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).
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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.
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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.
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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.