SYNOPSIS
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
“PRE-OPERATIVE INDICATORS OF OSSICULAR NECROSIS IN CHRONIC SUPPURATIVE OTITIS MEDIA ”
Name of the candidate : Dr. Celina Lovely Jayakumar
Guide : Dr. George J. Oliver Pinto
Course and Subject : M.S. Otorhinolaryngology
Department of Otorhinolaryngology,
Father Muller Medical College,
Kankanady, Mangalore – 575002.
August – 2010
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE II
PROFORMA FOR REGISTRATION OF THE SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / DR.CELINA LOVELY JAYAKUMAR.P.G. RESIDENT,
FR. MULLER MEDICAL COLLEGE, KANKANADY,
MANGALORE – 575002.
2. / NAME OF THE INSTITUTION / FR. MULLER MEDICAL COLLEGE, KANKANADY,
MANGALORE – 575002
3. / COURSE OF STUDY AND SUBJECT / M.S. OTORHINOLARYNGOLOGY
4. / DATE OF ADMISSION TO COURSE / 30-04-2010
5 / TITLE OF THE TOPIC:
“ PRE-OPERATIVE INDICATORS OF OSSICULAR NECROSIS IN CHRONIC SUPPURATIVE OTITIS MEDIA ”
6. / Brief Resume of the Intended Work:
6.1. Need for the study:
Chronic suppurative otitis media (CSOM) is defined as persistent bacterial infection of the middle ear cleft, lasting six weeks or more, with conductive hearing loss and a persistent perforation of the tympanic membrane. The malleus, incus, stapes and the tympanic membrane are vital for impedance-matching in the middle ear.
Tubotympanic CSOM may lead to bony resorption of ossicles due to increased osteoclastic activity, avascular necrosis, increased hyperemia or due to trapped middle ear cleft granulation tissue. Ossicular necrosis is expected in atticoantral CSOM but comes as a suprise in tubotympanic CSOM.
This is confirmed only at surgery. Preoperative high resolution CT scan of the temporal bone is useful in ascertaining ossicular integrity, but not done routinely due to high costs. Pre-operative knowledge of ossicular necrosis enables the surgeon to plan operative scheduling, allowing a longer duration for surgery and arrange for specific equipment and materials required for ossiculoplasty. Anesthetists would also use a longer acting anesthetic according to the surgeon's estimate of the duration of the surgery. The surgeon can discuss the outcome prior to surgery and obtain consent.
This study is intended to identify the predictive value of a series of common pre-operative clinical signs and investigations with ossicular necrosis in patients with CSOM.
6.2 Review of Literature
Otitis media is the most common otological condition during childhood which compromises sound conduction in the middle ear. In chronic cases it is estimated that the degree to which hearing is compromised is directly proportional to the damage caused to middle ear structures [1]. Hearing thresholds may be influenced by factors such as site and size of tympanic perforation, ossicular chain erosion as well as cholesteatoma.
In a study by Jareen Ebenezer & colleagues [2], 150 patients with tubotympanic CSOM were evaluated. A total of 24 (16%) patients had necrosis of lenticular process of incus. Most of these patients had moderate to moderately severe hearing loss (41 – 70 dB) with an air-bone gap ( ABG ) of more than 40 dB. The presence of middle ear granulation and pure tone audiometric average thresholds of 41 – 70dB hearing loss were concluded as predictors of incudal necrosis.
Fuh Cherng Jeng et al [3], conducted a retrospective study on 190 patients with CSOM. It was observed that persistently draining ears or a cholesteatoma extending to tympanic sinus were sgnificant predictors in patients with cholesteatoma. In non-cholesteatoma CSOM adherence of the edge of perforation to the promontory occurred significantly more frequently in patients with ossicular discontinuity.
In a study by Carrillo and collegues[4] it was observed that a wide air bone gap at higher frequencies suggested ossicular discontinuity whereas narrow ABG at low frequencies suggested absence of ossicular discontinuity. In the presence of cholesteatoma the chances of ossicular discontinuity was 88% although the ABG may not be significantly altered.
J.D.Swartz et al [5], studied ossicular erosions using computed tomography (CT) in 55 patients. The incus (particularly the long and lenticular process ) was the ossicle most commonly involved (50 cases). Fibrous replacement of the incudostapedial articulation was diagnosed in four cases on axial CT scan when an unusually wide joint was present.
6.3 Objective of the study:
1. To study the predictive value of pre-operative clinical findings with ossicular necrosis.
2. To study the correlation between audiological evaluation and ossicular necrosis.
7. / Materials and Methods:
Source of Data :This study will be conducted on 50 patients with tubotympanic CSOM who attend the out patient department of otorhinolaryngology from August 2010 to February 2011.
Study Design : This is a diagnostic study where all patients with tubotympanic CSOM will undergo a detailed clinical otoscopic and microscopic examination to evaluate the size and site of perforation, presence or absence of ear discharge granulation tissue and condition of middle ear mucosa. Pure tone audiogram will also be done.All patients will undergo cortical mastoidectomy with tympanoplasty under GA. The intraoperative findings of ossicular necrosis, defects and presence of granulation tissue will be noted.
Inclusion Criteria –-
· Clinical diagnosis of tubotympanic CSOM.
· Scheduled to undergo cortical mastoidectomy and tympanoplasty.
· Age more than 7 yrs.
Exclusion Criteria
· Patients with attico antral disease.
· Marginal perforations.
· Previous ear surgery.
Data Analysis
The collected data will be analyzed based on sensitivity, specificity, positive predictive value, negative predictive value and by chi – square test.
7.3 Does the study requires any investigations or interventions to be conducted on patients or other humans or animals?
YES
7.4 Has ethical clearance been obtained from your institution in case of 7.3
YES
8. LIST OF REFERENCES:
1.Silveira Netto et al, “The impact of chronic suppurative otitis media on
childrens' and teenagers' hearing.” International Journal of Pediatric
Otorhinolaryngology 2009,73;12:1751-1756.
2.Jareen E, Vedentam R, “ Preoperative predictors of incudal necrosis
in chronic suppurative otitis media.” Otolaryngology – Head and neck
Surgery (2010);142:415-420.
3.Fuh Cheng J.,Ming-Houi Tsai,Carolyn J.,”Relationship of ossicular
discontinuity in chronic otitis media.” Otology and Neurotology 2003;
24:29-32.
4.Carrillo et al, “ Probabilities of ossicular discontinuity in chronic
suppurative otitis media using pure tone audiometry.” Otology and
Neurotology 2007 Dec ;28(8):1034-7.
5.Swartz J.D et al, “Ossicular erosions in the dry ear : CT diagnosis.”
Radiology 1987;163;763 – 765.
9. / SIGNATURE OF THE CANDIDATE -
10. / REMARKS FROM GUIDE-
11. / NAME AND DESIGNATION OF
(IN BLOCK LETTERS)
11.1 GUIDE / DR. GEORGE J. OLIVER PINTO,
PROFESSOR AND HOD OF ENT,
DEPARTMENT OF ENT,
FR. MULLER MEDICAL COLLEGE
KANKANADY, MANGALORE – 575002
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT / DR. GEORGE J. OLIVER PINTO,
PROFESSOR AND HOD OF ENT.
DEPARTMENT OF ENT,
FR. MULLER MEDICAL COLLEGE
KANKANADY,
MANGALORE – 575002
11.6 SIGNATURE
12 / 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE