Well, almost! The much awaited indigenous, low-cost cochlear implant device being developed by the DRDO is just four months away from becoming available for clinical trials according to reports. Expected to be priced at Rs. 1 lakh, the device is far cheaper than the imported variety now in use.

The announcement was made by former president Dr. Abdul Kalam at the inaugural function of an otolaryngology workshop at New Delhi on 4 Feb 2012. Dr. V. Bhujanga Rao, chief controller of DRDO and the chief designer of the implant also made a presentation of the design details of the device.

Dr. Kalam first spoke of an indigenous, low-cost cochlear implant in 2005 at a CIGI conference. Since then, doctors and patients alike have been waiting for the project to see the light of day. This is indeed welcome news, but these are still early days. The device has to first undergo clinical trials before it can be approved for production.

The fact also remains that there is a great dearth of trained personnel required for cochlear implantation, both surgeons and speech therapists. It is estimated that around 9000 to 10000 children are born deaf each year. In addition, there are post-lingual children and adults who will benefit from implantation. The need of the hour is to train more people to meet the challenge of treating deafness in the country.

There is also a need for better screening programmes for the early detection of deafness. In India, universal hearing screening of newborns is neither mandatory nor routine unlike in many other countries. Many cases go sadly undetected until it is too late.

Spreading more awareness about the early detection of deafness and its treatment among both doctors and the general population will go a long way in helping to reduce the burden of deafness in India. And only with the involvement of more trained professionals can any ‘sound hearing’ be achieved.

Photo courtesy Zipfer

What do you think? Please leave a comment to share your views.

There are many ways to remove foreign bodies from the ear. The actual method used depends on the type of the foreign body. Detailed below are the various methods and the situations in which they are used.

Patient profile

The patient is very often (but not always) a small child who has accidentally (or experimentally!) inserted something into his ear canal or has had something inserted into the ear by a sibling or peer. The child may admit to the presence of a foreign object in the ear or the parents may have spotted something in the ear. Sometimes the child presents with pain and ear discharge.

They may also be seen in adults. They don’t usually cause symptoms, but impacted foreign bodies and insects in the ear canal can be painful.

Problems with ear foreign bodies

The ear canal is quite narrow, especially in children, so foreign objects can easily get impacted within, making removal difficult. Manipulating them can be painful as the skin lining the ear canal is closely adherent to the underlying bone. Also, parents and caregivers are often tempted to try removing them as they lie deceptively close to the opening. So initial manipulation may only result in pushing the object deeper into the canal or cause pain and bleeding, making the child very anxious at the second attempt.

Methods for removal

• Syringing
• Manual removal – hook, forceps, suction
• Removal using microscope and micro instruments
• Need for GA and post aural incision

Aural syringing or irrigation

This is one of the most convenient methods to remove foreign bodies from the ear canal. Water at body temperature is sprayed into the external auditory canal from a metallic aural syringe. The stream of water goes beyond the object inside the ear canal and pushes it out.

Points to remember:

• Water used should be at body temperature, using cold water can cause giddiness.
• The water jet should not be directed towards the tympanic membrane to avoid causing perforations.
• This method will not work when the object completely occludes the external auditory meatus.
• This method is not used for vegetative foreign bodies like seeds that can swell up after absorption of water and become impacted.

Manual removal

Objects in the ear can be removed in an OPD set up using a head light or a head mirror and Bull’s lamp. They can either be hooked out using the ring curette at one end of the Jobson Horne ear probe. Or they can be removed using aural forceps. Small aural suction tips may be used to remove them with the help of suction. Remember that touching the canal wall with the instrument will cause pain.

Using a microscope

Impacted objects, objects that become fragmented when removal is attempted and objects not clearly visible with a headlight because of their depth in the canal or because the canal itself is very narrow may be safely removed using a microscope and microforceps.

Role of general anesthesia, postaural incision

Very small children, uncooperative patients and severely impacted foreign bodies may require the use of general anesthesia (or sedation) for safe removal. Objects that have entered the middle ear may be removed using the postaural incision.

