Abstract
Importance
It is important that chronic otitis media with cholesteatoma be treated successfully in patients to protect them from having repeated surgeries with related surgical co-morbidities and hearing loss.
Objective
To evaluate the effectiveness of MESNA usage on the residual cholesteatoma rates of the patients who underwent surgery due to chronic otitis media with cholesteatoma.
Design
Retrospective single-institution study of a prospectively collected database.
Setting
Tertiary University Hospital.
Participants
Nine hundred and thirty-four patients underwent surgery due to chronic otitis media between September 2000 and March 2012 by the same surgeon. One hundred and forty-one cases out of 934 patients were selected who had cholesteatoma for the study. These randomly selected 141 cases were divided into two groups as follows: I. Forty-six cases were applied MESNA (Sodium 2-mercaptoethanesulfonate) intraoperatively, and II. Ninety-five cases were not applied MESNA intraoperatively. The cases that were followed-up at least one year were included in this study.
Intervention
MESNA ( Ureomitexan, MESNA, Baxter oncology, Germany ) was diluted with saline (20% MESNA and 80% saline) that was applied, and then a waiting period of approximately 5 min followed to start to dissect cholesteatoma matrix.
Main outcomes and measures
Residual cholesteatoma rates between intraoperative MESNA, a disulfide bond breaking chemical agent, applied and MESNA non-applied cases in the postoperative follow-up period were compared for the success of the surgery.
Results
MESNA was used in 46 patients out of 141 cases intraoperatively. Twenty-four of these patients underwent CWD (canal wall down), and twenty-two patients underwent CWU (canal wall up) mastoidectomy. For the other 95 subjects, 56 patients with CWD and 39 with CWU mastoidectomy, MESNA was not applied. Residual cholesteatoma rates were found to be significantly higher in MESNA non-applied group than MESNA applied group (p < 0.05). Residual cholesteatoma rates between CWD and CWU mastoidectomy procedures were not statistically significant (p > 0.05).
Conclusions and relevance
MESNA application that breaks disulfide bonds in the structure of the matrix in cholesteatoma surgery may assist the elimination of the disease, and increase surgical success by facilitating the elevation of the epithelium. Thereby, it causes a decrease in the possibility of remaining residual epithelium after surgery, which decreases the need for second-look surgery.
Trial registration
The retrospective research protocol was approved by the Inonu University Clinical Research Ethics Committee. Registration number:………
1
Introduction
Although the goal of surgery for chronic otitis media (COM) with cholesteatoma is the elimination of disease, residual cholesteatoma rate is reported to vary from 5% to 50% and develops from a remnant of keratinized epithelium that is left behind in a previous surgical procedure .
MESNA ( Sodium 2-mercaptoethanesulfonate ), which has been used in a variety of disorders, such as a mucolytic agent for pulmonary disorders and as a protective agent against the toxicity of some chemotherapeutic agents, is a synthetic sulfur compound and belongs to a class of thiol compounds that produce mucolysis by disrupting the disulfide bonds of the mucous polypeptide chains . MESNA can be used during ear surgeries, such as cholesteatoma or atelectatic ears, to make the dissection of tissue layers simpler .
The matrix of cholesteatoma is mainly composed of keratin, which has disulfide bonds and so can be disrupted by MESNA. This effect facilitates total dissection of the cholesteatoma matrix. It has been reported that there is no side effect and/or hazard of MESNA application into the middle ear on hearing . Thus some surgeons are permitted to use MESNA during cholesteatoma surgery.
The purpose of this study was to compare the residual cholesteatoma rates between the two groups; MESNA was used and not used in cholesteatoma surgeries that were performed by the same surgeon. Thereby, effectiveness of MESNA usage in chronic otitis media with cholesteatoma can be evaluated.
2
Materials and methods
The retrospective research protocol was approved by the Inonu University Clinical Research Ethics Committee. Nine hundred and thirty four patients, who underwent tympanoplasty and/or mastoidectomy by the same surgeon (MTK) between September 2000 and March 2012 at the department of Otolaryngology, Inonu University, Turkey, were analyzed by this retrospective study.
