Middle Ear Surgery - Polyps

benign pedunculated growth of fibrovascular tissue that arise due to congenital predisposition or chronic inflammation

inflammatory polyp

inflammatory polpys may arise from three locations?

Lining of auditory (eustachian tube)

Nasopharynx

Middle Ear

What are the consequences of polyps arising from the middle and/or inner ear?

Mass effect of infection

Horner's syndrome

Vestibular signs

Bony infection

what is the most common signalment for inflammatory polyps?

Cats

Average 2yo

Hx of URI

Hx of OE

external ear inflammatory polyp clinical signs?

Chronic OE that is unresponsive to topicals

Head shaking

Otorrhea

Visible or palpable painful mass

nasopharyngeal inflammatory polyp clinical signs?

Nasal d/c

Stertor

Sneezing

Dysphagia

Dyspnea

Megaesophagus

Middle ear inflammatory polyp clinical signs?

Head tilt

Horners

Ataxia

Nystagmus

Circling

Facial n. paralysis

Always do a ? if you suspect an inflammatory polyp to rule out other differentials

sedated otic exam

inflammatory polyp of nasal turbinates

hamartoma

TF facial palsy is a typical clinical sign of an inflammatory polyp in the middle ear

F

most likely neoplasia/large tumor

inflammatory polyp diagnostics?

PE

Radiographs to assess bulla and nasopharynx

CT

MRI if neurologic

Otoscopy

Anesthesized oral/nasopharyngeal exam

external ear inflammatory polyp tx?

traction avulsion

steps for external ear polyp traction avulsion?

Place patient under GA

Place hemostats, allis tissue forceps or alligators across stalk

Apply constant traction and rotate

Control hemorrhage with gentle pressure for 2-5 minutes

Clean residual debris from ear

unique steps for nasopharynx polyp traction avulsion?

Place patient under GA

Ensure adequate ET tube cuff inflation

Retract soft palate rostrally with spay hook or stay sutures

Pack laryngeal region/suction afterwards to control hemorrhage

What are your options for an inflammatory polyp after traction avulsion?

Medical management

Surgery (e.g. myringotomy, VBO, TECALBO)

when is medical management indicated for a polyp after traction avulsion ?

Clean bulla on imaging

No imaging will be performed

No signs of middle ear disease

what does medical management of a polyp consist of?

Prednisolone 1mg/kg 4-6 week taper

Veraflox for 2 weeks

Topical ear medication for 2 weeks

when is surgical management indicated for a polyp after traction avulsion ?

Recurrent polyp

Clinical signs of middle ear disease

Middle ear disease detected on imaging

surgical method of choice for polyps in cats?

ventral bulla osteotomy

cats have one small ? bulla chamber and one large ? bulla chamber

dorsolateral

ventromedial

area of bulla where the sympathetic nerves cross

promontory

important anatomy within bulla to avoid during a VBO?

promontory

cochlear window

vestibular window

surgical steps of a VBO?

Place patient in dorsal recumbency with a towel under the neck

Prep left and right sides from the rostral mandible to thoracic inlet

Betadine prep

Identify landmarks

Paramedian incision

Incise into subq and platysma

Expose mandibular salivary gland and mandibular lymph nodes

Incise fascia b/w digastricus and mylohyoid muscles

Identify external carotid a., lingual a., hypoglossal n., and the bulla

Osteotomy with Steimann pin or bone drill

Suction and remove all lining, tissue, and mucus from ventromedial compartment

Osteotomy into dorsolateral compartment and repeat

Close

Submit for culture and histopath

important landmarks to identify the bulla for a VBO?

Midline

Bifurcation of jugular vein

Ramus of mandible

Larynx

indications for a TECABO in cats with polyps?

Unsuccessful VBO with recurrent disease

Concurrent severe otitis externa

complication that occurs frequently with bilateral VBOs in cats?

dyspnea/airway obstruction

TF cats almost alway lose their hearing with VBOs

F

much less than that of TECABOs

50-95% of patients have ? after VBO

horners syndrome (usually resolves but may be permanent)

recurrence rate for nasopharyngeal polyps following traction avulsion ONLY?

10-41%

recurrence rate for external ear polyps following traction avulsion ONLY?

50%

recurrence rate for polyps following traction avulsion AND VBO?

5%