Strange foreign bodies in the ear

Children usually present with seeds, beads, small parts of toys, paper and the like. Insects are common among adults. They simply walk (or fly) into the dark recess, usually at night. Cotton buds are also common, the cotton part of the bud getting left behind after a patient cleans his ears.

Button batteries and hearing aid cells are dangerous foreign bodies – they get deep into the canal and may lie close to or on the tympanic membrane. They have a corrosive action when their chemicals start to leak and cause necrosis of the surrounding tissue.

I have seen patients with garlic in their ears. Apparently people insert a clove of garlic into their ear as a home remedy for cold – a large clove will easily swell up enough to completely block the ear.

How about your experience with ear foreign bodies? Have you seen something really strange? Have you used any novel technique to remove it? Leave a comment to share with us.

There is no history of headache or symptoms of nasal allergy like excessive sneezing and watery rhinorrhoea.

Examination

The external appearance of the nose is normal as are the vestibules. On anterior rhinoscopy, a solitary, greyish mass is seen in the left nasal cavity. The mass is smooth and glistening and occupies the lower part of the nasal cavity. The middle turbinate appears to be normal. The mass is further examined with a cotton tipped probe – it is insensitive to touch, does not bleed and can be probed all around.

Cold spatula test shows decreased fogging on the left side. There is no tenderness over the paranasal sinuses. The right nasal cavity, ears, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• What further tests does this condition require?
• How will you manage this case?

Discussion

Unilateral nasal obstruction may be caused by a deviated nasal septum, hypertrophied inferior turbinate, rhinolith, unilateral nasal polyps or a nasal tumour. Here, the cause of nasal obstruction is the mass in the nasal cavity. The appearance of the mass (smoothy, shiny, greyish) suggests a polyp. Polyps are insensitive to touch and do not bleed unlike hypertrophied turbinates and nasal tumours. Also, polyps can be probed all around (except at their point of origin from the middle meatus) whereas a hypertrophied inferior turbinate cannot be probed laterally where it is attached to the lateral nasal wall.

Since the polyp is unilateral and single, it is likely to be an antrochoanal polyp. AC polyps usually grow backwards and may be seen occupying the choana and even the nasopharynx sometimes. This can be seen by posterior rhinoscopy or nasal endoscopy. They cause bilateral nasal obstruction when they reach the nasopharynx.

Diagnosis

Antrochoanal polyp, right side

Management

Diagnostic nasal endoscopy is done to evaluate the nasal mass. The origin of the polyp from the middle meatus may be seen. AC polyps can sometimes be seen coming out of an accessory ostium of the maxillary sinus. CT scan of the nose and paranasal sinuses will help study the extent of the mass and also reveal any anatomical variations in the lateral wall of the nose (the knowledge of which is important during surgery).

The treatment is surgical removal. Part of the polyp is inside the maxillary antrum, this has to be removed completely as well to prevent a recurrence of the condition. Endoscopic sinus surgery is done to remove the polyp. Uncinectomy and middle meatal antrostomy are done as part of the procedure to widen the opening of the maxillary antrum and the polyp is completely removed.

Related posts:

Case of allergic rhinitis

See ENT cases for more case reports and discussions on diagnosis and management.

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A 25-year-old man presents to the ENT outpatient with complaints of right ear discharge for the past two years. The discharge is small in quantity, white to yellow in colour, purulent, often foul-smelling but not blood stained. It is continuous and not associated with upper respiratory infections.

He also complains of hearing loss in the right ear for about the past one year. He is unable to hear whispers and low tones. He does not complain of ear ache, tinnitus or giddiness. He has no nasal complaints, fever or headache.

Examination

The patient’s right pre-auricular region, post auricular region and pinna are normal. Slight purulent discharge is seen in the ear canal and on the tympanic membrane. This is cleaned away to visualize the tympanic membrane. The pars tensa appears normal but there is a perforation in the attic or pars flaccida. White flaky material can be seen through the perforation.

