Outpatient Tympanomastoidectomy

Factors Affecting Hospital Admission

Cliff A. Megerian, MD; Jackie Reily, MD;Frank M. O’Connell, MD; Stephen O. Heard, MD

Background: Outpatient tympanomastoidectomy iscommon in many medical centers. However, failure ofsame-day discharge is often the result of postoperativenausea and vomiting (PONV). Many times this leads tohospital admission after tympanomastoidectomy, and itis often difficult to predict before surgery whether PONVwill be an issue that impedes same-day discharge.

Objective: To determine the clinical factors correlatedwith the incidence of PONV requiring hospital admis-sion after chronic ear surgery by hypothesizing that thecomplexity of a particular case, as measured using a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge.

Study Design: Retrospective medical chart review of103 patients having mastoidectomy with tympano-plasty for chronic otitis media over a 2-year period.

Methods: We recorded patient age, clinical data, sur-gical times, types of agents used for induction and main-tenance of anesthesia, use of prophylactic antiemeticdrugs, types and doses of analgesic agents, and PONV.

Univariate and multivariate logistic regression analyseswere performed to determine which variables were as-sociated with PONV that required hospital admission.

Results: One third of patients studied were safely dis-charged from the hospital the day of surgery, and 92%were discharged within 23 hours. The most commoncause for observation admission to the hospital was PONV.The only variable in multivariate analysis that signifi-cantly correlated with PONV mandating hospital admis-sion after tympanomastoid surgery was a history of mo-tion sickness or PONV (odds ratio, 5.21; P=.02). Althoughseverity of disease did not correlate with length of hos-pital stay, it directly correlated with length of surgery.

Conclusions: A history of PONV or motion sickness ispredictive of PONV and length of hospital stay. Routineplanning for a 23-hour overnight observation stay seemswarranted for all patients undergoing tympanomastoid-ectomy, despite severity of disease.

Arch Otolaryngol Head Neck Surg. 2000;126:1345-1348

I N THE ERA of managed care, manyprocedures that in the past typi-cally involved an overnight hos-pital stay are being performed onan outpatient basis. This now in-

cludes tympanomastoid surgery. Despitethe complexity of surgery, same-day hos-pital discharge is frequently possible. How-ever, postoperative nausea and vomiting(PONV) is a common factor affecting pa-tients after tympanomastoidectomy forchronic otitis media and therefore con-tributes to the need for postoperative hos-pital admission.1,2 In this era of cost-containment, prevention of PONV andsubsequent hospitalization assumes greatimportance. Identification of variables thatcorrelate with PONV that necessitates ad-mission might be useful in developingstrategies to reduce the risk of PONV. Wesought to determine whether a correla-tion existed with surgical complexity, sur-

gical time, use of particular anestheticagents, intraoperative antiemetic drug ad-ministration, and a history of PONV (ormotion sickness) and the incidence ofPONV-induced hospital admission afterchronic ear surgery. We also sought to de-termine whether the complexity of a par-ticular case, as measured on a 10-pointscale, is predictive of surgical time or fail-ure of same-day hospital discharge.

RESULTS

A total of 103 consecutive tympanomas-toidectomies involving 103 separate pa-tients comprised the study group. Aver-age patient age was 34.5 years (range, 2-73years). Demographic data are detailed inTable 2. Revision surgery comprisedapproximately one third of the proce-dures, and nearly 60% of patients had chol-esteatoma.

ORIGINAL ARTICLE

From the Departments ofOtolaryngology–Head andNeck Surgery (Dr Megerian),Anesthesiology (Drs O’Connelland Heard), and Surgery(Dr Heard), UMass MemorialMedical Center and Universityof Massachusetts MedicalSchool, Worcester; and AlbertEinstein College of Medicine,New York, NY (Dr Reily).

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, NOV 2000 WWW.ARCHOTO.COM1345

©2000 American Medical Association. All rights reserved. on September 23, 2010 www.archoto.comDownloaded from

The median severity of disease score was 4 (range,1-10 [25th and 75th percentiles: 3 and 6, respectively]).The most common disease factors present were total or

near total drum perforation (90%), frequent otorrhea(81%), and granulomatous degeneration of middle earmucosa (60%). The absence of a stapes suprastructure(18%) and labyrinthine or fallopian canal dehiscence(21%) were the least frequent factors.

