Clin. Orolaryngol. 1992, 17, 567 -568
RAPID COMMUNICATION
Myringoplasty under local anaesthesia: day case surgery H.S.KADDOUR ENT Department, St James’s University Hospital, Beckett Street, Leeds LS9 7TF. U K Accepted for publication 16 July 1992 KADDOUR H . S .
(1992) Clin. Otolaryngol. 17, 567-568
Myringoplasty under local anaesthesia: day case surgery Eleven patients underwent fat graft myringoplasty, using EMLA cream local anaesthetic, as day cases, 10 of them were followed up, and 3 months post-operatively, 8/10 (80%) of the perforations were completely closed, with an average improvement of the hearing threshold of 11 dB. All the patients were satisfied with the procedure and it is concluded that fat graft myringoplasty under local anaesthesia as a day case is safe, simple, reliable and cost effective. It should be considered for closure of small perforations (30% or less) of the tympanic membrane. Keywords
myringoplasty local anaesthesia day surgery
Recent reforms of the National Health Service, with financial constraints, have stimulated surgeons to perform more day case surgery. Apart from the cost implications, there are advantages to the patients of a shorter hospital stay, decreased risk of cross-infection, more convenience, above all, shorter waiting time for surgery. Local anaesthesia offers further benefits in terms of reduced post-operative morbidity and speedier recovery. Consequently, patient satisfaction is increased, provided that the procedure undertaken is not painful. Day surgery would also allow hospitals to cut down their waiting lists, treat more patients and use their resources more efficiently. Fat graft myringoplasty has been performed in our unit for many years and it is felt desirable to assess its suitability as a day case local anaesthetic procedure.
Method PATIENTS
Eleven patients on the waiting list for myringoplasty were entered into the study. They were admitted into the hospital as day cases. There were 8 men and 3 women, their ages ranging from 15 to 51 years (mean 32 years). A11 the patients had dry central perforations, 30% or less in size, of the tympanic membrane.
ANAESTHESIA
All patients were given a single oral dose of 10-20 mg temazepam I h preoperatively. The ear canal was packed with ribbon gauze impregnated with EMLA cream. This was performed using the operating microscope to ensure that the anaesthetic cream was in contact with the tympanic membrane, and the pack was left in situ for at least 1 h.
OPERATIVE TECHNIQUE
After removal of the pack and aspiration of any residual cream, the perforation edges were excised to encourage migration of the mucosal layer and epithelium across the graft. Fat was harvested from the ear lobe (2% lignocaine plus 1 : 200 000 adrenaline infiltration anaesthesia was used). The fat graft was trimmed to size and inserted through the perforation as a ‘plug’ on a gelfoam bed. Small pieces of gelfoam were laid over the graft and the ear canal packed with BIPP gauze.
POST-OPERATIVE FOLLOW-UP
Before leaving the hospital, a few hours after the procedure, the patients were asked to grade the effectiveness of the local anaesthesia on a subjective scale of 1-4, a grading of 1 being
567
568
H.S.Kaddour
painless, 2 slight discomfort, 3 moderate discomfort, and 4 severe discomfort. The patients werc seen 3 weeks later, when the ear dressings were removed. They were then reviewed at 6 and 12 weeks post-operatively. All the patients had a preoperative pure tone audiogram and these were repeated 3 months post-operatively.
Results ANAESTHESIA
All the patients tolcrated the procedure very well. 5 patients (45%) felt the procedure was completely painless (grade I), and 6 (55%) slightly uncomfortable (grade 2). None of the patients experienced moderate or severe discomfort (grades 3 and 4). None of the patients asked for post-operative analgesia or felt any nausea or dizziness. All the patients were discharged a few hours later, and were satisfied with their procedure. SURGERY
One patient failed to attend for post-operative follow-up. At 3 months, 8/10 perforations were completely closed (80%), 1/10 was partially closed (lo%), and 1/10 was of the same size (IOYO). The preoperative air conduction threshold (averaged over 0.5, I , 2 and 4 kHz) was 28 dB for the group, and postoperatively was reduced to 17 dB, an improvement in the hearing threshold of 11 db. There was no single case of sensorineural loss or of post-operative tinnitus.