Tuning fork tests show the following results:

• Rinne negative in the right ear
• Weber’s test is lateralized to the right ear
• Absolute bone conduction is normal on both sides

The left ear, facial nerve, nose, paranasal sinuses, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• How will you manage this case?
• What surgery is required to treat this condition?

Discussion

Ear discharge of two years’ duration associated with hearing loss suggests chronic middle ear infection or otitis media. Scanty, white or yellow, purulent and foul smelling discharge is characteristic of unsafe or squamosal type of chronic otitis media. It may even be blood stained in the presence of granulations.

Unsafe COM is also characterized by perforation in the attic region or a marginal perforation in the posterosuperior quadrant of the pars tensa of the tympanic membrane. The whitish flaky material seen through the attic perforation is cholesteatoma. The tuning fork tests suggest conductive hearing loss in the right ear.

Diagnosis

Right chronic otitis media of the squamosal type with conductive hearing loss

Management

The aim of treatment is to stop the ear discharge and restore hearing.

Investigations

Pure tone audiometry is performed to evaluate the degree of hearing loss. X-rays of the mastoid may be taken to assess the status of pneumatization of the mastoid and look for the presence of cholesteatoma and any variations in the normal structures like the dural and sinus plates. But mastoid x-rays are not very sensitive and many surgeons don’t ask for them. CT scans are not indicated in every case of unsafe COM. The ear may be examined under the microscope for better understanding of the findings.

Treatment

Squamosal COM with cholesteatoma is not amenable to medical management. The treatment of this condition is modified radical mastoidectomy with tympanoplasty. This surgery ensures removal of pathology from the middle ear cavity and the mastoid while at the same time reconstructing the hearing mechanism.

Related posts:

Case of chronic otitis media, safe type

Case of acute otitis media

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A 15-year-old girl presents to the ENT outpatient with history of throat pain for the past 3 days. It began as mild discomfort or sore throat and has now developed into odynophagia or pain on swallowing. She also has fever – low grade and intermittent, not associated with chills or rigors. She has no history of cough or change in voice. She also has no nasal or ear symptoms.

She gives history of similar complaints occurring in episodes every few months for the past three years. The symptoms usually subside with treatment.

Examination

The patient is afebrile at the time of examination. Examination of her oral cavity reveals normal teeth, gums, lips, buccal mucosa, tongue and palate. The anterior pillars are congested. The tonsils are enlarged and congested. Debris is seen as white spots on the surface of the tonsils. The posterior pharyngeal wall is also congested. Indirect laryngoscopy is normal.

Palpation of the neck shows enlarged and tender jugulodigastric lymph nodes. The nose and ears are normal.

Questions

Answer the following questions before you go on to read the discussion below.

• What is your diagnosis?
• What investigations does the condition require?
• How will you manage this case?

Discussion

History of pain and fever suggest an inflammatory condition. Hypertrophied tonsils, congestion in the anterior pillars and tonsils and pus in the tonsils all suggest tonsillitis. Tonsillitis causes odynophagia or pain on swallowing which has to be differentiated from dysphagia or difficulty in swallowing. It may also cause symptoms like fever, cough and halitosis. Enlarged jugulodigastric lymph nodes are characteristic of pathology in the tonsils.

Diagnosis

Recurrent tonsillitis

Management

Tonsillitis is usually diagnosed clinically. A throat swab may be taken for culture and sensitivity and the most common organism isolated is GABHS (Group A beta hemolytic streptococci).

Medical management

The infection is treated with penicillin group of antibiotics. Analgesics like paracetamol are given for pain and fever. Adequate hydration should be maintained. In cases with severe pain, the patient may require IV fluids. Warm saline gargles will give symptomatic relief to the patient.

Surgical management

Since the patient is suffering with recurrent tonsillitis, with several episodes every year for the past 3 years, she is advised tonsillectomy. Tonsillectomy can be performed after about 6 weeks after the symptoms have subsided.

