prospective case-control study at a tertiary referral center. In 51 patients with unilateral ALHL (15 males, 36 females; mean age, 52.3 years), 35 patients with unilateral MD (14 males, 21 females; mean age, 43.1 years) and 11 healthy controls (11 males; mean age, 33.3 years), length of the external aperture of the vestibular aqueduct (EAVA) was measured on 3-dimensional computed tomography. Results were then compared among ALHL patients, MD patients, and controls.Results: On the affected side, mean length of the EAVA was 5.8 ± 2.7 mm in ALHL patients, 4.3 ± 2.0 mm in MD patients, and 6.5 ± 1.5 mm in controls. The EAVA was significantly shorter in MD than in ALHL or controls. Among ALHL patients, length of the EAVA was significantly shorter in patients with recurrence (4.5 ± 1.9 mm) than in those without recurrence (6.4 ± 2.5 mm).Conclusions: Hypoplasia of the endolymphatic sac may represent a predisposing factor for recurrence of ALHL and/or MD, as development of the endolymphatic sac is known to correlate with length of the EAVA. Conchal Approach TympanoplastyS. Christopher Man, MD (presenter); Desmond A. Nunez, FRCSC Objectives: (1) Review standard tympanoplasty approaches.(2) Describe a novel approach that minimizes soft tissue dissection and provides good access.Methods: The charts of consecutive adult patients who underwent a conchal approach tympanoplasty between January 2010 and December 2012 at an urban teaching hospital under the care of a single surgeon were reviewed. The patient's age in decades at the time of surgery, sex, and proportion of intact tympanic membranes noted at follow-up were recorded. Postoperative analgesic use and patient recorded satisfaction with the cosmetic appearance of the ear using a Likert type scale from 1 least to 5 most satisfied was collected for consecutive patients undergoing the procedure in 2013. The mean patient satisfaction score was calculated.Results: In the 3-year period from 2010-2012, the charts of 75 adults were reviewed. There were 45 females and 30 males with ages ranging from third to eighth decades. Complete tympanic membrane closure was achieved in 74 (98.7%). Twenty-one adults treated in 2013 recorded a mean satisfaction score with the appearance of the postoperative ear scar of 4.8 out of 5. Postoperative analgesic consumption consisted of acetaminophen or diclofenac sodium on the day of surgery. No patients used analgesics beyond postoperative day 2.Conclusions: The conchal approach tympanoplasty is associated with a high graft take rate, low morbidity and high patient satisfaction with scar cosmesis.
A 12-year-old boy presented to the Children's Emergency Department with sudden-onset palpitations that began while he was watching television. He had experienced similar symptoms before, and had been instructed to take his medication as a 'pillin-the-pocket' should they occur. He did not report any chest pain or shortness of breath. His father brought him to the hospital as his symptoms had persisted despite two doses of medications. Clinical examination revealed a well-appearing child with normal heart sounds and a mildly elevated heart rate of 128 beats per minute (bpm). No cardiac murmurs or adventitious lung sounds were heard. His blood pressure and oxygen saturation were within normal limits.A 12-lead electrocardiogram (ECG) was obtained. What does the ECG (Fig. 1) show?
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