Discussion EMLA cream, a eutectic mixture of lignocaine and prilocainc, has been used as topical anaesthetic for alleviating pain associated with venepuncture,’ minor otological procedures such as myringotomy,2 and manipulation of the fractured nose.’ The manufacturers rccommcnd that the cream does not come into contact with mucosal surfaces since systemic absorption can be rapid. Application to the perforated tympanic membrane, therefore, should be accurate and preferably with the operating microscope. Preoperative explanation of the procedure and description of the surgical steps during the procedure was effective in allaying any anxiety. None of the patients complained of post-operative pain or asked for analgesia. All of them described the procedure as either painless or slight discomfort (grades 1 and 2). The 80% success rate of complete closure of tympanic
membrane perforations, 3 months post-operatively, compares favourably with the 76% success rate of a previous study of fat graft in the same unit! Gibb5 estimated the success rate for fat and other miscellaneous graft materials as 82% compared with 88% for temporalis fascia. Although an 80% success rate is inadequate to recommend fat graft myringoplasty for routine use, it has many advantages. It is a simple, safe, fast and reliable procedure, even in the hands o f a relatively inexperienced surgeon. It is particularly suitable for small perforations (30% or less in size of the tympanic membrane). Fat is easily harvested from the ear lobe with less morbidity than a temporalis fascia graft. Day case surgery has tremendous economic and financial benefits. It has been estimated that twice as many patients could be treated for the same cost if their operations were carried out as day cases under general anaesthesia.6 The 1990 Audit Commission Report,’ estimated an extra 186 000 patients could be treated in England and Wales every year, at no additional cost, if all District Health Authorities used day case facilities to the extent of the 25% that use it most. The effect on cutting the waiting list is quite obvious. There are additional advantages in terms of patient convenience; patients are treated sooner and spend less time away from home. It is therefore not a surprise that all the patients were satisfied with the procedure being done under local anaesthesia as a day case and that they would recommend it to a friend in a similar situation.
Acknowledgements I would like to thank M r A.G.Gandhi and Mr I.D.Fraser, Consultant ENT Surgeons at St James’s University Hospital in Leeds, for allowing me to operate on their patients.
References I HAILENB., CARLESSON P. & UPPFELDT A. (1985) A clinical study of lignocaine-prilocaine cream to relieve the pain of venepuncture. Br. J. Anoesrh. 57, 326 B. & HAWTHORNE M. (1988) The use of anaesthetic 2 BINGHAM EMLA cream in minor otological surgery. J. Laryngol. Otol. 102, 571 3 EL-KHOLYA. (1989) Manipulation of the fractured nose using topical anaesthesia. J . Laryngol. Orol. 103, 580- 58 1 4 TERRY R.M., BELLINI M.J., CLAYTON M.I. & GANDHI A.G. (1988) Fat graft myringoplasty -a prospective trial. Clinic. Orolaryngol. 13, 227-229 5 GIBBA.G. & CHANGS.K. (1982) Myringoplasty (a review of 365 operations). J. Laryngol. Otol96, 91 5- 930 6 BUCKLEY J.G., MITCHELL D.B., HICKEYS.A. & FITZGERALD O’CONNOR A.F. (1991) Submucous resection of the nasal septum as an outpatient procedure. J . Laryngol. Orol. 105, 544-546 7 AUDITCOMMISSION (1990) A short cut to better services- Day surgery in England and Wales. Ann. Royul. Col. Surg. 72(Suppl.)
RAPID COMMUNICATION
Myringoplasty under local anaesthesia: day case surgery H.S.KADDOUR ENT Department, St James’s University Hospital, Beckett Street, Leeds LS9 7TF. U K Accepted for publication 16 July 1992 KADDOUR H . S .
(1992) Clin. Otolaryngol. 17, 567-568
Myringoplasty under local anaesthesia: day case surgery Eleven patients underwent fat graft myringoplasty, using EMLA cream local anaesthetic, as day cases, 10 of them were followed up, and 3 months post-operatively, 8/10 (80%) of the perforations were completely closed, with an average improvement of the hearing threshold of 11 dB. All the patients were satisfied with the procedure and it is concluded that fat graft myringoplasty under local anaesthesia as a day case is safe, simple, reliable and cost effective. It should be considered for closure of small perforations (30% or less) of the tympanic membrane. Keywords
myringoplasty local anaesthesia day surgery
Recent reforms of the National Health Service, with financial constraints, have stimulated surgeons to perform more day case surgery. Apart from the cost implications, there are advantages to the patients of a shorter hospital stay, decreased risk of cross-infection, more convenience, above all, shorter waiting time for surgery. Local anaesthesia offers further benefits in terms of reduced post-operative morbidity and speedier recovery. Consequently, patient satisfaction is increased, provided that the procedure undertaken is not painful. Day surgery would also allow hospitals to cut down their waiting lists, treat more patients and use their resources more efficiently. Fat graft myringoplasty has been performed in our unit for many years and it is felt desirable to assess its suitability as a day case local anaesthetic procedure.
Method PATIENTS
Eleven patients on the waiting list for myringoplasty were entered into the study. They were admitted into the hospital as day cases. There were 8 men and 3 women, their ages ranging from 15 to 51 years (mean 32 years). A11 the patients had dry central perforations, 30% or less in size, of the tympanic membrane.
ANAESTHESIA
All patients were given a single oral dose of 10-20 mg temazepam I h preoperatively. The ear canal was packed with ribbon gauze impregnated with EMLA cream. This was performed using the operating microscope to ensure that the anaesthetic cream was in contact with the tympanic membrane, and the pack was left in situ for at least 1 h.
OPERATIVE TECHNIQUE
After removal of the pack and aspiration of any residual cream, the perforation edges were excised to encourage migration of the mucosal layer and epithelium across the graft. Fat was harvested from the ear lobe (2% lignocaine plus 1 : 200 000 adrenaline infiltration anaesthesia was used). The fat graft was trimmed to size and inserted through the perforation as a ‘plug’ on a gelfoam bed. Small pieces of gelfoam were laid over the graft and the ear canal packed with BIPP gauze.