See ENT cases for more case reports and discussions on diagnosis and management.

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There is also history of excessive sneezing and nasal discharge. The discharge is thin and watery, not foul smelling or blood-stained and is occasionally associated with watering of the eyes. There is history of itching in the nose, palate and eyes. There is no history of fever. The symptoms are often triggered off by exposure to dust.

Examination

The external appearance of the nose is normal. There is no abnormality in the vestibule. Anterior rhinoscopy reveals serous discharge in both nasal cavities. The inferior turbinates are hypertrophied, bluish and boggy on both sides. There is no septal deviation. There is no tenderness over the paranasal sinuses.

The ear, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• What investigations are required for this condition?
• How will you manage this case?
• Does it require surgical management?

Discussion

Bilateral nasal obstruction is caused by conditions that affect both nasal cavities – inflammatory conditions like rhinitis and sinusitis, polyps and deviated nasal septum. While the presence of nasal discharge suggests an inflammatory condition like rhinitis or sinusitis, watery nasal discharge is seen in the early part of infective rhinitis, allergic rhinitis and in CSF rhinorrhea.

History of excessive sneezing, watering of the eyes,itching in the nose, eyes and throat and onset or worsening of symptoms with exposure to dust all suggest allergic rhinitis.

The serous nasal discharge and hypertrophied inferior turbinates seen on examination also indicate allergy. The nasal mucosa is usually pale in this condition, but acute exacerbation of symptoms often causes the turbinates to become boggy and bluish.

Diagnosis

Allergic rhinitis

Management

While allergic rhinitis is usually diagnosed clinically, investigations are required to detect the allergens responsible for it. The following tests are performed:

• Skin tests
• RAST (radioallergosorbent test)
• Estimation of serum IgE
• Absolute eosinophil count – raised

As for treatment, allergen avoidance, when possible, is the best measure. Here is a look at other treatment options.

Medical management

• Antihistamines – These are helpful in controlling symptoms caused by allergy. First generation antihistamines cause sedation, so it is better to prescribe second generation antihistamines like levocetrizine, fexofenadine or loratidine.
• Nasal decongestants – These are occasionally used to relieve congestion and nasal obstruction.
• Topical nasal steroids – Steroids are powerful anti-inflammatory agents and are used in long standing cases. Topical steroid sprays help avoid the systemic side effects of oral steroids. The agents used are fluticasone, mometasone, budesonide and beclomethasome.
• Leukotriene receptor antagonists – These act similarly to antihistamines but against leukotriene receptors. Eg – monteleukast.
• Cromolyn sodium – This is a mast cell stabilizer but only helps prevent episodes of allergy and has to be given before the onset of symptoms.

Immunotherapy

Immunotherapy is a form of desensitization where incremental doses of the causative allergen are given as injections. This therapy works when the allergy is caused by a single or few allergens and they are identified accurately.

Surgical treatment

Nasal allergy itself does not require any surgical treatment. But the presence of other pathology like polyps, or coexisting conditions like sinusitis or DNS may require surgical correction.

See ENT cases for more case reports and discussions on diagnosis and management.

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A 4-year-old boy is brought to the ENT outpatient by his mother with complaints of severe right earache since the previous day. The pain was most severe at night. This morning the mother noticed slight watery discharge from the right ear. The patient has fever. He has been suffering from cold and nasal discharge since about three days.

There is no past history of similar complaints. There is no history of repeated upper respiratory infections or nasal complaints. There is also no other significant medical history. The child’s immunization status is up to date.

Examination

The child is febrile. His right ear canal is filled with whitish, mucoid discharge. Cleaning the discharge reveals a red and congested tympanic membrane with a small perforation in the posteroinferior quadrant from which pulsatile discharge is seen coming out.

Tragus sign is negative. There is no mastoid tenderness and no swelling is seen in the postauricular region. The left ear is normal.

