Complications Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
Postoperative Infection of the External Auditory Canal Yukiko Shinjo National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
Reconstruction of the external auditory canal (EAC) and tympanoplasty performed for congenital aural stenosis/atresia are one of the most difficult otological surgeries. This is because the congenital anomaly makes the structures inside the temporal bone less reliable as landmarks for surgery and it becomes difficult to understand the anatomy compared with ordinary otological surgeries. We should be careful to prevent intraoperative complications, such as facial palsy or functional inner ear disorders, and also make efforts to prevent postoperative complications such as stenosis and infection of the reconstructed EAC. Postoperative infection of the reconstructed EAC will be explained below.
The incidence of otorrhea following reconstruction of the EAC/tympanoplasty performed for congenital aural atresia has been reported to be 12–30% to date, and there appear to be no great differences among surgical procedures and institutions [1–3]. We previously surveyed postoperative otitis externa in 127 ears in 104 patients who underwent reconstruction of the EAC/tympanoplasty for congenital aural microtia/ atresia at the University of Tokyo Hospital and the Dokkyo Medical University Hospital between 1999 and 2010. The results showed that 87 of 127 ears did not develop postoperative infection. Infection was transient in most patients who experienced infection. Recurrent infection of four or more times were observed in 11 ears (8.7%) (fig. 1). Persistent recurrent infection has not been observed so far.
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Incidence of Postoperative Infection of the EAC
4 times 6%
5 times 2%
6 times 1%
3 times 4%
Twice 8%
Once 11%
None 69%
Fig. 1. Incidence of postoperative otitis external following reconstruction of the EAC/ tympanoplasty performed for congenital aural microtia/atresia (1999–2011). n = 127.
The causes of postoperative infection of the EAC are considered to be stenosis of the EAC, poor circulation of the constructed eardrum, and hair growth on the transplanted skin of the EAC, if inguinal skin was used but not split thickness skin graft from of temporal scalp.
Causative bacteria in the infected ears were identified in the above surgery. Of the detected bacteria, coagulase-negative staphylococci were predominant, followed by gram-positive bacilli and Staphylococcus aureus (fig. 2). Normal bacterial flora were detected in many patients, and in most cases infection was limited to a short period by local sterilization and administration of antibiotics. In patients with four or more recurrent infections, the proportion of the normal flora decreased and that of drug-resistant bacteria such as Pseudomonas aeruginosa, methicillin-resistant S. aureus and fungi increased (fig. 3). Given that reconstruction of the EAC/tympanoplasty are sub-aseptic surgeries that open the respiratory luminal organs, prophylactic antibiotic therapy is started on the day of surgery. The use of antibiotics is critical and warranted because surgeries are not performed in an aseptic field. Recently, how to best administer antibiotics considering the potential for emergence and proliferation of drug-resistant bacteria
Postoperative Infection of the EAC Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
99
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Bacterial Flora
GNR 5%
MRSA 7%
Fungi 2%
Other 4% CNS 26%
P. aeruginosa 16%
Fig. 2. Bacterial flora that were detected by bacterial culture in infected ears. CNS = Coagulase-negative staphylococcus; GPR = Grampositive bacillus; MRSA = methicillin-resistant S. aureus; GNR = Gram-negative bacillus. n = 87.
GPR 22%
S. aureus 18%
Fungi 10%
Other 3%
CNS 27%
GNR 7%
MRSA 10%
100
P. aeruginosa 20% S. aureus 10%
Shinjo Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Fig. 3. Bacterial flora that were detected by bacterial culture in ears with four or more recurrent infections. n = 30.
GPR 13%
50 40
None Once Twice 3 times or more
30 20 10 0
Pedicled periosteum flap only
Pedicled flap + TPF
Pedicled flap + TPF + split-thickness skin graft
Pedicled flap + TPF + split-thickness skin graft + washing
n = 60
12
10
45
Fig. 4. Incidence rates of postoperative otitis external following reconstruction of the EAC/tympanoplasty by surgical procedure. TPF = Temporoparietal fascia flap.
has been a topic of debate. The use of antibiotics for prevention of postoperative infections should be carefully considered to avoid excessive treatment duration and doses.