Two hundred and twenty-four of the 934 patients had cholesteatoma. For these patients, canal wall down (CWD) or canal wall up (CWU) mastoidectomy was performed using standard retro auricular incisions under general anesthesia with or without MESNA application. MESNA ( Ureomitexan, MESNA, Baxter oncology, Germany ) was diluted with saline (20% MESNA and 80% saline) and applied during the surgery, after cholesteatoma debris was aspirated which caused only a remnant of cholesteatoma matrix to be left behind. After waiting approximately 5 min, which resulted in breaking of disulfide bonds in the structure of the cholesteatoma matrix, the cholesteatoma matrix was dissected using a dissector or cotton; the same surgical procedures, except MESNA application, were implemented for MESNA not used group. All of the cases in MESNA applied and non-applied subjects were selected randomly. MESNA applied group is fewer in number, when it is compared with non-applied group, due to the fact that the safety of MESNA usage has been reported for the last 8–10 years in the literature . We had applied MESNA in some patients, and not applied in some patients that were selected randomly for the last 8 years in the current study. Before that time, all subjects were operated without using MESNA. This is the limitation of the study.
CWD and CWU mastoidectomy was performed in 145 and 79, respectively, of the 224 patients who had cholesteatoma. MESNA was used with 63 patients. Forty-one of these patients underwent CWD and 22 CWU mastoidectomy. For the other 104 patients with CWD and 57 with CWU mastoidectomy (total 161), MESNA was not applied.
The patients were followed-up for at least one year. Postoperative follow-up was performed by otomicroscopic examination. If necessary, diffusion magnetic resonance imaging and/or second-look tympanoplasty was performed by the same surgeon. Diffusion MRI scans were reported by an experienced otoradiologist who was informed about the clinical settings of the cases. An experienced otologic surgeon in our department performed all of the operations including second-look operations, if needed. In this study, we focused on the outcomes only residual cholesteatoma, we did not include recurrent disease. Residual cholesteatoma rates for MESNA applied and non-applied groups were compared using Pearson’s chi-squared test.
2
Materials and methods
The retrospective research protocol was approved by the Inonu University Clinical Research Ethics Committee. Nine hundred and thirty four patients, who underwent tympanoplasty and/or mastoidectomy by the same surgeon (MTK) between September 2000 and March 2012 at the department of Otolaryngology, Inonu University, Turkey, were analyzed by this retrospective study.
Two hundred and twenty-four of the 934 patients had cholesteatoma. For these patients, canal wall down (CWD) or canal wall up (CWU) mastoidectomy was performed using standard retro auricular incisions under general anesthesia with or without MESNA application. MESNA ( Ureomitexan, MESNA, Baxter oncology, Germany ) was diluted with saline (20% MESNA and 80% saline) and applied during the surgery, after cholesteatoma debris was aspirated which caused only a remnant of cholesteatoma matrix to be left behind. After waiting approximately 5 min, which resulted in breaking of disulfide bonds in the structure of the cholesteatoma matrix, the cholesteatoma matrix was dissected using a dissector or cotton; the same surgical procedures, except MESNA application, were implemented for MESNA not used group. All of the cases in MESNA applied and non-applied subjects were selected randomly. MESNA applied group is fewer in number, when it is compared with non-applied group, due to the fact that the safety of MESNA usage has been reported for the last 8–10 years in the literature . We had applied MESNA in some patients, and not applied in some patients that were selected randomly for the last 8 years in the current study. Before that time, all subjects were operated without using MESNA. This is the limitation of the study.
CWD and CWU mastoidectomy was performed in 145 and 79, respectively, of the 224 patients who had cholesteatoma. MESNA was used with 63 patients. Forty-one of these patients underwent CWD and 22 CWU mastoidectomy. For the other 104 patients with CWD and 57 with CWU mastoidectomy (total 161), MESNA was not applied.
The patients were followed-up for at least one year. Postoperative follow-up was performed by otomicroscopic examination. If necessary, diffusion magnetic resonance imaging and/or second-look tympanoplasty was performed by the same surgeon. Diffusion MRI scans were reported by an experienced otoradiologist who was informed about the clinical settings of the cases. An experienced otologic surgeon in our department performed all of the operations including second-look operations, if needed. In this study, we focused on the outcomes only residual cholesteatoma, we did not include recurrent disease. Residual cholesteatoma rates for MESNA applied and non-applied groups were compared using Pearson’s chi-squared test.
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