Study designs and participants
This case series was conducted at a tertiary care hospital after obtaining consent from patients and approval by the ethical committee. The otorhinolaryngology practice has markedly changed during COVID-19 pandemic. Ear surgery carries a high risk of infection due to aerosol generating procedures. Measures to minimize the viral transmission risk were implemented at all levels.
Otolaryngology health care providers were consulted for tracheostomy, epistaxis, foreign body removal, ear surgery with complications and the head and neck malignancies which required urgent attention and intervention. The details of patients who underwent surgical procedure at our centre between April to July 2020 were reviewed. During this period we undertook six cases of emergency ear surgeries. The three of the six cases involved mastoid drilling( as part of the mastoid surgery) and the rest were managed for a foreign body in the ear. Here we present briefly, the cases done at our tertiary centre strictly following the MOHFW (Ministry of health and family welfare, Government of India) guidelines, with appropriate personal protective equipment (PPE) , which includes cover all gown (impermeable gown), N95 mask, gloves, goggles and face shield .
68 year-old-male, a known case of chronic otitis media (mucosal) left ear with uncontrolled diabetes presented with complaints of pain and discharge involving left ear associated with deviation of tongue and absence of gag reflex on left side, suggestive of skull base osteomyelitis. He had undergone tympanoplasty for left ear four month prior at a civil hospital, however, he continued to have persistence of ear discharge. Because of the strict lockdown consequent to surge of COVID-19 cases, he could not seek timely medical attention. He reported to our hospital with persistence of symptoms. Examination revealed subperiosteal abscess (mastoid region), edematous ear canal ( with granulations) , ipsilateral hypoglossal nerve palsy ( Fig 1) and absence of the gag reflex. Rest of the otoneurological examination was unremarkable. Presurgical workup included obtaining pus culture swab (from EAC),baseline haematological investigations, COVID -19 status and imaging [high resolution computed tomography (HRCT) temporal bone and Magnetic resonance imaging (MRI) brain]. The patient was initially managed with aural toileting, strict glycemic control and appropriate antibiotics. The patient was taken up for surgery ( cortical mastoidectomy and tympanoplasty) ensuring strict precautions with level 2 PPE, minimum number of health care providers inside operation theatre, one drape over the microscope and another drape around surgical area to prevent inadvertent mastoid bone particle dispersal (Fig 1). The patient became symptom free and the subsequent follow-up examination at two week post surgery demonstrated normal gag reflex with near complete resolution of hypoglossal nerve paralysis. He was given long term antibiotics with resultant complete resolution of disease.
38-year-old male, a known hypertensive presented with complaints of left ear fullness for fifteen days and diplopia of seven days duration with associated intermittent mild headache and no other ear complaints. There was past history of chronic serous otitis media (left ear) for which cortical mastoidectomy was undertaken three years back .
Examination revealed inflamed and bulging left tympanic membrane , Left lateral rectus palsy and moderate mixed hearing loss. HRCT temporal bone documented hypodense soft tissue attenuation contents in epitympanum and mastoid along with bony erosions at the petrous apex, suggestive of acute on chronic otomastoiditis left ear. Contrast enhanced MRI showed heterogenous enhancement in middle ear and mastoid along with diffuse enhancement and thickening of the dura, suggestive of pachymeningitis. He was assessed by multispeciality team including otolaryngologist, neurophysician, radiologist and endocrinologists. Work up excluded other differential such as meningitis, tuberculosis, autoimmune disease, IgG4 diseases and vasculitis. He was thus managed as a case of acute on chronic otitis media (left ) with intracranial complication. Parentral antibiotics were initiated, and his symptoms of headache and diplopia resolved in a few days. He underwent revision cortical mastoidectomy with type I tympanoplasty left ear, with aim of surgery being to remove source of infection and to obtain representative tissue for HPE(Histopathological examination) . The HPE documented chronic nonspecific inflammatory cells with no bacterial, tubercular or fungal growth obtained. The patient recovered completely with no residual neurological deficit following six weeks of parentral antibiotics.
A 72- year- old male presented with moderate intensity headache of one month duration. The clinical examination confirmed seventh, ninth, and tenth cranial nerve paralysis. Otoscopy showed normal external auditory canal and tympanic membrane. HRCT documented dependent soft tissue attenuation contents in the middle ear and mastoid, erosions in the region of central skull base with a demonstrable collection in retropharyngeal area , overall imaging features favoring skull base osteomyelitis. Patient underwent nasal endoscopy ,retropharyngeal abscess drainage and cortical mastoidectomy under general anesthesia(GA). He was continued on parentral antibiotics and showed clinical improvement.
Case 4 to 6
We managed three cases of ear foreign bodies in children successfully in our outpatient department, taking strict preventive measures as use of a disposable gown, face shield and gloves to minimize risk of viral transmission.