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The Cochrane Database of Systematic... Jan 2020Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Chronic suppurative otitis media (CSOM), sometimes referred to as chronic otitis media (COM), is a chronic inflammation and often polymicrobial infection (involving more than one micro-organism) of the middle ear and mastoid cavity, characterised by ear discharge (otorrhoea) through a perforated tympanic membrane. The predominant symptoms of CSOM are ear discharge and hearing loss. Topical antibiotics, the most common treatment for CSOM, act to kill or inhibit the growth of micro-organisms that may be responsible for the infection. Antibiotics can be used alone or in addition to other treatments for CSOM, such as antiseptics or ear cleaning (aural toileting).
OBJECTIVES
To assess the effects of topical antibiotics (without steroids) for people with CSOM.
SEARCH METHODS
The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 April 2019.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) with at least a one-week follow-up involving participants (adults and children) who had chronic ear discharge of unknown cause or CSOM, where the ear discharge had continued for more than two weeks. The interventions were any single, or combination of, topical antibiotic agent(s) of any class, applied directly into the ear canal as ear drops, powders or irrigations, or as part of an aural toileting procedure. The two main comparisons were topical antibiotic compared to a) placebo or no intervention and b) another topical antibiotic (e.g. topical antibiotic A versus topical antibiotic B). Within each comparison we separated studies where both groups of participants had received topical antibiotic a) alone or with aural toileting and b) on top of background treatment (such as systemic antibiotics).
DATA COLLECTION AND ANALYSIS
We used the standard Cochrane methodological procedures. We used GRADE to assess the certainty of the evidence for each outcome. Our primary outcomes were: resolution of ear discharge or 'dry ear' (whether otoscopically confirmed or not), measured at between one week and up to two weeks, two weeks to up to four weeks and after four weeks; health-related quality of life using a validated instrument; ear pain (otalgia) or discomfort or local irritation. Secondary outcomes included hearing, serious complications and ototoxicity measured in several ways.
MAIN RESULTS
We included 17 studies with a total of 2198 participants. Twelve studies reported the sample size in terms of participants (not ears); these had a total of 1797 participants. The remaining five studies reported both the number of participants and ears, representing 401 participants, or 510 ears. A: Topical antibiotics versus placebo or no treatment (with aural toilet in both arms and no other background treatment) One small study compared a topical antibiotic (ciprofloxacin) with placebo (saline). All participants received aural toilet. Although ciprofloxacin was better than saline in terms of resolution of discharge at one to two weeks: 84% versus 12% (risk ratio (RR) 6.74, 95% confidence interval (CI) 1.82 to 24.99; 35 participants, very low-certainty evidence), the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other. The study authors reported that "no medical side-effects and worsening of audiological measurements related to this topical medication were detected" (very low-certainty evidence). B: Topical antibiotics versus placebo or no treatment (with use of oral antibiotics in both arms) Four studies compared topical ciprofloxacin to no treatment (three studies; 190 participants) or topical ceftizoxime to no treatment (one study; 248 participants). In each study all participants received the same antibiotic systemically (oral ciprofloxacin, injected ceftizoxime). In at least one study all participants received aural toilet. Useable data were only available from the first three studies; ciprofloxacin was better than no treatment, resolution of discharge occurring in 88.2% versus 60% at one to two weeks (RR 1.47, 95% CI 1.20 to 1.80; 2 studies, 150 participants; low-certainty evidence). None of the studies reported ear pain or discomfort/local irritation. C: Comparisons of different topical antibiotics The certainty of evidence for all outcomes in these comparisons is very low. Quinolones versus aminoglycosides Seven studies compared an aminoglycoside (gentamicin, neomycin or tobramycin) with ciprofloxacin (734 participants) or ofloxacin (214 participants). Whilst resolution of discharge at one to two weeks was higher in the quinolones group the very low certainty of the evidence means that it is very uncertain whether or not one intervention is better or worse than the other (RR 1.95, 95% CI 0.88 to 4.29; 6 studies, 694 participants). One study measured ear pain and reported no difference between the groups. Quinolones versus aminoglycosides/polymyxin B combination ±gramicidin We identified three studies but data on our primary outcome were only available in one study. Comparing ciprofloxacin to a neomycin/polymyxin B/gramicidin combination, for an unknown treatment duration (likely four weeks), ciprofloxacin was better (RR 1.12, 95% CI 1.03 to 1.22, 186 participants). A "few" patients experienced local irritation upon the first instillation of topical treatment (numbers/groups not stated). Others Other studies examined topical gentamicin versus a trimethoprim/sulphacetamide/polymixin B combination (91 participants) and rifampicin versus chloramphenicol (160 participants). Limited data were available and the findings were very uncertain.