There is discharge in both nasal cavities and the nasal mucosa is congested. The posterior pharyngeal wall is congested. There are no palpable lymph nodes in the neck.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• What is the ‘lighthouse sign’?
• What is the importance of examining the mastoid region in this case?
• How will you manage this patient?

Discussion

Acute earache with ear discharge is seen in acute otitis media and acute otitis externa or furuncle. In the case of furuncle, the ear pain is severe. Even the touching or handling the pinna may be painful making ear examination difficult especially in children. Also, the tragus sign, where there is tenderness on pressing on the tragus, will be positive.

In cases of acute otitis media, the pain often becomes severe at night. Earache is followed by ear discharge due to rupture of the ear drum. The pain may subside with the onset of discharge. Ear discharge in AOM may be watery to mucopurulent and may also be blood stained sometimes. Pulsatile discharge from a small perforation in the tympanic membrane occurs due to the accumulation of pus under great pressure in the middle ear and is called the ‘lighthouse sign’.

AOM often causes acute mastoiditis where there is spread of infection to the mastoid air cell system. This can lead to complications like mastoid abscess, hence the importance of examining the postauricular region for mastoid tenderness and swelling.

Diagnosis

Acute otitis media of the right ear

Management

The aim of treatment is to combat the acute infection and give symptomatic relief to the patient.

Since the child has severe pain and fever, he should be given an antibiotic. Amoxicillin is the drug of choice. NSAIDs may be given for their analgesic and antipyretic effects. Nasal decongestants help relieve  congestion in the nose. Antihistamines and steroids have no role in the treatment of AOM, although antihistamines help treat coexistent nasal symptoms.

Surgical management

Severe pain due to a tympanic membrane bulging under pressure and very small perforations that inadequately drain pus from the middle ear often require a surgical procedure called myringotomy. An incision is made on the tympanic membrane to drain pus from the middle ear.

Related posts:

Case of chronic otitis media, safe type

Case of chronic otitis media with cholesteatoma

A 30-year-old male patient presents to the ENT outpatient with history of left ear discharge for the past two years. The ear discharge is intermittent and occurs in episodes that last for a few days each. These episodes are often associated with acute upper respiratory infections.

The discharge is moderate in quantity, white in colour and thick and sticky (mucoid) in consistency. It is not foul smelling or blood stained. There is no associated ear ache. The patient complains of decreased hearing in the left ear since about a year. He finds it difficult to hear whispers and low tones. There is no history of tinnitus or giddiness.

The patient has no complaints of nasal obstruction or discharge or headache. He does not have any other systemic illnesses, has never undergone any surgery and is not allergic to any drugs.

Examination

The patient’s left ear canal is filled with mucoid discharge. On cleaning it, a large central perforation is seen on otoscopy. Tuning fork tests results are as follows:

• Rinne negative in the left ear
• Weber’s lateralized to the left ear
• ABC is normal on both sides

Facial nerve function is normal. Examination of the right ear, nose, paranasal sinuses, oral cavity and neck don’t reveal anything.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• Interpret the tuning fork tests in this case.
• What is the cause of deafness in this patient?
• How will you manage this patient?

Discussion

Chronic ear discharge associated with decreased hearing occurs in chronic otitis media (COM). Mucoid or mucopurulent , non-foulsmelling and non-bloodstained ear discharge that occurs in episodes associated with upper respiratory infections is characteristic of mucosal type of COM (or safe COM). Central perforations or pars tensa perforations are also typical of mucosal COM.

A negative Rinne test suggests conductive hearing loss. In Weber’s test, sound is lateralized to the ear with conductive deafness or the worse ear when both ears have conductive deafness. Absolute bone conduction is normal (or the same as the examiner) when the hearing is normal or when there is conductive deafness. So the tuning fork tests in this case show that the patient has conductive hearing loss in his left ear. This can be confirmed and the degree of deafness evaluated with pure tone audiometry.