The average total anesthetic time was 214 minutes,and the average actual surgical time was 158 minutes.Thirty-four patients (33%) were discharged from the hos-pital the same day of surgery, and 95 patients (92%) weredischarged within the 23-hour observation window; 61patients (59%) were discharged within 23 hours and af-ter an overnight stay. Eight patients (8%) were formallyadmitted to the hospital after surgery (stay .23 hours),all for monitoring of preexisting medical conditions (heartdisease, mental retardation, pulmonary disorders, renaltransplant, etc). The most common indications for 23-hour hospital admission were PONV (65%) and after-noon surgery (19%). No other complications (wound in-fection, hematoma, or flap necrosis) were noted.

Univariate and multivariate logistic regression analy-ses were performed to determine which variables wereassociated with PONV severe enough to cause a 23-hour hospital admission. The only variable in the uni-variate analysis (Table 3) and multivariate analysis(Table 4) that was significantly associated with this

Table 1. Severity of Disease Scale*

PreoperativePerforation/tympanosclerosis resulting in expected total drum

replacementFrequent drainage (.4/y)History of previous chronic ear surgery to affected earClinical evidence of cholesteatoma (examination or computed

tomography)Age 70 y, current smoker, diabetic, immune dysfunction

IntraoperativeCholesteatoma medial to incusCanal wall-down procedureAbsent stapes superstructureLabyrinthine fistula or facial nerve involvement by cholesteatomaGranulomatous degeneration of middle ear mucosa

*Each item is 1 point, with a possible total score of 10.

Table 2. Clinical Characteristics of the Study Population

Patients, No. (%)

SexMale 54 (52)Female 49 (48)

Surgery performedCanal wall-up mastoidectomy 50 (49)Canal wall-down mastoidectomy 53 (51)

Reconstruction performedType I 44 (43)Type III 46 (45)Type IV 8 (8)Type V 1 (1)Tympanomastoid obliteration 4 (4)

Primary procedures 68 (66)Revision procedures 35 (34)Chronic otitis media with cholesteatoma 61 (59)

PATIENTS, MATERIALS,AND METHODS

Consecutive patients (n=103) with chronic otitis me-dia who underwent tympanoplasty with mastoidec-tomy between February 1, 1995, and November 30,1997, were evaluated. All procedures were per-formed by one otologic surgeon (C.A.M.) at UMassMemorial Medical Center in Worcester. Patients un-dergoing tympanoplasty without mastoid surgery orsimple mastoidectomy were excluded.

The surgical philosophy and operative techniquehave been described in detail in previous studies.3,4 A1-stage mastoidectomy with tympanoplasty was usedfor all patients. The components of a canal wall-downprocedure (primary and revision) included a postau-ricular incision, development of a Koerner flap, thor-oughexenterationofallmastoidcells(particularlythoseof the tegmen, tip, andsinoduralangle), loweringof thefacial ridge to the level of the facial nerve, canalplasty,a wide meatoplasty, and obliteration of the mastoidwith bone pate or an inferiorly based musculoperios-teal flap followed by split-thickness skin grafting andtympanoplasty. The components of a canal wall-upmastoidectomy included a postauricular incision, de-velopment of a Koerner flap, thorough exenteration ofall mastoid air cells, a posterior tympanotomy via thefacialrecess,meatoplasty,canalplasty,andsplit-thicknessskin grafting with tympanoplasty. After surgery, allpatients received a mastoid dressing without a drain.The dressing was not removed until postoperative day5 to 7, during the first outpatient visit.

A retrospective medical chart review was used tocollect clinical data about the study population, in-cluding age, sex, type of surgery and reconstruction(primary vs revision surgery), presence of cholestea-toma, length of surgery and anesthesia, types of an-esthetic agents used, use of intraoperative antiemeticdrugs, and a history of PONV or motion sickness.