POST-OPERATIVE FOLLOW-UP
Before leaving the hospital, a few hours after the procedure, the patients were asked to grade the effectiveness of the local anaesthesia on a subjective scale of 1-4, a grading of 1 being
567
568
H.S.Kaddour
painless, 2 slight discomfort, 3 moderate discomfort, and 4 severe discomfort. The patients werc seen 3 weeks later, when the ear dressings were removed. They were then reviewed at 6 and 12 weeks post-operatively. All the patients had a preoperative pure tone audiogram and these were repeated 3 months post-operatively.
Results ANAESTHESIA
All the patients tolcrated the procedure very well. 5 patients (45%) felt the procedure was completely painless (grade I), and 6 (55%) slightly uncomfortable (grade 2). None of the patients experienced moderate or severe discomfort (grades 3 and 4). None of the patients asked for post-operative analgesia or felt any nausea or dizziness. All the patients were discharged a few hours later, and were satisfied with their procedure. SURGERY
One patient failed to attend for post-operative follow-up. At 3 months, 8/10 perforations were completely closed (80%), 1/10 was partially closed (lo%), and 1/10 was of the same size (IOYO). The preoperative air conduction threshold (averaged over 0.5, I , 2 and 4 kHz) was 28 dB for the group, and postoperatively was reduced to 17 dB, an improvement in the hearing threshold of 11 db. There was no single case of sensorineural loss or of post-operative tinnitus.
Discussion EMLA cream, a eutectic mixture of lignocaine and prilocainc, has been used as topical anaesthetic for alleviating pain associated with venepuncture,’ minor otological procedures such as myringotomy,2 and manipulation of the fractured nose.’ The manufacturers rccommcnd that the cream does not come into contact with mucosal surfaces since systemic absorption can be rapid. Application to the perforated tympanic membrane, therefore, should be accurate and preferably with the operating microscope. Preoperative explanation of the procedure and description of the surgical steps during the procedure was effective in allaying any anxiety. None of the patients complained of post-operative pain or asked for analgesia. All of them described the procedure as either painless or slight discomfort (grades 1 and 2). The 80% success rate of complete closure of tympanic
membrane perforations, 3 months post-operatively, compares favourably with the 76% success rate of a previous study of fat graft in the same unit! Gibb5 estimated the success rate for fat and other miscellaneous graft materials as 82% compared with 88% for temporalis fascia. Although an 80% success rate is inadequate to recommend fat graft myringoplasty for routine use, it has many advantages. It is a simple, safe, fast and reliable procedure, even in the hands o f a relatively inexperienced surgeon. It is particularly suitable for small perforations (30% or less in size of the tympanic membrane). Fat is easily harvested from the ear lobe with less morbidity than a temporalis fascia graft. Day case surgery has tremendous economic and financial benefits. It has been estimated that twice as many patients could be treated for the same cost if their operations were carried out as day cases under general anaesthesia.6 The 1990 Audit Commission Report,’ estimated an extra 186 000 patients could be treated in England and Wales every year, at no additional cost, if all District Health Authorities used day case facilities to the extent of the 25% that use it most. The effect on cutting the waiting list is quite obvious. There are additional advantages in terms of patient convenience; patients are treated sooner and spend less time away from home. It is therefore not a surprise that all the patients were satisfied with the procedure being done under local anaesthesia as a day case and that they would recommend it to a friend in a similar situation.
Acknowledgements I would like to thank M r A.G.Gandhi and Mr I.D.Fraser, Consultant ENT Surgeons at St James’s University Hospital in Leeds, for allowing me to operate on their patients.
References I HAILENB., CARLESSON P. & UPPFELDT A. (1985) A clinical study of lignocaine-prilocaine cream to relieve the pain of venepuncture. Br. J. Anoesrh. 57, 326 B. & HAWTHORNE M. (1988) The use of anaesthetic 2 BINGHAM EMLA cream in minor otological surgery. J. Laryngol. Otol. 102, 571 3 EL-KHOLYA. (1989) Manipulation of the fractured nose using topical anaesthesia. J . Laryngol. Orol. 103, 580- 58 1 4 TERRY R.M., BELLINI M.J., CLAYTON M.I. & GANDHI A.G. (1988) Fat graft myringoplasty -a prospective trial. Clinic. Orolaryngol. 13, 227-229 5 GIBBA.G. & CHANGS.K. (1982) Myringoplasty (a review of 365 operations). J. Laryngol. Otol96, 91 5- 930 6 BUCKLEY J.G., MITCHELL D.B., HICKEYS.A. & FITZGERALD O’CONNOR A.F. (1991) Submucous resection of the nasal septum as an outpatient procedure. J . Laryngol. Orol. 105, 544-546 7 AUDITCOMMISSION (1990) A short cut to better services- Day surgery in England and Wales. Ann. Royul. Col. Surg. 72(Suppl.)