AUTHORS' CONCLUSIONS
We are uncertain about the effectiveness of topical antibiotics in improving resolution of ear discharge in patients with CSOM because of the limited amount of low-quality evidence available. However, amongst this uncertainty there is some evidence to suggest that the use of topical antibiotics may be effective when compared to placebo, or when used in addition to a systemic antibiotic. There is also uncertainty about the relative effectiveness of different types of antibiotics; it is not possible to determine with any certainty whether or not quinolones are better or worse than aminoglycosides. These two groups of compounds have different adverse effect profiles, but there is insufficient evidence from the included studies to make any comment about these. In general, adverse effects were poorly reported.
Topics: Administration, Topical; Anti-Bacterial Agents; Chronic Disease; Humans; Otitis Media, Suppurative; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31896168
DOI: 10.1002/14651858.CD013051.pub2 -
Auris, Nasus, Larynx Apr 2020Luc's abscess is a rare complication of acute otitis media, with a challenging diagnosis and a controversial surgical treatment. The aim of the present study was to...
OBJECTIVES
Luc's abscess is a rare complication of acute otitis media, with a challenging diagnosis and a controversial surgical treatment. The aim of the present study was to review the published literature in order to clarify the clinical features and the surgical management of those patients.
METHODS
A systematic review of the literature was carried out for published reports or case series in English language, describing a temporo-zygomatic (or Luc's) abscess which complicated an acute or chronic otitis media and/or mastoiditis, confirmed through CT scan or MRI of the petrous bone. The collected clinical and radiological data were merged and critically appraised.
RESULTS
Eighteen reports of Luc's abscess were included. Adding our case report, a total of 21 cases were included in the analysis. Abscess drainage plus myringotomy alone vs. abscess drainage plus myringotomy and mastoidectomy were the two surgical management approaches described in the literature. Patients undergoing first line mastoidectomy were successfully treated in all cases, while among those undergoing a more conservative approach, one failure required subsequent mastoidectomy.
CONCLUSIONS
The clinical features of Luc's abscess are rather constant and help in rising the suspicion before the radiological diagnosis. Although cases with associated intra-cranic complications have been reported, the limited existing data do not permit to advocate the mastoidectomy over a more conservative surgical approach. However, the decision to avoid mastoidectomy as the first line surgical treatment should be based on the clinical and radiologic assessment, after an accurate counseling, particularly in the case of a pediatric patient.
Topics: Abscess; Anti-Bacterial Agents; Drainage; Edema; Erythema; Eyelids; Female; Humans; Infant; Mastoidectomy; Mastoiditis; Middle Ear Ventilation; Otitis Media; Temporal Bone; Tomography, X-Ray Computed; Zygoma
PubMed: 31812444
DOI: 10.1016/j.anl.2019.11.003 -
Sports Medicine (Auckland, N.Z.) Apr 2019Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented...
BACKGROUND
Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented cases to improve understanding and inform future preventative approaches.
OBJECTIVE
This review aimed to understand the extent of VAD in sport and characterise trends suggestive of mechanisms of injury.
METHODS
Electronic databases were searched using terms related to VAD and sport. Records were included if they described one or more cases of VAD attributed to sport.
RESULTS
A total of 79 records described 128 individual cases of VAD in sport, of which 118 were confirmed by imaging or autopsy and included in analyses. Cases were attributed to 43 contact and non-contact sports. The median age of cases was 33 years (IQR 22-44), and 75% were male. There were 22 cases of fatal injury, of which ten involved an impact to the mastoid region and seven involved an impact to the head or neck. Non-fatal cases of VAD were attributed to impact to the head or neck (not mastoid region), movement or held position without impact, and in some cases no reported incident.
CONCLUSIONS
VAD attributed to sports participation is uncommonly reported and the mechanisms are varied. Impact to the mastoid region is consistently implicated in fatal cases and should be the focus of injury prevention strategies in sport. Efforts may also be directed at improving the prognosis of cases with delayed presentation through clinical recognition and imaging. The review was registered on the international prospective register for systematic reviews ( http://www.crd.york.ac.uk/PROSPERO ) (CRD42018090543).
Topics: Athletic Injuries; Humans; Mastoid; Neck; Risk Factors; Sports; Vertebral Artery Dissection; Wounds, Nonpenetrating
PubMed: 30758815
DOI: 10.1007/s40279-019-01066-0 -
European Archives of... Mar 2019To investigate validity evidence, and strengths and limitations of performance metrics in mastoidectomy training.
