Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
Name of the Candidate and
DR.BHAT SUPRIYA MOHAN
Address (In Block Letters)
PG IN ENT
SRI VENKATESHWARA ENT INSTITUTE,
VICTORIA HOSPITAL,
BANGALORE: 560002.
2.
Name of the institution
BANGALORE
MEDICAL
COLLEGE
AND
RESEARCH INSTITUTE,
BANGALORE.
3.
Course of study and Subject
M.S. IN ENT
4.
Date of admission to the course
02-05-2009
5
Title of the topic
A CLINICAL STUDY AND MANAGEMENT
OF CAVITY PROBLEMS ENCOUNTERED IN
CANAL WALL DOWN MASTOIDECTOMY.
6. BRIEF SUMMARY OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Chronic suppurative otitis media (CSOM) is a long standing infection of a part or whole
of middle ear cleft characterized by intermittent or persistent, chronic purulent drainage
through a perforated tympanic membrane. One of the surgical modalities of treatment for
this is canal wall down mastoidectomy (CWDM) which broadly means a procedure
requiring removal of the posterior wall of external auditory canal. It includes both radical
and modified radical mastoidectomy.
The advantages of this procedure include excellent intraoperative exposure of
cholesteatoma facilitating eradication of disease and easy detection of recurrence
postoperatively. It decreases the need for second stage operation and hence is costeffective. The above factors make it an optimum surgery especially in the Indian setting.
The major drawback with this procedure is the cavity problems like discharging ear,
granulations, wax and keratin accumulation, difficulty in prescribing hearing aids,
dizziness and small meatus encountered postoperatively. Few studies have been carried
out in this respect especially in the Indian scenario. If cavity problems and the means to
prevent or alleviate them are identified, quality of life of patients can be improved.
Hence the need for this clinical study.
6.2 REVIEW OF LITERATURE
Chronic otitis media with cholesteatoma is a potentially dangerous disease because it can
lead to life threatening intracranial complications. The objective of surgery for chronic
otitis media with cholesteatoma and chronic otomastoiditis is to eradicate the disease and
prevent recurrence. CWDM is the most widely used surgical method worldwide. It is
supposed to be easier, of shorter duration, necessitates less surgical experience than the
canal wall-up procedures, and has low recurrence and residual rate. The anatomic and
functional outcome is satisfactory, and the rate of complications is acceptably low. A
tympanoplasty can also be performed simultaneously.1, 2
In a retrospective review of 101 patients who underwent canal wall down procedure, the
average visits per patient was 13.3 (median of 11 visits). The greatest number of visits
occurred in the first 24 months after surgery with the commonest reasons being the
removal of the clinical features of chronic cavity inflammation like wax, keratin
accumulation, discharge, debris and granulation tissue. Residual or recurrent
cholesteatoma, residual perforations and structural cavity problems were infrequent.3
A retrospective study was conducted to evaluate the long-term, anatomic and functional
outcome of CWDM performed for chronic otitis media with cholesteatoma and chronic
otomastoiditis resistant to all conservative treatment. 1 to 24 years after surgery, cavities
were found to be dry and self-cleaning in 95% of cases, and still humid with otorrhea, in
5% of the cases. The study concluded that anatomic and functional results are
satisfactory, and the rate of complications is acceptably low provided both patient and the
surgeon engage in a long-term follow-up.4
Assessment of 10 year results of CWDM for acquired cholesteatoma in 136 patients
showed cholesteatoma recurrence in 23 patients (17%) and after revision the
cholesteatoma recurred again in three patients (2% of the total series). 133 (98%) of the
ears operated on were dry, two (1%) were moist and one ear (0.7%) was discharging. The
tympanic membrane was intact in 125 ears (92%) and perforated in 11 ears (8%). Only
14% of patients had hearing levels of 20 dB or better and 46% had 40 dB or better
hearing. There were 7 (5%) totally deaf ears. The author concluded that the surgical
technique of CWDM should be improved in order to lower the recurrence rate and to
improve hearing results.5
Another study emphasized that rehabilitation of the tympanomastoid cavity is important
to achieve a long-standing trouble free cavity and good functional hearing levels. From
1980 to 2004, 1602 CWDM were performed of which 978 had primary surgery and 624
were revision cases. Healing of cavity and tympanic membrane (TM) graft was achieved
in 1548 (94.2%) of cases. Revision surgery was performed in 32 cases for recurrence or
residual cholesteatoma, mostly in the attic and middle ear. Persisting discharge was
present in 12 cases. Serviceable hearing air-bone (A-B) gap closure up to 20 dB was
achieved in 1017 (63.5%) cases. Hearing was worse than pre-operative level in 154
(9.6%) cases. There was no improvement in hearing in 397 (24.8%) cases. Serviceable
hearing was obtained after second stage ossiculoplasty in 34 (2%) cases. It was concluded
that proper post operative follow up, analysis of the failure cases and modifications in
standardized procedures are necessary to get a dry ear and serviceable hearing.6
A retrospective review with respect to intraoperative findings in revision canal wall down
mastoidectomy showed that the mastoid cavity following primary surgery was found to
be dry only in 60% of the cases. Four factors which influenced whether the resulting
mastoid cavity would remain dry were: presence of an open middle ear, a large cavity, a
high facial ridge and a small meatus. If all four factors were present then the cavity had a
100% chance of discharging. Many cases of revision mastoid surgery have identifiable
inadequacies in the primary surgical technique. Attention to key surgical principles
should improve the dry ear rate post canal wall down mastoidectomy.7
This study identified what constitutes a problem cavity and techniques to avoid such
difficulties. Problem cavity is likely to exhibit a small meatus behind which can be found
a high facial ridge, partially removed posterior and superior canal walls, a partially