A 10-point severity of disease scale was generatedthat took into account preoperative and intraoperativecharacteristics that could add to the complexity of sur-gery and surgical and anesthetic time (Table 1). Theseverityofdiseasescorewas thengenerated foreachpa-tient via a review of clinical and surgical records.

Univariate and multivariate logistic regressionanalyses were performed to determine which vari-ables were associated with PONV that required ad-mission to the hospital. To minimize the exclusion ofpotentially important variables, the P value was set at.3 for the univariate analysis. Significant independentvariables derived from the univariate process were thenincluded in the multivariate analysis, where the P valuewas set at .05. Independent variables that had morethan 2 identifiers included type of reconstruction,induction agent, inhalational agent, and severity ofdisease. For these variables with n identifiers, n−1 de-sign variables were created.5 Other data are presentedas mean±SD and were analyzed using the t test.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, NOV 2000 WWW.ARCHOTO.COM1346

©2000 American Medical Association. All rights reserved. on September 23, 2010 www.archoto.comDownloaded from

PONV was a history of previous PONVor motion sick-ness. No correlations were observed for use of nitrousoxide, time of anesthesia and surgery, extent of surgery,use of intraoperative antiemetic drugs, and PONV.

The severity of disease score correlated well withlength of surgery but not with length of hospital stay orPONV. Surgical time for patients with severity of dis-ease scores between 1 and 5 was 150.5±51.5 minutes,and surgical time for those with scores between 6 and10 was 169.2±38.4 minutes (P=.049).

COMMENT

The major finding of this study is that PONV was the prin-cipal reason for admission to a 23-hour observation unit,and a history of PONV or motion sickness was the onlyvariable that predicted PONV severe enough to requirehospital admission. In addition, it seems that the lengthor complexity of surgery is not predictive of the need forhospital admission.

The incidence of PONV in patients undergoing am-bulatory surgery is approximately 35%.6 However, for pa-tients undergoing otologic surgery, the incidence of nau-sea, vomiting, or retching can be as high as 80%.7 Moststudies that have used perioperative antiemetic drugs toreduce the high incidence of PONV in this patient popu-lation have included a diverse group of surgical proce-dures (eg, tympanoplasty, stapedectomy, ossiculo-

plasty, mastoidectomy, and tympanomastoidectomy). Theresults of these studies are difficult to extrapolate to thetympanomastoidectomy surgery population because thesepatients often need continuous suction irrigation, a ca-loric vestibular stimulant that is not often used duringother middle ear surgical procedures.

In this series, there were no cases of iatrogenic in-ner ear injury such as unexplained sensorineural hear-ing loss, labyrinthine penetration, or disruption of thestapes footplate, and preoperative bone lines were pre-served in all patients. Therefore, PONV was uniformlyascribed to a combination of anesthetic adverse effectsand the stresses on the ear during surgery, including pro-longed exposure, caloric and suction irrigation, and high-speed drilling of perilabyrinthine bone.

Of interest is the observation that the prophylacticadministration of antiemetic drugs did not seem to havean effect on the incidence of PONV necessitating hospi-tal admission. Several randomized, prospective clinicaltrials8-12 have demonstrated that prophylactic use of 5-hy-droxytryptamine-3 (5-HT3) receptor antagonists re-duces the incidence of PONV in patients undergoingmiddle ear surgery by 30% to 50%. In this study, no 5-HT3

receptor antagonists were used prophylactically, al-though other antiemetic agents were administered in-traoperatively to 44% of patients. The majority of pa-tients in our study received droperidol. Other studies10

have reported rates of 42% for PONV when droperidolis used in a preemptive fashion, a rate similar to the 50%we observed in this study. Use of prophylactic anti-emetic drugs, including 5-HT3 receptor antagonists, seemsto be ineffective in patients with a history of motion sick-ness or previous PONV. Honkavaara8 reported that pa-tients with a history of motion sickness who underwentmiddle ear surgery received no benefit from intraopera-tive administration of the 5-HT3 receptor antagonist on-dansetron hydrochloride. The whole concept of anti-emetic prophylaxis for outpatient surgery has been calledinto question recently. Scuderi et al13 found that intra-

Table 4. Multivariate Analysis*

Variable Estimate P

Odds Ratio(95% Confidence

Interval)

Age .50 y 0.44 .41 1.56 (0.53-4.56)Removal of canal wall −1.13 .21 0.32 (0.06-1.89)Type of reconstruction

III vs I −0.44 .61 0.64 (0.11-3.66)IV vs I −2.36 .05 0.09 (0.01-1.03)TMO vs I −0.13 .93 0.87 (0.04-20.40)

Induction agent(volatile agent vsthiopental)

0.76 .33 2.14 (0.46-9.89)

History of postoperativenausea and vomiting afterany procedure ormotion sickness†

1.65 .02 5.21 (1.36-19.88)

Maintenance inhalationalagent (desflurane vsisoflurane)

0.84 .20 2.31 (0.64-8.36)

*TMO indicates tympanomastoid obliteration.†P,.05.

Table 3. Univariate Analysis*

Variable Estimate P

Odds Ratio(95% Confidence

Interval)

Severity of diseasescore 0-5 vs 6-10

0.20 .63 1.22 (0.55-2.71)

Age .50 y 0.55 .23 1.73 (0.70-4.29)Sex −0.41 .31 0.66 (0.30-1.46)Presence of cholesteatoma −0.22 .59 0.80 (0.36-1.79)Removal of canal wall −0.45 .26 0.64 (0.29-1.41)History of previous

ear surgery−0.18 .66 0.84 (0.37-1.87)

Anesthetic time .200 min −0.01 .97 0.99 (0.45-2.16)Induction agent

Propofol vs thiopental −0.26 .52 0.77 (0.34-1.72)Etomidate vs thiopental −0.45 .72 0.64 (0.05-7.51)Volatile agent vs thiopental 0.74 .28 2.09 (0.54-8.06)

Use of nitrous oxide 0.02 .96 1.02 (0.44-2.36)Fentanyl dose .2 µg/kg 0.12 .83 1.12 (0.39-3.28)Use of intraoperative

antiemetic drugs−0.21 .61 0.81 (0.36-1.82)

Type of reconstructionIII vs I 0.46 .25 1.59 (0.72-3.53)IV vs I −1.24 .13 0.29 (0.06-1.47)TMO vs I 1.72 .13 5.56 (0.58-53.02)

History of postoperativenausea and vomiting ormotion sickness†

−1.38 .01 0.25 (0.09-0.74)

Maintenance inhalational agentHalothane vs isoflurane 0.53 .45 1.69 (0.42-6.86)Desflurane vs isoflurane 1.04 .06 2.83 (0.94-8.51)Sevoflurane vs isoflurane −0.87 .46 0.42 (0.04-4.29)

*TMO indicates tympanomastoid obliteration.†P,.05.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, NOV 2000 WWW.ARCHOTO.COM1347

©2000 American Medical Association. All rights reserved. on September 23, 2010 www.archoto.comDownloaded from

operative use of antiemetic agents in a diverse group ofpatients had no effect on the time to hospital discharge,rate of unplanned hospital admissions, return to normalactivity, or patient level of satisfaction with control ofPONV. These authors, however, had no instance of hos-pital admission because of intractable PONV. Whetherthese findings can be extrapolated to the patient under-going tympanomastoidectomy remains to be deter-mined. The high rate of overnight observation forpatients in this study indicates that a better method(eg, administration of 5-HT3 receptor antagonists withor without dexamethasone9) to provide prophylaxis forPONV is needed, and this could result in fewer 23-hourhospital admissions.

A substantial proportion of our patients (33%) weredischarged directly from the postanesthesia care unit. Toour knowledge, this is one of the first studies to exam-ine the potential for same-day discharge for patients un-dergoing tympanomastoidectomy. Dickins14 reviewed hiscolleagues’ 9-year experience with 1750 otologic surgi-cal procedures in inpatient and ambulatory settings. Therewere 221 tympanomastoidectomies, of which 58% were“ambulatory.” These patients were discharged from thepostanesthesia care unit to a “motel unit” on a differentfloor of the clinic. The incidence of PONV was not re-ported. No patient who was discharged from the post-anesthesia care unit had to be readmitted to the hospi-tal, an observation that indicates that selective dischargefrom the postanesthesia care unit to home is safe.

