Extending otology services to rural settings: Value of endoscopic ear surgery.

INTRODUCTION: Few centers, mainly located in urban settings offer otological surgical services, yet majority of patients requiring these services are rural based and are generally unable to access these centers with resulting disease chronicity and complications. This paper aims to describe the access of otological surgical services by a rural population.
METHODOLOGY: This is a retrospective study of patients who accessed otological services at three secondary health institutions and one tertiary referral institution. All patients requiring ear surgery over a 4-year period were studied. The initial 2 years without ear endoscopic surgery was compared with the 2 years when ear endoscopic surgery was introduced. Hospital records were studied and relevant data were extracted.
RESULTS: Six hundred and nine ears required surgery over 4 years. Age ranged from 3 to 62 years, with a ratio of 1.4 males: 1 female. During the initial 2 years, all patients were referred from the three secondary health institutions to the urban-based tertiary institution for microscopic ear surgery, 94% failed to proceed on the referral. In the second 2 years, 34% were considered suitable for endoscopic ear surgery, of which 78% accepted and had surgery within the locality. Of the 66% referred, only 5% proceeded on the referral.
CONCLUSION: With operator training and investment in portable ear endoscopy set, bulk of ear surgery needing magnification can be treated in the rural setting. This represents a most feasible means of extending the service to the targeted population.

Introduction

Financial constraints among other factors have led to the establishment of few centers capable of offering otology surgical services. These centers are all located in urban settings in tertiary health institutions. Majority of patients requiring these services, however, are of low socio-economic status and reside in rural Nigeria.[1] Costs and “urban intimidation” among other factors lead to poor referral uptake by this population, resulting in chronicity and development of preventable, often fatal complications. Majority of ear surgery done at the tertiary referral centers were for complications.[2] There is a need to develop a means of extending otological services into the rural setting without compromising standard care. This study aims to describe access of the rural population to otology services and propose a method for the extension of otology surgical services to this population.

Methodology

This is a retrospective study of patients who accessed otology surgical services at three secondary health institutions and one tertiary institution. All the three secondary health facilities had visiting consultant ENT surgeons visiting once weekly and had existing ENT clinics, ENT nurses, wards, and operating theater with provision for local and general anesthesia. Only patients with otologic disease requiring surgery with magnification were included in the study. The study covered 4 years, an initial 2 years prior to the introduction of oto-endoscopy (April 2010–March 2012) and the following 2 years when oto-endoscopy was available (April 2012–March 2014). An operating microscope was available only at the tertiary institution. Microsurgical ear instruments were mobile and could be accessed by all the centers.

Any patient with indication for ear surgery presenting to any of the three secondary health institutions was assessed for suitability to undergo surgery either at the secondary health institution or referred to the tertiary health facility.

Hospital records from all the four institutions were studied and information on bio data, diagnosis, referrals, and otology operations performed was retrieved. Data obtained were analyzed by simple descriptive statistics. Data obtained for the period of April 2010–March 2012 were compared with that obtained for the period of April 2012–March 2014.

Results

A total of 3008 new patients were seen in the ENT clinics of the three secondary health facilities in the 4-year period (April 2010–March 2014). About 1774 (59%) ears presented with ear disease, of which 609 ears (45%) required some form of microscopic/endoscopic surgical intervention of external auditory canal, tympanic membrane, or middle ear. Age range of patients was between 3 and 62 years. There were 315 males to 294 females (1.4:1).

Between April 2010 and March 2012, 267 ears had indications for surgical intervention of external meatus, tympanic membrane, or middle ear. None was operated at the secondary health facilities; all cases were referred to the tertiary institution. At the tertiary facility, only 15 cases (6%), of which 73% were children below 12 years reported and had microscope-assisted surgical intervention. Age range was 3–33 years, male:female (1.5:1). Complicated chronic suppurative otitis media was the main indication for referral [Table 1]. All cases had satisfactory postoperative outcome.