Diagnosis

Left chronic otitis media, mucosal type with conductive hearing loss

Management

The aim of treatment in this case is to stop the discharge and restore hearing.

Medical management

In this patient, the acute episode of ear discharge is first treated with systemic broad spectrum antibiotic and antibiotic ear drops. The discharge may be sent for culture and sensitivity tests to help select the antibiotic. Aural toilet or dry mopping of the ear where the ear is thoroughly cleaned using suction or cotton swabs has to be done. It is also important for the patient to prevent entry of water into the ear canal.

Analgesics may be prescribed if the patient has earache. Antihistamines help when nasal allergy is a contributing factor. With measures like these, the ear discharge ceases and the ear becomes ‘dry’.

The ear may be examined under the microscope to assess the perforation and other pathology in the ear. Pure tone audiometry is performed to assess the type and degree of hearing loss. X-ray of the mastoid bones may be taken to check the status of mastoid pneumatization.

Surgical management

The perforation and hearing loss are treated by tympanoplasty. Cortical mastoidectomy may be performed to eradicate pathology in the mastoid air cells.

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Unilateral choanal atresia symptoms and signs, pictures of endoscopy and CT scans and a short video on nasal endoscopy of the condition. 

Unilateral choanal atresia is a rare condition with an incidence of 1 in 7000 live births. While it has characteristic clinical and radiological features, it is sadly often missed on both endoscopy and scans. Here is a detailed look at the clinical features of unilateral choanal atresia, its radiological and endoscopic appearance with a short video showing diagnostic nasal endoscopy of the condition.

Clinical features of unilateral choanal atresia

Unlike bilateral choanal atresia which is usually a respiratory emergency immediately after birth, the unilateral variety can often go undetected until adulthood. Patients most often present with history of longstanding unilateral nasal obstruction and discharge. The obstruction is continuous and unaffected by season, position or other factors.

The nasal discharge is white, thick and mucoid. The cause of nasal discharge is not really pathology in the nose. The normal nasal and sinus secretions of the affected side cannot be transported into the pharynx as on the normal side and so remain in the nasal cavity and present as discharge.

Examination and endoscopy in unilateral choanal atresia

On examination, a cold spatula test will show absent fogging on the affected side indicating nasal obstruction. Anterior rhinoscopy will usually only reveal the presence of thick, mucoid secretions with nasal structures like the inferior and middle turbinates appearing normal and may be mistaken for sinusitis.

Earlier, tests like passing a rubber catheter through the nasal cavity were used to detect choanal atresia. In the presence of a choanal block, the catheter would not make its way into the nasopharynx.

Diagnostic nasal endoscopy is the best method to visualize the atretic choana. In the first pass, most of the structures appear normal but covered by thick mucoid secretions. But as the endoscope proceeds posteriorly, the nasal cavity ends blindly, with the medial and lateral walls fusing with each other. In cases of partial choanal atresia, there may be a small opening into the nasopharynx.

Radiological appearance of choanal atresia

CT scan picture of choanal atresia

Even though the atresia has already been seen by endoscopy, a CT scan is most helpful while planning treatment of the condition. CT scans help assess whether the atretic plate is completely bony or partly bony and partly cartilaginous. Scans also give information about the thickness of the atretic plate.

CT appearance of unilateral choanal atresia is characteristic, but easily missed. It is better seen on axial sections than coronal cuts. This is because the atretic plate, itself present in a coronal plane, may be missed between cuts.

In an axial section, the nasal cavity can be seen becoming narrower towards the choana. In cuts where the free end of the septum is usually visible just anterior to the nasopharynx, the vomer in the posterior end of the septum is thickened and fuses with the lateral wall. When the atretic plate is not completely bony, it may appear to be made of membrane or soft tissue on scans.

And finally, here’s a video of diagnostic nasal endoscopy being performed in a case of unilateral choanal atresia.