Creative Ideas for Surgical Procedures
Postoperative Infection of the EAC Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
101
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Nishizaki et al. [2] listed utilization of a pedicled flap, minimal opening of mastoid cells, and keeping the operative field clean as methods for prevention of infection. We have also refined the surgical procedure to prevent postoperative infection. We use the pedicled periosteum flap and TPF flap to completely cover the osseous EAC wall to maintain the blood circulation of the skin of the reconstructed EAC. After that, we create the skin tube of the EAC with split-thickness skin grafts from the scalp to prevent postoperative hair growth on the skin of the reconstructed EAC. Moreover, we recently began instructing patients to wash their postoperative EAC with warm water daily to keep their ears clean after hospital discharge. The incidence of postoperative otitis external decreased after introduction of this refinement, and it is considered a very useful method (fig. 4).
Conclusion
Many plastic surgeons still do not recommend joint surgery for reconstruction of the EAC and the auricle because they believe that permanent postoperative stenosis and infection will occur postsurgically. However, infection does not persist long term, although transient infection may occur if our surgical procedure is introduced. It is more important in surgery for reconstruction of the EAC/tympanoplasty than ordinary ontological surgeries to use appropriate antibiotics and keep the operative field clean to prevent bacterial infection, particularly with drug-resistant bacteria. Postoperative infection can be controlled effectively and appropriately through careful selection of the surgical procedure and postoperative care.
References 3 Teufert KB, De La Cruz A: Advances in congenital aural atresia surgery: effects on outcome. Otolaryngol Head Neck Surg 2004;131:263–270.
Yukiko Shinjo National Institute of Sensory Organs, National Tokyo Medical Center 2-5-1 Higashigaoka, Meguro-Ku Tokyo 152-8902 (Japan) E-Mail [email protected]
102
Shinjo Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
1 Shih L, Crabtree JA: Long-term surgical results for congenital aural atresia. Laryngoscope 1993; 103: 1097–1102. 2 Nishizaki K, Masuda Y, Karita K: Surgical management and its post-operative complications in congenital aural atresia. Acta Otolaryngol (Stockh) Suppl 1999;540:42–44.
Postoperative Infection of the External Auditory Canal Yukiko Shinjo National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
Reconstruction of the external auditory canal (EAC) and tympanoplasty performed for congenital aural stenosis/atresia are one of the most difficult otological surgeries. This is because the congenital anomaly makes the structures inside the temporal bone less reliable as landmarks for surgery and it becomes difficult to understand the anatomy compared with ordinary otological surgeries. We should be careful to prevent intraoperative complications, such as facial palsy or functional inner ear disorders, and also make efforts to prevent postoperative complications such as stenosis and infection of the reconstructed EAC. Postoperative infection of the reconstructed EAC will be explained below.
The incidence of otorrhea following reconstruction of the EAC/tympanoplasty performed for congenital aural atresia has been reported to be 12–30% to date, and there appear to be no great differences among surgical procedures and institutions [1–3]. We previously surveyed postoperative otitis externa in 127 ears in 104 patients who underwent reconstruction of the EAC/tympanoplasty for congenital aural microtia/ atresia at the University of Tokyo Hospital and the Dokkyo Medical University Hospital between 1999 and 2010. The results showed that 87 of 127 ears did not develop postoperative infection. Infection was transient in most patients who experienced infection. Recurrent infection of four or more times were observed in 11 ears (8.7%) (fig. 1). Persistent recurrent infection has not been observed so far.
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Incidence of Postoperative Infection of the EAC
4 times 6%
5 times 2%
6 times 1%
3 times 4%
Twice 8%
Once 11%
None 69%
Fig. 1. Incidence of postoperative otitis external following reconstruction of the EAC/ tympanoplasty performed for congenital aural microtia/atresia (1999–2011). n = 127.
The causes of postoperative infection of the EAC are considered to be stenosis of the EAC, poor circulation of the constructed eardrum, and hair growth on the transplanted skin of the EAC, if inguinal skin was used but not split thickness skin graft from of temporal scalp.