Table 1

Microscopic ear operations of referred cases at tertiary health institution 2010-2012

Procedure	No. of cases
Tympanomastoidectomy	8
Exploratory tympanotomy for foreign body retrieval	5
Myringotomy + grommet insertion	2
Total	15

During the period of April 2012–March 2014, 342 ears had indication for surgical intervention. One hundred and seventeen (34%) were considered suitable for endoscopic surgical intervention, of which 92 (26%) had endoscopic ± open operation [Table 2]. Two hundred and twenty-five ears (66%) were referred, of which 18 (5%) presented to the tertiary institution for microscope-assisted ear surgery. Age range was 3–28 years with children below 12 years constituting 61%, with male:female ratio of 1:1.25. Hearing loss from otitis media with effusion and complicated chronic otitis media were the most common indications for referral [Table 3]. All cases had satisfactory postoperative outcome.

Table 2

Endoscopic procedures at 3 secondary health institutions 2012-2014

Endoscopic procedures	No. of cases
Tympanoplasty	29
Transcanal ± postauricular endoscopic assisted tympanomastoidectomy	19
Endoscopic aural biopsy/Polypectomy	17
Exploratory tympanotomy for foreign body retrieval, traumatic facial nerve palsy, others	14
Myringotomy + grommet insertion	12
External auditory meatal exostosis	1
Total	92

Table 3

Microscopic ear operations of referred cases at tertiary health institution 2012-2014

Procedure	No. of cases
Myringotomy + gommet insertion	8
Tympanomastoidectomy	5
Tympanoplasty	4
Exploratory tympanotomy for foreign body retrieval	1
Total	18

Discussion

Ear disease was found to be the most common reason for attendance at the ENT outpatient clinics accounting for nearly 60% of ENT clinic attendance in the rural population studied, this has similarly been reported by other researchers.[234] Most patients in the study were noted to be from the lower socio-economic class, this has similarly been reported by other studies.[56]

This study found that 45% of patients with ear disease in the rural setting required some form of surgical intervention. Main indications included repair of a perforated tympanic membrane, myringotomy and grommet insertion, ossiculoplasty, cholesteatoma surgery, and exploration of the middle ear. This high number may be a reflection of lack of early access to health-care facilities and complications from chronicity of ear disease.

During the initial period covered by this study, there was neither operating microscope nor ear microsurgical instruments in any of the secondary institutions, and all cases were referred to the tertiary institution. However, a very poor referral uptake was noted as only 6% of cases referred presented to and had intervention at the tertiary institution. Reasons for this were multiple including costs, deliberate refusal, sociocultural factors, and logistic problems, with costs being a constant feature. Adoga et al. observed that the cost of management of ear disease in Nigeria was much higher than Nigeria's monthly minimum wage.[7] Studies elsewhere found an average of 25% nonattendance at hospital-based otolaryngology clinic with reasons being timing of appointment, waiting time, and part-time visiting doctors rather than full-time doctors.[89] Nonattendance was not found to be related to the nature, severity, or duration of the disease, and resolution of symptoms was also not a reason.[10]

In the second half of the period under study, oto-endoscopy was available for use at all the three secondary institutions. In the absence of the operating microscope, the endoscope was used for suitable cases requiring operation. Two-thirds of the patients were referred, but about one-third were considered suitable for endoscopic approach, and of these, 78% of them readily accepted and underwent the surgery within their locality at a much lower cost compared to the neighboring referral tertiary institution. From this, it can be deduced that the prospect or anxiety over the type of ear surgical operation by itself was not a significant factor in deciding to accept surgery or referral by this population. With improved surgeon expertise and skill, it is expected that the percentage of referrals will be reduced as more cases are treated at the peripheral setting.