TCA cautery of tympanic membrane perforation - notice how the edges have turned white after cautery

Is chemical cautery of tympanic membrane perforations just some old technique that was used to repair ear drum defects in the pre-tympanoplasty days? Or is it a viable option in the treatment of ear drum perforations? Here is a look at the history of the procedure, indications, contraindications and details on how to perform TCA cautery of the tympanic membrane and its results.

According to Glasscock-Shambaugh Surgery of the Ear, the procedure was originated by Roosa in 1876. Derlacki popularized the technique in the 1950s and the procedure is referred to as the Derlacki method. (1)

TCA cautery involves applying a saturated solution of trichloroacetic acid onto the rim of the perforation. Pars tensa perforations are usually lined by squamous epithelium that has grown over the rim of the perforation. The idea behind using TCA cautery is that trichloroacetic acid destroys the fibrosis in the edge of the perforation and promotes growth of new tissue giving the tympanic membrane a chance to heal. It does much the same thing that freshening the edges of the perforation does during tympanoplasty.

Procedure

The procedure is done using an operating microscope. The tip of a metal applicator is wrapped tightly with a small amount of cotton. The tip is dipped in a saturated solution of TCA which is then applied to the edges of the perforation. Care is taken not to touch any part of the external auditory canal as TCA can burn skin. The perforation is then covered with a piece of gelfoam.

When TCA is applied, the edge of the perforation and some of the surrounding normal ear drum turns white. Later, there is formation of granulation tissue. The patient is followed up regularly to monitor the healing process. Some patients may require several sittings for complete healing to occur. It is important to decide to stop this treatment when healing doesn’t take place even after multiple applications and recommend tympanoplasty instead.

An alternative to TCA is silver nitrate solution.

Selection of cases

This procedure appears to work well for small pars tensa perforations (Shambaugh recommends less than 4mm). It is important to ensure that the perforation is dry and that there is no active infection, attic pathology or cholesteatoma or ossicular pathology. Here is a summary of the indications and contraindications for the procedure.

Indications:

• Small central pars tensa perforation
• Dry perforation
• No ossicular pathology or cholesteatoma

Contraindications:

• Active infection, discharging ear
• Cholesteatoma
• Marginal perforations
• Ossicular pathology
• Extensive tympanosclerosis

Protocol

Here is a brief suggested protocol to follow while selecting cases for chemical cautery.

•  Small pars tensa perforation that has not discharged for some time – think TCA cautery.
• First make sure the ear is dry and there is no active infection, cholesteatoma or attic pathology – this can be achieved by examination under microscope.
• Next, ensure that the ossicular chain is intact – a pure tone audiogram can help rule out ossicular pathology.

Uncooperative patients and narrow external auditory canals may pose problems in performing this procedure. TCA cautery also appears to work well in treating traumatic perforations. Perforations that persist after ventilation tube removal may also be treated by this method. Its main advantage is that it can be performed as an office procedure.

Results

Uppal KS, et al reported a 78% success rate with an average of 2.8 applications (2) while Goldman NC reports 64% success rate in patients on a waiting list for definitive surgery, reducing the waiting list by 26% (3). Scaramella LF had a success rate of 82.4% with the technique (4) while Derlacki himself reported an 80.4% success rate over two decades (5).

TCA cautery for the repair of tympanic membrane perforations appears to be a good office procedure. Selection of appropriate cases is very important for its success.

References:

1. Glasscock-Shambaugh surgery of the ear, 6^th edition, PMPH-USA 2010
2. Uppal KS. Closure of tympanic membrane perforations by chemical cautery.  IJOHNS vol 49 no 2 151-153
3. Goldman NC. Chemical closure of tympanic membrane perforations.  ANZ J Surg. 2007 Oct;77(10):850-1
4. Scaramella LF. Effectiveness of nonsurgical office closure of tympanic membrane pars tensa perforations. Ear Nose Throat Journal Aug2002
5. Derlacki EL. Office closure of central tympanic membrane perforations: A quarter century of experience. Trans Am Acad Ophthalmol Otolaryngol 1973;77:53-66