OBJECTIVE
To investigate validity evidence, and strengths and limitations of performance metrics in mastoidectomy training.
METHODS
A systematic review following the PRISMA guidelines. Studies reporting performance metrics in mastoidectomy/temporal bone surgery were included. Data on design, outcomes, and results were extracted by two reviewers. Validity evidence according to Messick's framework and level of evidence were assessed.
RESULTS
The search yielded a total of 1085 studies from the years 1947-2018 and 35 studies were included for full data extraction after abstract and full-text screening. 33 different metrics on mastoidectomy performance were identified and ranked according to the number of reports. Most of the 33 metrics identified had some amount of validity evidence. The metrics with most validity evidence were related to drilling time, volume drilled per time, force applied near vital structures, and volume removed.
CONCLUSIONS
This review provides an overview of current metrics of mastoidectomy performance, their validity, strengths and limitations, and identifies the gap in validity evidence of some metrics. Evidence-based metrics can be used for performance assessment in temporal bone surgery and for providing integrated and automated feedback in virtual reality simulation training. The use of such metrics in simulation-based mastoidectomy training can potentially address some of the limitations in current temporal bone skill assessment and ease assessment in repeated practice. However, at present, an automated feedback based on metrics in VR simulation does not have sufficient empirical basis and has not been generally accepted for use in training and certification.
LEVEL OF EVIDENCE
2a.
Topics: Clinical Competence; Humans; Mastoid; Mastoidectomy; Otologic Surgical Procedures; Simulation Training; Temporal Bone
PubMed: 30604063
DOI: 10.1007/s00405-018-05265-9 -
The Laryngoscope Mar 2019There is no standard of care for treatment of pediatric acute mastoiditis (PAM). We systematically reviewed the English literature to evaluate the efficacy of PAM... (Comparative Study)
Comparative Study
OBJECTIVE
There is no standard of care for treatment of pediatric acute mastoiditis (PAM). We systematically reviewed the English literature to evaluate the efficacy of PAM treatment options.
METHODS
PubMed, Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from inception to January 2016, along with manual bibliography searches, for studies describing surgical or medical therapy. Two independent evaluators reviewed each abstract and article.
RESULTS
We identified 310 articles, and 55 met inclusion criteria. Thirty-three evaluated surgical options and included 2,930 patients (mean age = 2.8 years) including those with myringotomy ± tube placement (n = 920); 140 needed additional surgery, drainage of subperisoteal abscess (SPA) (n = 142) ± myringotomy or tube placement, 29 patients needed additional surgery and mastoidectomy ± myringotomy or tube placement (n = 612), with 611 reporting resolution. Using a random effects model, the estimated success probability with 95% confidence intervals (CI) are myringotomy ± tube placement 94% (95% CI: 84.5%-97.8%), and drainage of subperiosteal abscess with concurrent myringotomy ± tube placement was 86.5% (95% CI: 66.4%-95.4%). Using a random effects model, mastoidectomy success was 99.7% (95% CI: 77.5%-100%). Nineteen studies evaluated medical therapy (n = 990 patients). The average cure rate was 71.7% (median = 70%; range, 26.3%-100%), and estimated success was 72.9% (95% CI: 60.5%-82.5%) by meta-analysis.
CONCLUSIONS
Myringotomy with or without tube placement and mastoidectomy have the highest cure rates for PAM. With SPA, incision and drainage with myringotomy with or without tube can be considered. Medical treatment cured nearly 72% of children. Ultimately, management should be based on surgeons' experience and judgment, patient characteristics, and severity of disease. Laryngoscope, 129:754-760, 2019.
Topics: Acute Disease; Child; Humans; Mastoiditis; Treatment Outcome
PubMed: 30284265
DOI: 10.1002/lary.27462 -
JAMA Otolaryngology-- Head & Neck... May 2018The ideal surgical treatment of cholesteatoma has been subject to discussion for years because both traditional surgical techniques (canal wall down [CWD] and canal wall...
IMPORTANCE
The ideal surgical treatment of cholesteatoma has been subject to discussion for years because both traditional surgical techniques (canal wall down [CWD] and canal wall up [CWU] tympanoplasty) have their own advantages and disadvantages. A more recently propagated surgical approach, to combine the CWD or CWU tympanoplasty technique with obliteration of the mastoid and epitympanum, is showing promising results.
OBJECTIVE
To systematically review the literature on recurrent and residual cholesteatoma rates after single-stage CWU and CWD tympanoplasty with mastoid obliteration.
EVIDENCE REVIEW
A systematic search of literature was performed to identify relevant publications in multiple electronic databases. The initial search was conducted in December 2016 and was updated in July 2017. Each study was reviewed by 2 independent reviewers on predetermined eligibility criteria. The methodological quality was determined using the methodological index for nonrandomized studies (MINORS) scale, and the relevance to the current topic was determined using a 4-criterion checklist.
FINDINGS
The searches identified a total of 336 potentially relevant publications; 190 articles were excluded based on title and abstract. The full-text articles of the remaining 146 citations were assessed for eligibility, resulting in 22 articles. After assessing these remaining articles for methodological quality and relevance to the current topic, another 8 studies were excluded, and a total of 13 studies (1534 patients) were included. Of the 1534 patients who underwent CWD or CWU tympanoplasty with mastoid obliteration, the rate of recurrent disease was 4.6%, and the rate of residual disease was 5.4%. In CWU tympanoplasty with mastoid obliteration, these rates were 0.28% and 4.2%, respectively and in CWD tympanoplasty with mastoid obliteration, 5.9% and 5.8%, respectively.
CONCLUSIONS AND RELEVANCE
We show the recurrent and residual disease rates after either CWU or CWD tympanoplasty with mastoid obliteration to be qualitatively similar to, if not better than, previously reported rates of for nonobliterative techniques. In this study, the lowest recurrent and residual rates were reported when combining the CWU tympanoplasty with mastoid obliteration, on average 0.28 and 4.2%, respectively.
Topics: Cholesteatoma, Middle Ear; Humans; Mastoid; Recurrence; Retrospective Studies; Tympanoplasty
PubMed: 29543959
DOI: 10.1001/jamaoto.2017.3401 -
The Journal of Laryngology and Otology Feb 2018Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the... (Review)
Review
BACKGROUND
Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the diagnosis and management of acute mastoiditis, resulting in considerable disparity in conservative and surgical management.
OBJECTIVES
To review the current literature, proposing recommendations for the management of paediatric acute mastoiditis and appraising the treatment outcomes.
METHOD
A systematic review was conducted using PubMed, Web of Science and Cochrane Library databases.
RESULTS
Twenty-one studies were included, with a total of 564 patients. Cure rates of medical treatment, conservative surgery and mastoidectomy were 95.9 per cent, 96.3 per cent and 89.1 per cent, respectively.
CONCLUSION
Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy may be an appropriate first-line management when treating acute mastoiditis.
Topics: Acute Disease; Anti-Bacterial Agents; Child; Humans; Mastoiditis; Otitis Media; Otologic Surgical Procedures; Pediatrics; Treatment Outcome
PubMed: 28879826
DOI: 10.1017/S0022215117001840 -
Frontiers in Neurology 2017Superior canal dehiscence syndrome (SCDS) can be treated surgically in patients with incapacitating symptoms. However, the ideal treatment has not been determined. (Review)
Review
BACKGROUND
Superior canal dehiscence syndrome (SCDS) can be treated surgically in patients with incapacitating symptoms. However, the ideal treatment has not been determined.
OBJECTIVES
This systematic literature review aims to assess available evidence on the comparative effectiveness and risks of different surgical treatments regarding: (1) symptom improvement; (2) objectively measurable auditory and vestibular function; (3) adverse effects, and (4) length of hospitalization.
SEARCH METHOD AND DATA SOURCES
A systematic database search according to PRISMA statement was conducted on Pubmed, Embase, and Cochrane library. In addition, reference lists were searched. No correspondence with the authors was established. The last search was conducted on June 9, 2017.
STUDY ELIGIBILITY CRITERIA
Retrospective and prospective cohort studies were held applicable under the condition that they investigated the association between a surgical treatment method and the relief of vestibular and/or auditory symptoms. Only studies including quantitative assessment of the pre- to postoperative success rate of a surgical treatment method were included. Case reports, reviews, meta-analysis, and studies not published in English, Dutch, or German were excluded.
DATA COLLECTION AND ANALYSIS
The first author searched literature and extracted data; the first and last analyzed the data.
MAIN RESULTS
Seventeen studies (354 participants, 367 dehiscences) met the eligibility criteria and were grouped according to surgical approach. Seven combinations of surgical approaches and methods for addressing the dehiscence were identified: plugging, resurfacing, or a combination of both through the middle fossa (middle fossa approach); plugging, resurfacing, or a combination of both through the mastoid (transmastoid approach); round window reinforcement through the ear canal (transcanal approach). Several studies showed high internal validity, but quality was often downgraded due to study design (1). Outcome measures and timing of postsurgical assessment varied among studies, making it unfeasible to pool data to perform a meta-analysis.
CONCLUSION
A standardized protocol including outcome measures and timeframes is needed to compare the effectiveness and safety SCDS treatments. It should include symptom severity assessments and changes in vestibular and auditory function before and after treatment.
PubMed: 28790965
DOI: 10.3389/fneur.2017.00347 -
Journal of Oral and Maxillofacial... Feb 2018The purpose of this study was to describe distances from commonly used anatomic landmarks to the main trunk of the facial nerve during parotid surgery.
PURPOSE
The purpose of this study was to describe distances from commonly used anatomic landmarks to the main trunk of the facial nerve during parotid surgery.
MATERIALS AND METHODS
A systematic search of the published literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies from January 1, 1990 to January 1, 2017 that measured distances to the main trunk of the facial nerve from common anatomic landmarks were eligible. Inclusion criteria were English-language articles with distances measured from the main trunk of the facial nerve to anatomic landmarks. The primary outcome variable was the distance from the respective anatomic landmarks. Other variables included surgical approach, year, and existential status of subject (cadaveric or living).
RESULTS
The search yielded 1,412 studies (1,397 by PubMed, 15 by reference searching), with 10 studies meeting the inclusion criteria. Within the 10 studies, there were 30 reported means and 375 dissected cadavers. The most common incision was the standard preauricular incision; the mean distances to the facial trunk from landmarks were 13.6 ± 11.0 mm (n = 6 reported means) for the tragal pointer, 8.79 ± 3.99 mm (n = 7 reported means) for the posterior belly of the digastric muscle, 10.5 ± 1.4 mm (n = 4 reported means) for the tip of the mastoid process, 14.99 ± 1.68 mm (n = 3 means) for the transverse process of C1, 3.79 ± 2.92 mm (n = 6 means) for the tympanomastoid fissure, 9.80 ± 0 mm (n = 1 mean) for the styloid process, and 11.77 ± 1.42 mm (n = 3 means) for the external auditory meatus. Formal assessment of inter-study variability could not be assessed because of the small number of studies and measurements.
CONCLUSION
There are substantial variations in measurements from anatomic landmarks to the main trunk of the facial nerve in the literature. Therefore, multiple landmarks can be used to identify the main trunk of the facial nerve during parotid surgery. The distances reported in this study can guide surgeons during parotid surgery to decrease the risk of facial nerve damage.
Topics: Anatomic Landmarks; Facial Nerve; Humans; Parotid Diseases
PubMed: 28738189
DOI: 10.1016/j.joms.2017.06.039 -
Otolaryngology--head and Neck Surgery :... Jan 2017Objective The aim of this report is to provide a review of the current literature for assessment of performance for mastoidectomy, to identify the current assessment... (Review)
Review
Objective The aim of this report is to provide a review of the current literature for assessment of performance for mastoidectomy, to identify the current assessment tools available in the literature, and to summarize the evidence for their validity. Data Sources The MEDLINE database was accessed via PubMed. Review Methods Inclusion criteria consisted of English-language published articles that reported use of a mastoidectomy performance assessment tool. Studies ranged from 2007 to November 2015 and were divided into 2 groups: intraoperative assessments and those performed with simulation (cadaveric laboratory or virtual reality). Studies that contained specific reliability analyses were also highlighted. For each publication, validity evidence data were analyzed and interpreted according to conceptual definitions provided in a recent systematic review on the modern framework of validity evidence. Conclusions Twenty-three studies were identified that met our inclusion criteria for review, including 4 intraoperative objective assessment studies, 5 cadaveric studies, 10 virtual reality simulation studies, and 4 that used both cadaveric assessment and virtual reality. Implications for Practice A review of the literature revealed a wide variety of mastoidectomy assessment tools and varying levels of reliability and validity evidence. The assessment tool developed at Johns Hopkins possesses the most validity evidence of those reviewed. However, a number of agreed-on specific metrics could be integrated into a standardized assessment instrument to be used nationally. A universally agreed-on assessment tool will provide a means for developing standardized benchmarks for performing mastoid surgery.
Topics: Clinical Competence; Humans; Mastoid; Osteotomy; Quality Assurance, Health Care
PubMed: 27677598
DOI: 10.1177/0194599816670886