Overall, referral uptake was very poor and it was unlikely that the illness of these patients resolved spontaneously or that they presented elsewhere because the closest tertiary institution they were referred to, also happened to be the cheapest in terms of costs. Measures such as use of reminders by text messages to patient's phones that have improved clinic attendance elsewhere could be exploited, but may not be practical in this setting.[1112] Majority of the cases that proceeded on referral to the tertiary institution were children and they presented with complications of chronic suppurative otitis media, alarming hearing loss from otitis media with effusion, and complicated failed ear foreign body extraction, only 3% presented as “cold cases” for tympanoplasty. Earlier studies have shown that complicated chronic otitis media was the most common indication for micro ear surgery in developing counties.[24] Overall, 67% of those who proceeded on referral were children, understandably from parental concerns, however the referral uptake by the adult population, especially the elderly was particularly poor.

There is a need to develop a means of providing this important health service to the rural populace. Findings from this study have shown that a practical approach to achieving this is through the utilization of endoscopic ear surgery. Due to the ease of mobility of surgical equipment required for endoscopic ear surgery compared to the operating microscope, the otology surgical service could be more readily delivered to this population.

In a cross-sectional study of Canadian otolaryngologist regarding endoscopic ear surgery, Yong et al. found that 70% of practitioners use the endoscope in their practice and 81% believed that endoscopy have a role to play in future ear surgery.[13] Tarabichi also concluded that endoscopy holds the greatest promise in tympanoplasty and cholesteatoma surgery.[14] Endoscopic ear surgery is gaining momentum as an alternative to the traditional microscope ear surgery. Major advantages of the endoscopic technique include complete view of the tympanic membrane, posterior retraction pockets, facial recess and hypotympanum, and the major disadvantages include one-handed technique and the need for specialized training.[14] In this study, the major difficulty arising from the one-handed technique was in the placement of graft or grommet, which increased operating time, but with more practice, this gradually improved.

The greatest application of endoscopic ear surgery in practice is in tympanoplasty and cholesteatoma surgery, and these happen to constitute bulk of ear surgery. When compared with the traditional microscope surgery, Dündar et al. and Nassif et al. separately reported significantly lower operating time when endoscopy was used.[1516] With the endoscopy group, hospital stay was found to be shorter and graft take success rate was slightly better.[16] While some have reported better improvements in the postoperative air bone gap (ABG) in the endoscopy group, others found no significant difference in the postoperative ABG in the two groups.[151718] Compared to the microscope technique, the endoscopic technique was found to be more conservative, better at disease clearance while preserving the ossicular integrity resulting in less morbidity and fewer complications.[1719202122] In this study, the major intraoperative complications encountered were bleeding while raising the tympanomeatal flap, control of which increases the operating time. In addition, instances of damage to tympanomeatal flap occurred, when bone drilling became necessary, this tended to occur less frequently with more practice.

Most pediatric endoscopic surgeries in this study were for myringotomy and grommet insertion, these were usually straight-forward cases with no difficulties except for longer operating time and in the few cases bleeding was encountered or placement of grommet proved difficult. However, endoscopic ear surgery has been applied successfully in the pediatric population with encouraging results for tympanoplasty and cholesteatoma surgery.[15222324] Although in this study, due to operator-limited experience, endoscopy was limited to biopsy/polypectomy for suspected neoplasia, and a case of external auditory canal exostosis was successfully excised using a conventional mastoid drill after elevation of meatal flap, the technique has, however, been applied with success in carefully chosen cases for benign middle ear neoplasms and excision of cochlear schwannoma.[2526] Exploration for middle ear neoplasms was also carried out successfully in 14 cases in this study for varied indications including foreign body retrievals and two cases of post-traumatic tympanomastoid facial nerve decompression. This technique can potentially be applied for the exploration of tympanomastoid segments of the facial nerve, and when combined with the microscope, the lateral skull base could be approached for petrous apex lesions.[2728] The technique of endoscopic ear surgery has also been applied exclusively in cochlear implants.[2930] Because of this potentially wide applicability of endoscopic ear surgical technique, there has been a call by the proponents of this technique for otology surgeons to master it in addition to the traditional microscope technique.

Conclusion

With operator training and modest investment in portable ear endoscopy set, the bulk of ear diseases could be treated in the rural setting by endoscopic ear surgery. This represents a feasible means of extending modern otological surgical services to a rural populace that is unwilling to access urban-based health centers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.