Causative bacteria in the infected ears were identified in the above surgery. Of the detected bacteria, coagulase-negative staphylococci were predominant, followed by gram-positive bacilli and Staphylococcus aureus (fig. 2). Normal bacterial flora were detected in many patients, and in most cases infection was limited to a short period by local sterilization and administration of antibiotics. In patients with four or more recurrent infections, the proportion of the normal flora decreased and that of drug-resistant bacteria such as Pseudomonas aeruginosa, methicillin-resistant S. aureus and fungi increased (fig. 3). Given that reconstruction of the EAC/tympanoplasty are sub-aseptic surgeries that open the respiratory luminal organs, prophylactic antibiotic therapy is started on the day of surgery. The use of antibiotics is critical and warranted because surgeries are not performed in an aseptic field. Recently, how to best administer antibiotics considering the potential for emergence and proliferation of drug-resistant bacteria
Postoperative Infection of the EAC Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
99
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Bacterial Flora
GNR 5%
MRSA 7%
Fungi 2%
Other 4% CNS 26%
P. aeruginosa 16%
Fig. 2. Bacterial flora that were detected by bacterial culture in infected ears. CNS = Coagulase-negative staphylococcus; GPR = Grampositive bacillus; MRSA = methicillin-resistant S. aureus; GNR = Gram-negative bacillus. n = 87.
GPR 22%
S. aureus 18%
Fungi 10%
Other 3%
CNS 27%
GNR 7%
MRSA 10%
100
P. aeruginosa 20% S. aureus 10%
Shinjo Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Fig. 3. Bacterial flora that were detected by bacterial culture in ears with four or more recurrent infections. n = 30.
GPR 13%
50 40
None Once Twice 3 times or more
30 20 10 0
Pedicled periosteum flap only
Pedicled flap + TPF
Pedicled flap + TPF + split-thickness skin graft
Pedicled flap + TPF + split-thickness skin graft + washing
n = 60
12
10
45
Fig. 4. Incidence rates of postoperative otitis external following reconstruction of the EAC/tympanoplasty by surgical procedure. TPF = Temporoparietal fascia flap.
has been a topic of debate. The use of antibiotics for prevention of postoperative infections should be carefully considered to avoid excessive treatment duration and doses.
Creative Ideas for Surgical Procedures
Postoperative Infection of the EAC Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
101
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
Nishizaki et al. [2] listed utilization of a pedicled flap, minimal opening of mastoid cells, and keeping the operative field clean as methods for prevention of infection. We have also refined the surgical procedure to prevent postoperative infection. We use the pedicled periosteum flap and TPF flap to completely cover the osseous EAC wall to maintain the blood circulation of the skin of the reconstructed EAC. After that, we create the skin tube of the EAC with split-thickness skin grafts from the scalp to prevent postoperative hair growth on the skin of the reconstructed EAC. Moreover, we recently began instructing patients to wash their postoperative EAC with warm water daily to keep their ears clean after hospital discharge. The incidence of postoperative otitis external decreased after introduction of this refinement, and it is considered a very useful method (fig. 4).
Conclusion
Many plastic surgeons still do not recommend joint surgery for reconstruction of the EAC and the auricle because they believe that permanent postoperative stenosis and infection will occur postsurgically. However, infection does not persist long term, although transient infection may occur if our surgical procedure is introduced. It is more important in surgery for reconstruction of the EAC/tympanoplasty than ordinary ontological surgeries to use appropriate antibiotics and keep the operative field clean to prevent bacterial infection, particularly with drug-resistant bacteria. Postoperative infection can be controlled effectively and appropriately through careful selection of the surgical procedure and postoperative care.
References 3 Teufert KB, De La Cruz A: Advances in congenital aural atresia surgery: effects on outcome. Otolaryngol Head Neck Surg 2004;131:263–270.
Yukiko Shinjo National Institute of Sensory Organs, National Tokyo Medical Center 2-5-1 Higashigaoka, Meguro-Ku Tokyo 152-8902 (Japan) E-Mail [email protected]
102
Shinjo Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 98–102 (DOI: 10.1159/000350970)
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 3/25/2016 3:35:10 AM
1 Shih L, Crabtree JA: Long-term surgical results for congenital aural atresia. Laryngoscope 1993; 103: 1097–1102. 2 Nishizaki K, Masuda Y, Karita K: Surgical management and its post-operative complications in congenital aural atresia. Acta Otolaryngol (Stockh) Suppl 1999;540:42–44.
