Results
Fifty-seven otologists responded to the survey invitation; two had less
than 5 years of experience and were excluded. Thus, a total of 55
responses (11 women) were analyzed, representing 41% of AFON members;
the mean age of the participants was 48.7 ± 12 years. Among
participants, 67% (N=37) had more than 15 years of otological surgery
experience, 35% (N=19) worked in a public hospital, 27% (N=15) had a
private practice, and 38% (N=21) had a public/private practice. In
terms of clinical practice, 76% (N=42) worked with pediatric and adult
patients, with children accounting for 30% of their practice; 12
participants practiced surgeries only on adults.
Table 1 shows the most frequent approach used by participants for
various surgical procedures. Figure 1 shows the different types
of ear canal packing used for these procedures. The most frequent
packing used was ear wick combined with silicon sheets, ranging from
33% for Open Technique Tympanoplasty (OTT) to 70% for Canal Wall
Reconstruction (CWR). The second-most popular packing was ear wick for
all procedures, ranging from 10-33%, except for OTT where paraffin
gauze accounted for 27% of the participants’ habits. The use of
absorbable ear packing ranged from 6% (canaloplasty) to 22%
(myringoplasty and closed technique tympanoplasty).
———————Insert Table 1————————————
———————Insert Figure 1————————————
Figure 2 shows the different packing materials used for the
various surgical approaches. For 33% (endaural) to 60% (transmeatal
and enlarged) approaches, the most frequently used ear packing was ear
wick combined with silicone sheet. The use of absorbable ear packing
ranged from 7% (enlarged approach) to 26% (endaural approcach). Among
participants, 62% used the same packing material for all surgical
procedures. Among those who varied the packing material according to
procedure, 65% had more than 10 years of otologic experience.
———————Insert Figure 2————————————
Table 2 summarizes post-operative management habits. Among
participants, 39% (open tympanoplasty) to 60% (ossiculoplasty and
myringoplasty) prescribed local antibiotics, 78% (canaloplasty) to 95%
(ossiculoplasty and canal wall reconstruction) prescribed oral
analgesic, and 5% (myringoplasty) to 47% (open tympanoplasty)
prescribed oral antibiotics. Among participants, 75% performed packing
removal 7-10 days after surgery, 11% after 2 weeks and 7% before 7
days.
—————————Insert table
2————————————
Nearly all participants (96%) were reluctant to provide no packing. The
reasons for this reluctance included stenosis of the EAC (26%),
misplacement of the tympanomeatal flap and blunting (7%), and
perturbation of wound healing (7%). Some participants also commented on
the risk of external contamination, less efficacy of local treatments,
and synechia. One participant commented on the increased risk of
iatrogenic cholesteatoma, and another reported the risk of filling of
the anterior angle.
DiscussionThe present data shows great variability among ENT surgeons regarding
ear packing among the procedures analyzed. The most-frequent packing was
the combination of ear wick and silicone sheet, but other packing
materials were often used. We also found heterogenous habits amongst
pre-, peri-, and post-operative management. Nearly all participants were
reluctant to proceed after ear surgery without packing.
The heterogeneity in the practices of EAC packing among French ENT
surgeons may be explained by the lack of scientific evidence and thus,
the lack of recommendation. Only one guideline exists for pediatric
populations which recommends the use of resorbable ear pack or a
material that allows atraumatic removal7. A previous
study compared four types of ear packing (paraffine gauze, POP oto wick,
silicone sheet and tricortyl ointment) and found no significant
difference in terms of pain, discomfort, and postoperative complications
(granulation, stenosis, discharge)4. While the
postoperative practice of packing is widespread, it also presents some
drawbacks such as subsequent uncomfortable hearing loss, especially in
patients who have a mild hearing loss before the
surgery6. The removal of the packing can be a source
of stress for patients, which may be why the combination of ear wick and
silastic was most frequently used. Silastic reduces adhesion to the EAC
skin, thereby reducing pain during packing removal, which is ideal for
children and/or anxious patients. There is also a lower risk to harm the
tympano meatal flap8..
A previous pediatric study showed a low rate (7.5%) of infection
without packing after major ear surgery9, as well as
better patient satisfaction and cost effectiveness (due to reduced
follow-up visits). As such, “no packing” may be advantageous for
surgical procedures where the dissection of the tympanomeatal flap is
minimal (e.g., stapes surgery or otoendoscopic procedure).
The price of the packing is another consideration, as it differs
significantly among ear packing agents For example, in the University of
Tours ENT center, prices range from 0,10\euro (parrafin gauze) to
17,7\euro (silicone sheet). Considering these differences, a
medico-economical study would be useful to determine the best ratio
between price and efficacy of various packings, and to compare with no
packing.
Some study limitations should be discussed. First, while the number of
responses may seem limited (N=55), it represents 41% of the AFON
members. Still, with this limited number of participants, a large
variability of ear packing management was demonstrated. The percentage
of respondents is comparable to the percentage of people who generally
reply to online questionnaires (40%)10. Another limit
was the questionnaire, which required participants to indicate their
most frequent surgical approach from among 6 choices, rather than an
exhaustive report of surgical approaches.