removed lateral attic wall, a deep mastoid tip cavity, no tympanic membrane or a
perforation and active mucopurulent drainage. The most common cause of problem
cavity was poor execution of open technique.8
6.3 OBJECTIVE OF THE STUDY
1. To identify the cavity problems following canal wall down mastoidectomy.
2. Preventive measures to be taken in the intraoperative and early and late postoperative
period to reduce the occurrence of complications, hence the morbidity.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
The study will include patients of all age groups & either sex undergoing canal wall
down mastoidectomy operation in Sri Venkateshwara ENT Institute, Victoria Hospital
and Bowring & Lady Curzon Hospitals attached to Bangalore Medical College and
Research Institute, Bangalore during the study period from December 2009 to July 2011.
7.2 METHODS OF COLLECTION OF DATA
1. Detailed History taking.
2. Clinical examination.
3. Relevant investigations.
4. Indication for canal wall down mastoidectomy.
5. Postoperative follow up of patients to identify the occurrence of the cavity problems.
SAMPLE SIZE: 50 cases undergoing canal wall down mastoidectomy will be included
in the study.
7.3 INCLUSION CRITERIA
1. Patients of all age group and either sex.
2. Patients who have undergone canal wall down mastoidectomy.
7.4 EXCLUSION CRITERIA
1. Patients who have undergone canal wall up mastoidectomy
Statistical analysis of the data parameters will be done using following statistical tests.
1. Chi-square test.
2. Fisher exact test.
3. Analysis of variance.
7.5 Does the study require any investigation or intervention to be conducted on
patients or other humans or animals? If so, please describe briefly
Yes
1. Complete Haemogram, Bleeding time, Clotting time, Urine Analysis.
2. Random blood sugar, Blood Urea, Serum Creatinine.
3. Chest X-Ray, ECG.
4. Pure Tone Audiometry.
5. Pus for Culture and Sensitivity.
6. X-Ray Mastoid
7. Computed Tomography or Magnetic Resonance Imaging (if necessary).
After informing the patients and obtaining prior written informed consent, the patient will
be subjected to investigations as indicated and confirmed to well recognized, practiced
and established modalities of treatment.
No animal study is required.
7.6 Has the ethical clearance been obtained from your institution in case of 7.5?
Yes.
8. LIST OF REFERENCES
1. Grewal DS, Hathiram BT, Saraiya SV. Canal wall down tympanomastoidectomy: the
'on-disease' approach for retraction pockets and cholesteatoma. J Laryngol Otol.
2007 Sep; 121(9): 832-9.
2. Nikolopoulos TP, Gerbesiotis P. Surgical management of cholesteatoma: the two
main options and the third way- atticotomy / limited mastoidectomy. Int J Pediatr
Otorhinolaryngol. 2009 Sep; 73(9): 1222-7.
3. Khalil HS, Windle-Taylor PC. Canal wall down mastoidectomy: A long term
commitment to the outpatients? BMC Ear Nose Throat Disord. 2003 Sep 4; 3(1): 1.
4. Kos MI, Castrillon R, Montandon P, Guyot JP. Anatomic and functional long-term
results of canal wall-down mastoidectomy. Ann Otol Rhinol Laryngol. 2004 Nov;
113(11): 872-6.
5. Vartiainen E. Ten-year results of canal wall down mastoidectomy for acquired
cholesteatoma. Auris Nasus Larynx. 2000 Jul; 27(3): 227-9.
6. Mahadevaiah A, Parikh B, Govindaraj R. Rehabilitation of the Tympanomastoid
cavity In Canal Wall Down procedures. Indian Journal of Otolaryngol Head Neck
Surg. 2007 Jun; 59(2): 120-123.
7. Phelan E, Harney M, Burns H. Intraoperative findings in revision canal wall down
mastoidectomy. Ir Med J. 2008 Jan; 101(1): 14.
8. Glasscock M, Nissen A, Schwaber M, et al: Open mastoid procedures:Contemporary
indications and surgical technique. Laryngoscope. 1985; 95: 1037-1043.
9.
Signature of Candidate:
10.
Remarks of Guide:
Cavity problems following canal wall down mastoidectomy are many which may be
troublesome to the patients. Hence this study may help us to understand better about the
problems and various steps to prevent these and to learn various modalities of treatment
of these problems as and when they occur. As this Institution has got all the infrastructure
and facilities this study can be undertaken.
11.
11.1 NAME & DESIGNATION OF GUIDE: Dr. M.RAJASHEKHAR
MBBS, MS (ENT)
Professor of ENT
Bangalore Medical College &
Research Institute
Bangalore: 560002
11.2 SIGNATURE:
11.3 CO-GUIDE (IF ANY)
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT:
Dr.H.S. SATISH
MBBS, DLO, MS(ENT)
Sri Venkateshwara ENT Institute
Bangalore Medical College
& Research Institute
Bangalore: 560002
11.6 SIGNATURE:
12.
12.1 REMARKS OF CHAIRMAN & PRINCIPAL:
SIGNATURE: