Objectives What is a Cholesteatoma? - SOHN Nursesohnnurse.com/wp-content/uploads/pdf/412 Raines -...
Transcript of Objectives What is a Cholesteatoma? - SOHN Nursesohnnurse.com/wp-content/uploads/pdf/412 Raines -...
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Pediatric Cholesteatoma
Melissa M. Raines, MSN, CPNP, APNPPediatric Nurse Practitioner
Department of Otolaryngology
Medical College of Wisconsin/Childrens Hospital of Wisconsin
SOHN Congress 2013
Vancouver, British Columbia, Canada
Disclosures
I have no relevant financial relationships
or commercial interests to reveal
in regards to this presentation.
Objectives
1. Describe the pathogenesis of cholesteatoma formation
2. Identify the impact cholesteatoma can have on a child and their family
3. Define key points in the history, physical examination and diagnostic techniques used in diagnosis confirmation
4. Discuss surgical options and medical therapies for patients with cholesteatoma(s)
5. Examine the post-operative expectations for the patient with a cholesteatoma
6. Participate in a case study discussion of a pediatric patient diagnosed with a cholesteatoma
What is a Cholesteatoma?
Cyst-like expansile lesion(s) of the temporal
bone lined by stratified squamous epithelium
that contain desquamated keratin
Most frequently involve the middle ear (ME) and mastoid but may develop anywhere in the
pneumatized portions of the temporal bone
Physiology of Cholesteatoma
The matrix contains fully differentiated squamousepithelium resting on connective tissue
Deeper layers of the epithelium of a cholesteatoma matrix show activity in the form of downgrowths into the underlying connective tissue
There is always a layer of granulation tissue in contact with bone
The layer of granulation tissue elaborates various enzymes such as collagenase resulting in bone destruction
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Histology History 1st description of cholesteatoma like mass by DuVerney in
1683
Misnomer originated by Johannes Mueller in 1838 Described it as a layered pearly tumor of fat, which was
distinguished from other fat tumors by the biliary fat or cholesterin that is interspersed among the sheets of polyhedral cells
Cholesteatomas do not contain fat and not usually cholesterin
More appropriate term suggested by Schuknecht was keratoma
In 1889, Habermann known for 1st temporal bone report describing the pathology of cholesteatoma
(Bluestone et al, 1978), (Golz et al, 1999), (Al Anazy, 2006)
Anatomy Review
www.studyblue.com www.directhearingaids.co.uk
www.kck.usm.my
Anatomy -Middle Ear Regions
Name based on position relative to superior
and inferior aspect of external auditory canal
(EAC)
Epitympanum
Mesotympanum
Hypotympanum
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Anatomy Middle Ear Regions Epitympanum
Lies above short process of malleus; includes the head of the malleus, body of incus and associated ligaments and mucosal folds
Mesotympanum Includes the stapes, long process of incus, handle of malleus and
oval and round windows
Eustachian tube exits from anterior aspect
2 recesses extend posteriorly that are often not visible Facial recess Sinus tympani
Hypotympanum Lies inferior & medial to floor of bony canal; irregular bony
groove that is seldom involved by cholesteatoma www.kck.usm.my
Cholesteatoma Classification
AcquiredCongenital
www.nejm.org , www.ganfyd.org
Incidence
The true incidence is not known
Mean annual incidence of 9.2 cases per 100,000 persons of all ages (range 3.7 to 13.9) (Kemppainen, Puhakka, Laippala, Sipil & Karma, 1999)
Approximately 5 to 15 per 100,000 in children alone (Bluestone & Klein, 2003)
Congenital cholesteatomas account for 1 to 5 percent in most published series (Bennett, Warren, Jackson & Kaylie, 2006)
Spilsbury, Miller, Semmens & Lannigan, 2010: 0.9% percent was seen in a retrospective series of 45,980
children who had undergone 1 set of ventilation tubes
Two or more ventilation tube placements increased rate of cholesteatoma to 21%
Incidence In 172 cases of congenital cholesteatoma between 1981
and 2000, the following observations were made: 72 percent of cases occurred in boys The average age was 5 y/o
Nearly one-half of cases involved 2 quadrants; 82 percent of cases confined to one quadrant were in the anterosuperiorquadrant
The ossicular chain and mastoid were involved in 43 percent and 23 percent of cases, respectively
Cholesteatomas are bilateral in approximately 4 percent of cases
Bilateral congenital cholesteatomas are more common in boys, whereas bilateral acquired cholesteatomas are more common in girls
(Potsic, Korman , Samadi & Wetmore, 2002), (Lin, Daniel, James & Friedberg, 2004)
Congenital Cholesteatoma
Definition(s): Congenital rest of
epithelial tissue in the ear without tympanic membrane perforation and without history of otitismedia (Derlacki & Clemis, 1965)
Includes a normal pars flaccida and pars tensawith no history of otorrheaand no history of otologicprocedures (Levenson et al, 1989)
Not excluded if there is a history of otitis media
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Congenital Cholesteatoma
White, cyst-like structure in the middle ear (ME)
space or temporal bone
Can occur anywhere in temporal bone
Most common in the
anterosuperior quadrant
(AS) in the ME above the
eustachian tube (ET)
opening in the
mesotympanum
Congenital Cholesteatoma
Pathogenesis not completely understood
Most popular theory
Presence of an epidermoid residue in the AS quadrant of the ME in the human fetus, on the
lateral wall of the ET, near the annulus
Failure to reabsorb the epidermoid residue normally found in embryos between the 10th and
33rd week of gestation has been observed(Michaels, 1986), (Teed, 1936)
Acquired Cholesteatoma
2 types
Primary acquired
Secondary acquired
Occur after birth
Most common type typically as result of
chronic middle ear (ME)
disease
Acquired Cholesteatoma
Primary acquired
Most common
Forms as retraction
pockets of the TM
Occurs mostly in pars
flaccida although pars
tensa retractions can occur
Bacteria can affect the
keratin matrix, forming
biofilms leading to chronic
infection and epithelial
proliferation
Secondary acquired
Form as result of either squamous epithelial
migration from the TM or
implantation of squamous
epithelium into the ME
during surgery (ie:
Ventilation tube placement
or tympanoplasty)
Perforations from infection
or trauma
Acquired Cholesteatoma
radiopaedia.org
Acquired Cholesteatoma Staging Stage 1
Confined to ME (hypo- & mesotympanum) without erosion of ossicular chain
Stage 2 Same as 1, but in addition, there is erosion of one or more ossicles
Stage 3 Involvement of middle ear and mastoid gas-cell system without erosion of
ossicles
Stage 4 Same as 3, but with erosion of one or more ossicles
Stage 5 Extensive cholesteatoma of the middle ear, mastoid, & other portions of the
temporal bone including one or more ossicles
Not able to complete surgical removal (ie: medial to labyrinth) A fistula of the labyrinth may or may not be present
Stage 6 Same as 5 but now cholesteatoma extends beyond the temporal bone
(Bluestone & Klein, 2003)
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Predisposing Factors
History of recurrent acute otitis media and/or chronic middle ear effusions
Older age at first placement of tympanostomy tubes, and increasing number of, and longer interval between, insertions
Cleft palate
Craniofacial anomalies
Turner syndrome
Down syndrome
Family history of chronic middle ear disease and/or cholesteatoma
Signs and Symptoms
Acquired Typically present with recurrent or persistent
purulent otorrhea and hearing loss
Also can present with tinnitus, vertigo or dysequillibrium
Facial nerve twitching, palsy or paralysis Can result from inflammatory process or mechanical
compression of the nerve
Congenital Conductive hearing loss
Impact of Cholesteatoma
Hearing loss (HL)
Late recognition of cholesteatoma formation still a
problem
Speech delay
Psychosocial effects
Cholesteatoma in Children vs. Adults
More aggressive disease in children than
adults
Very extensive disease is found in children at the time of surgery vs. adults
Rates of persistent and recurrent cholesteatomaare higher in children
Persistent eustachian tube dysfunction
Well pneumatized mastoid complex(Bluestone & Klein, 2003), (Visvanathan et al, 2012)
Cholesteatoma in Children vs. Adults
Children frequently unaware of signs and symptoms
Rarely complain about HL; especially if unilateral
Frequently no otorrhea
Otalgia may be absent
Unable to determine fullness of the ear, tinnitus, mild vertigo
Most adults have history of HL that is progressive and recurrent otorrhea
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Complications
Accumulation of keratin may cause:
Infection
Otorrhea
Bone destruction
Hearing loss Conductive &/or SNHL
Vertigo
Facial nerve paralysis
Labyrinthine fistula
Intratemporal infection
Intracranial complications
Epidural and subdural abscesses
Parenchymal brain abscesses
Meningitis
Thrombophlebitis of the dural venous sinuses
Brain herniation
Complications: Epidural Abscess
Complications: Sigmoid Sinus
ThrombosisPatient History
Recurrent acute otitis media
Chronic otitis media with effusion Cleft palate
Craniofacial abnormalities Turner or Down syndromes
Family history of chronic ME including cholesteatoma New onset HL in previously operated ear
Persistent otorrhea > 2weeks Foul smelling otorrhea
Otalgia Concern about intratemporal or intracranial complication with otalgia symptomology
Fullness of the ear Tinnitus
Mild vertigo Facial muscle weakness
Physical Exam
White mass behind intact TM
Deep retraction pocket with or without
granulation and skin debris
Focal granulation on surface of TM
Otorrhea >2 weeks despite treatment
Hearing loss
Differential Diagnoses
Tympanosclerosis
White foreign body
Exostoses
Prosthetic and graft material
Inclusion cysts of the tympanic membrane
Bulging acute otitis media(Sie, 1996)
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Differential Diagnoses Diagnosis
May go undetected for many years as s/s may
be lacking
Otoscopy/Oto-microscopy
Detailed otologic history
Audiogram
CT scan of the temporal bones
Diffusion weighted MRI
Diagnosis
CT Scan
CT of the temporal bones without contrast in the
coronal and axial views often of value
Identifies
Extent of disease
Possibility of ossicular involvement
Complications such as labyrinthine fistula
Used to aide in decisions regarding surgical
approach and extent of surgery
Axial View
http://bestpractice.bmj.com/best-
practice/monograph/1033/resources/image/bp/4.html
Treatment
Surgical intervention
Tympanoplasty
Canal Wall-Up mastoidectomy (CWU)
Canal Wall-Down mastoidectomy (CWD)
Partial Ossicular Replacement Prosthesis (PORP)
Total Ossicular Replacement Prosthesis (TORP)
Second-Look Procedure
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Cholesteatoma Surgery in Children -
Goals
1. Eradicate disease
2. Preserve or reconstruct the anatomic
structure
3. Preserve or restore hearing
4. Prevent residual and recurrent disease
(Bluestone, 2002)
Tympanoplasty
Tympanoplasty
Surgical reconstruction of the
TM/ossicle transformer mechanism
ie: If a perforation is present, it will be repaired
with a connective tissue graft but unlike with a
myringoplasty, the middle ear is explored
Ossicles can be repositioned (ossiculoplasty) to
restore ossicular chain continuity
Trans-canal or post-auricular
Tympanoplasty
(Trans-Canal & Post-Auricular) Pros
Trans-canal
Shorter surgery
Less discomfort
Patient perception
Post-Auricular
Better exposure
Better graft harvest
Anterior exposure
Better handedness
Limited disruption of canal skin vasculature
Faster healing
Tympanoplasty
(Trans-Canal & Post-Auricular) Cons
Trans-canal
Limited exposure
Difficult handedness
Smaller grafts
Disruption of vascular supply to canal skin
Canal needs to heal
Post-Auricular
Longer surgery
More discomfort
Patient perception
Tympanoplasty
www.pedsent.com & www.med.unc.edu
Mastoidectomy
Mastoidectomy
Removal of mastoid bone
Involves the surgical exposure and removal of
mastoid air cells
http://www.ghorayeb.com/mastoidectomy.html
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emedicine.medscape.com
Tympanomastoidectomy with
Tympanoplasty
Tympanomastoidectomy with tympanoplasty
Tympanoplasty performed in combination with
mastoidectomy
Canal Wall-Up procedure (aka: Closed cavity procedure)
Canal Wall-Down procedure (aka: Open cavity procedure)
Canal Wall-Up Mastoidectomy
Posterior canal wall remains intact Preserves middle ear structures
Hope that ME function may improve with age
Higher rate of reoccurrence and need for second surgery
Hearing aids fit better
Maintenance free Fewer activity restrictions
More natural appearance Better hearing results
Canal Wall-Up Mastoidectomy
Canal Wall-Down Mastoidectomy
Every effort made to avoid CWD procedure
Hearing may be worse (typically worse)
Open mastoid cavity
Enlarged canal visible to the naked eye About 2x the size
More difficult to clean in children Would require general anesthesia for cleaning and
debridement
Swimming Common activity for children; More susceptible to
infection with water exposure
Canal Wall Down Mastoidectomy
Pros
Greatly reduces the risk of recurrence
Good option for those with co-morbidities that are at high risk undergoing anesthesia
Good option for those who have poor-follow-up
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Canal Wall Down Mastoidectomy
www.susmedicos.com
Canal Wall-Up vs. Canal Wall-Down
Literature Controversy with CWU vs. CWD
Osborn, Papsin and James, 2012 Retrospective review 1996-2010 420 patients (435 total ears)
Extent of cholesteatoma graded according to Mills Classification
Pre & post air conduction hearing thresholds assessed
CWU preferred Preserved canal in 89.5% of cases Financial and emotional costs of 2nd look offset by avoiding open
cavity management
Better hearing results
CWD Lower rates of reccurence and revision
Canal Wall-Up vs. Canal Wall-Down
Literature Wilson, Hoggan & Shelton, 2013
Case series with chart review
All cases treated with Intact Canal Wall (ICW) mastoidectomy over 9 years with at least 2 years of follow-up data
145 patients with 156 affected ears (median age 5.3 years; range 2.1-14.8 years)
35% had residual cholesteatoma at 2nd stage
13 patients (8%) had recurrence with 6 needing CWD mastoidectomy
ICW mastoidectomy w/tympanoplasty continues to be successful treatment
Substantial recurrence rate at 2nd stage justifying need for staging Recurrence rate using ICW is low; excellent disease control and
functional results for majority of patients
Ossicular Reconstruction
Partial Ossicular Replacement Prosthesis (PORP)
Used when the stapes superstructure is Intact
Stapes superstructure is bridged with a synthetic
biocompatible prosthesis to
the tympanic membrane,
graft or malleus
PORP is positioned on the stapes head
Total Ossicular Replacement Prosthesis (TORP)
Used only when the stapes footplate is available
Used when an intact spesfootplate is bridged with a
synthetic biocompatible
prosthesis to the tympanic
membrane, graft or malleus
TORP is placed on the stapes footplate
(Batti & Bluestone, 2002)
PORP & TORP
www.getfitosc.com
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Prosthesis Middle Ear Prosthesis
www.entusa.com
Second-Look Procedure
Detects residual cholesteatoma or recurrent disease as the middle ear and mastoid are not directly visible Recommended at 6 months post-op in children 12 months post-op in adults Difference secondary to children experiencing more
aggressive disease
If disease is found at second-look, it is removed and the child is recommended to go to the OR again in 6 months Repeated until residual disease is not present
Alternative To Second-Look Procedure
Diffusion Weighted MRI Imaging (DWI)
More recently introduced in cholesteatoma
diagnosis
Non-invasive
Prevents unnecessary second-look surgery in patients without cholesteatoma
Alternative To Second-Look Procedure
How it works: Provide information about diffusion of water molecules in
biological tissue
Greater the diffusion of water molecules, the less signal enhancement appears in the image; lower the diffusion of water molecules, the greater signal enhancement appears
Not exactly known why cholesteatoma shows a high level of signal enhancement on DWI
DWI shows a cholesteatoma as high signal intensity; granulation and other tissue visualized at a low signal intensity
Resultant image is bright at cholesteatoma and darker at surrounding tissues
Diffusion Weighted MRI
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Diffusion Weighted MRI Study
Turkish Study (Evlice, Tarkan, Kiroglu, Bicakci, Ozdemir, Tuncer & Cekic, 2012)
58 chronic otitis media patients with suspected cholesteatoma evaluated 2 weeks pre-operatively (41 with no previous surgery & 17 with previous surgery scheduled for second-look)
Mean age 22 y/o (Range 9-67 y/o)
All underwent Echo-planar diffusion-weighted MRI pre-operatively
Operative findings and pathology results compared with MRI results
Diffusion Weighted MRI Study
Results Cholesteatoma found in 63% of patients with no
history of surgical intervention and 58% found in second-look group
Diffusion-weighted MRI accurate in 90% of group 1 and 76% of group 2 patients
Conclusion Echo-planar diffusion-weighted MRI is a valuable
imaging technique for detection of primary of recurrent acquired cholesteatoma
Can be considered instead of second-look procedure
Surgical Risks & Complications
Tympanoplasty with or without Mastoidectomy
Infection
Hearing loss
Tinnitus
Dizziness
Taste disturbance and mouth dryness
General anesthesia complications
Mastoidectomy
Facial paralysis
Hematoma
Spinal fluid leak
Dural injury
Intracranial complications
General anesthesia complications
http://www.youtube.com/watch?v=xCQBSNF5DY
Post-Operative Course
Bulky dressing covering the ear for 24 hours Numbness of the ear
Resolves over weeks to several months
Sharp, sudden stabbing pains are common May take weeks to resolve
Protrusion of the ear
Pain with eating/chewing Taste disturbance (metallic taste)
May take up to 6 months to resolve
Blood tinged otorrhea www.otomed.com
Post-operative Course
Packing/sponge plug/wick may extrude Inform family not to not replace
Hearing noises such as swishing, gurgling, your heartbeat is normal and slowly subsides
Decreased hearing Swelling Hemotympanum Packing(All normal; takes several weeks to resolve)
Dysequillibrium with quick movements Common for several days to 1 week post-op
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Care & Cleaning of the Ear
Strict water precautions until 1st post-op appointment
If post-auricular incision present, may clean gently with soap and water after 1st post-op visit
No water in canal up to 2-3 months Place cotton ball with Vaseline in outer part of canal
No commercial ear plugs recommended May put pressure on packing
Sleep with head elevated 30 degrees for 1 week; try not to lye on ear that was surgically repaired Decreases swelling
Pad eyeglasses if you wear them
Consider use of ice pack for 15-20 minutes at a time
Care & Cleaning
Clean post-auricular incision with H2O2 on a cotton swab morning and night
Do not clean external auditory canal
May use antibiotic ointment until 1st post-op visit Place dry cotton ball in outer canal to absorb
drainage; change at least 2x daily and as needed
Cover ear in frigid weather if post-auricular incision Post-op numbness Sensitivity
Activity Restrictions
No work or school for 1 week
Light activity during the 1st week
No strenuous activity, exertion, sports or lifting over 20 lbs for 1 month
No playing musical wind instruments for 6 weeks
No vigorous nose blowing or popping of the ears for 6 weeks
Keep mouth open with sneezing Helps avoid transmission of pressure to the ear
Use stool softener if constipated Avoids straining
No airline flights for 1 month
Medications
Prescription pain medication Shouldnt be necessary after 7-10 days
No aspirin, aspirin containing products or anti-inflammatory agents until 1st post-op visit
Blood thinners may be started 1 week after
Oral antibiotics prescribed for 1 week
Otic drops Typically not started until 1st post-op visit
Typically will need for multiple weeks
Post-Operative Follow-Up
Post-op visit #1 scheduled for 7-10 days following surgery
Recommended to call for: Increased pain, post-auricular erythema or swelling Incision drainage Opening of incision Malodorous, discolored post-auricular drainage Fever over 100.5 Developed weakness of facial muscles on surgical side
Developing/increasing vertigo Severe nausea or vomiting
Future Follow-Up
Every 3 months for the 1st year post-op
Every 6 months for the 2nd & 3rd years post-op
After the 3rd year; annually for 5-7 more years
(Bluestone & Rosenfeld, 2002)
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Future Follow-up
Pediatric 29 year study
Retrospective study 1982-2011
81 ears; 73 studied
Acquired only; congenital excluded; 18 years or younger
Follow-up every 6 months for the first 5 years then annually
Recidivism of cholesteatoma occurred in 7 ears
Mean detection time was 10.4 years (range 1.9-17.2 years)
2 were residual disease and 5 were recurrent
Recommend: Follow-up as long as possible or at least until adulthood
(Kuo, Shiao, Liao, Ho & Lien, 2012)
Prevention
No methods currently for congenital
Primary acquired Pathogenesis not clearly understood; assumed that
ETD is required for formation
No way to correct ET function directly
Provide secondary ventilation to the ME with ventilation tube placement
Secondary acquired are often iatrogenic Surgeon takes all steps to prevent implantation of
squamous epithelium into ME
Case Study
History 2 y/o little boy with history of recurrent acute
otitis media
Underwent bilateral myringotomy & ventilation tube (BM&T) placement just prior to new patient appointment w/us at outside facility
At time of surgery, right-sided middle ear abnormality noted; ventilation tubes were placed
CT scan of the temporal bones obtained and he was referred to CHW
Case Study
What are we concerned about based on this
information?
Congenital cholesteatoma
What are your next steps?
Physical exam
Audiogram
Review CT scan of the temporal bones
Case Study
Physical exam
Otoscopy & Micro-otoscopy
Ears well formed externally with normal canals
Right TM showed whitish discoloration anteriorly
but no obvious cholesteatoma formation;
Ventilation tube was in place and patent
Left tympanic membrane was clear with a tube that was in place and patent
Case Study Audiogram 6/22/2011
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Case Study Case Study
Right middle ear exploration with ventilation tube removal, atticotomy and cholesteatoma removal, tympanoplasty with fascia
Findings: Extensive congenital cholesteatoma throughout the ME
space extending into the eustachian tube into the attic
Did not extend posteriorly into the mastoid Involved the malleolus, incus, hypotympanum, eustachian
tube, attic and part of the stapes; incus and malleoluswere removed along with substantial portion of the TM
Middle ear mucosa diseased at grade 2 D/Cd on Ciprodex, Lortab
Case Study
Post-Op Visit (2 weeks later) Subjective:
No concerns 1st week post-op Right otalgia was playing outside without head coverage
No otorrhea Using Ciprodex as prescribed
Now only using Tylenol at bedtime for pain
Objective/Physical Exam: Right post-auricular incision well approximated, C/D/I Canal with small amount of gel foam which was removed under microscopy
TM with small amount of gelfoam left alone; could not completely visualize TM but healing
Plan: Continue Ciprodex BID
Strict water precautions f/u 1 week
Case Study
Post-Op Visit #2 Subjective:
Patient without complaint
Objective/Physical exam: Right post-auricular incision healing well
External auditory canal clear without gelfoam
TM healing well
Plan: Follow-up 2 months
Plan for second-look procedure in 9-12 months
Case Study
Post-Op Visit #3 Subjective:
No parental concerns
Objective/Physical exam:
Micro-otoscopy
Right post-auricular site healed
Right TM with post-surgical changes; no visible
cholesteatoma
Audiogram obtained
Case Study
Post-Op Visit #3 Post-Op Audiogram
3/14/2012
Pre-Op Audiogram 6/22/2011
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Case Study
Post-Op Visit #3
Plan:
See at second-look procedure scheduled in 4
months
Case Study
Second-Look Procedure
Right middle ear exploration with tympanoplasty
and PORP ossicular reconstruction
Discharged with Ciprodex, Cefdinir & Lortab
Follow-up in 1 week
Case Study
Post-Op Visit #1 for Second-Look
Procedure Subjective:
Doing well, no otorrhea, no otalgia, afebrile, good oral intake, sleeping well
Objective: Post-auricular incision well approximated; C/D/I Few superior sutures removed Some gelfoam in canal; left alone TM healing well
Plan: Ciprodex BID for 14 days Strict water precautions f/u 2 weeks
Case Study
Post-Op Visit #2 for Second-Look
Procedure Subjective:
No concerns, no otorrhea, no otalgia, afebrile, good oral intake, sleeping well
Using Ciprodex as recommended
Objective: Post-auricular incision well healed Significant gelfoam; partial removal as it was adhered
to TM
Plan: Continue Ciprodex BID for 1 month with return at that
time
Case Study
Post-Op Visit #3 for Second-Look
Procedure Subjective:
No concerns, no otorrhea, no otalgia, afebrile, good oral intake, sleeping well
Stopped using drops early
Objective: Post-auricular incision well healed
Cerumen and dry gelfoam removed
TM clear with post-surgical changes
Audiogram obtained
Case Study
Pre-op Audiogram 6/22/2011
(1st Audio)
Post-op 2nd Look Procedure 9/18/2012
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Case Study
Post-Op Visit #3 for Second-Look
Procedure Plan
D/C water precautions
Follow-up in 6 months
Case Study
Post-Op Visit #4 for Second-Look
Procedure
Subjective:
No parental concerns
Objective:
Small less than 5% TM perforation on the right;
cartilage healing well
Audiogram Normal bilaterally!!!
Plan:
Follow-up in 4 months
Audiogram 2/21/2013
Questions??? Thank You!
Dr. David Friedland
Dr. Steven Harvey
Dr. Joseph Kerschner
Roxanne Link, APNP
Kristina Keppel, APNP
References
Al Anazy, F.H. (2006). Iatrogenic cholesteatoma in children with otitis media with effusion in a
training program. International Journal of Pediatric Otorhinolaryngology (70), 1683-1686.
Batti, J.S., & Bluestone, C.D. Ossiculoplasty. In: Surgical atlas of pediatric otolaryngology. Bluestone, C.D., & Rosenfeld, R.M. (Eds), BC Decker, Inc 2002. p.75-89.
Bennett, M., Warren, F., Jackson, G.C., & Kaylie, D. (2006). Congenital cholesteatoma: Theories, facts, and 53 patients. Otolaryngologic Clinics of North America 39(6),1081.
Bluestone, C.D. Mastoidectomy & Cholesteatoma. In: Surgical atlas of pediatric otolaryngology. Bluestone, C.D., & Rosenfeld, R.M. (Eds), BC Decker, Inc 2002. p.91-122.
Bluestone, C.D., Cantekin, E.I., Beery, Q.C., & Stool, S.E. (1978). Function of the Eustachian tube related to surgical management of acquired aural cholesteatoma in children.
Laryngoscope (88), 1155-1164.
Bluestone, C.D., & Klein, J.O. Intratemporal complications and sequelae of otitis media. In:
Pediatric otolaryngology, 4th ed, Bluestone, C.D., Stool, S.E., Alper, C.M., Arjmand, E.M.,
Casselbrant, M.L., Dohar, J.E., & Yellon, R.F. (Eds), Saunders, Philadelphia 2003. p.687-753.
References
Department of Otolaryngology and Communication Sciences-Division of Otology, Neuro-Otology & Skull Base Surgery. (n.d.). A guide to cholesteatoma [Brochure].
Department of Otolaryngology and Communication Sciences-Division of Otology,
Neuro-Otology & Skull Base Surgery. (2011). Risks and complications of surgery:
Tympanoplasty with or without mastoidectomy [Fact Sheet].
Department of Otolaryngology and Communication Sciences-Division of Otology, Neuro-Otology & Skull Base Surgery. (2011). Post-operative instructions for ear surgery
[Fact Sheet].
Derlacki, E.L., & Clemis, J.D. (1965). Congenital cholesteatoma of the middle ear and mastoid. Annals of Otology, Rhinology & Laryngology (74),706-727.
Evlice, A., Tarkan, O., Kiroglu, M., Bicakci, K., Ozdemir, S., Tuncer, U. & Cekic, E. (2012). Detection of recurrent and primary acquired cholesteatoma with echo-planar diffusion-
weighted magnetic resonance imaging. The Journal of Laryngology & Otology (126),
670-676.
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References
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Isaacson, G. (2007). Diagnosis of Pediatric Cholesteatoma. Pediatrics (120), 603-608.
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Contact information
Melissa Raines, MSN, CPNP, APNP
Phone: 414-266-4957
E-mail: [email protected]
Physician Referral and Consultation: (800) 266-0366