The severity of disease scale was devised to take intoconsideration preoperative and intraoperative findingsor maneuvers that could contribute to the need for pro-longed surgery or anesthetic time, including granulo-mous degeneration of the middle ear, the absence of sta-pes suprastructure requiring ossiculoplasty or type IVtympanoplasty, cholesteatoma, or a cholesteatoma cours-ing medial to the incus. We sought to determine whetherthe complexity of surgery by virtue of the severity of dis-ease scale or length of surgery could affect PONV andsubsequent admission to the hospital. This could be help-ful in surgical planning and patient counseling and in ob-taining preoperative approval for a hospital stay. Noneof the factors related to surgical complexity seemed topredict the need for hospital admission due to the pres-ence of PONV. Although the complexity of diseases char-acterized on the 10-point scale had significant correla-tion with length of surgery, length of surgery itself hadno correlation with need for hospital admission.

CONCLUSIONS

Tympanomastoid surgery can safely be performed on anoutpatient basis. Most patients (92%) can be dischargedthe day of surgery or within a 23-hour observation win-dow. However, a history of PONV or motion sickness iscorrelated with the incidence of PONV and the need for

23-hour overnight observation in patients undergoingtympanomastoidectomy. The severity of disease as mea-sured on a 10-point scale is predictive of surgical timebut not length of hospital stay or PONV. Antiemetic drugprophylaxis without 5-HT3 receptor antagonists has noeffect on the incidence of PONV requiring hospital ad-mission. Further research is required to determine whetheruse of 5-HT3 receptor antagonists can reduce PONV in acost-effective fashion in this patient population. Until thattime, patients should be counseled about the possibilityof postoperative observation admission to the hospital,especially when a history of PONV or motion sicknessis present.

Accepted for publication February 2, 2000.Reprints: Cliff A. Megerian, MD, Department of

Otolaryngology–Head and Neck Surgery, University ofMassachusetts Medical School, 55 Lake Ave N, Worcester,MA 01655 (e-mail: Megeriac@ummhc.org).

REFERENCES

1. Jellish WS, Leonetti JP, Murdoch JR, Fowles S. Propofol-based anesthesia ascompared with standard anesthetic techniques for middle ear surgery. Otolaryn-gol Head Neck Surg. 1995;112:262-267.

2. Jellish WS, Leonetti JP, Fahey K, Fury P. Comparison of 3 different anesthetictechniques on 24-hour recovery after otologic surgical procedures. OtolaryngolHead Neck Surg. 1999;120:406-411.

3. Jackson CG, Schall DG, Glasscock ME, Macias JD, Widick MH, Touma BJ. A sur-gical solution for the difficult chronic ear. Am J Otol. 1996;17:7-14.

4. Merchant SN, Wang P, Jang CH, et al. Efficacy of tympanomastoid surgery forcontrol of infection in active chronic otitis media. Laryngoscope. 1997;107:872-877.

5. Hosmer DW, Lemeshow S. Applied logistic regression. In: Barnett V, Bradley RA,Hunter JS, et al, eds. Wiley Series in Probability and Mathematical Statistics.NewYork, NY: John Wiley & Sons Inc; 1989.

6. Kovac AL, Scuderi PE, Boerner TF, et al, for the Dolasetron Mesylate PONV Treat-ment Study Group. Treatment of postoperative nausea and vomiting with singleintravenous doses of dolasetron mesylate: a multicenter trial. Anesth Analg. 1997;85:546-552.

7. Honkavaara P, Saarnivaara L, Klemola UM. Prevention of nausea and vomitingwith transdermal hyoscine in adults after middle ear surgery during general an-aesthesia. Br J Anaesth. 1994;73:763-766.

8. Honkavaara P. Effect of ondansetron on nausea and vomiting after middle earsurgery during general anaesthesia. Br J Anaesth. 1996;76:316-318.

9. Fujii Y, Toyooka H, Tanaka H. Prophylactic antiemetic therapy with a combina-tion of granisetron and dexamethasone in patients undergoing middle ear sur-gery. Br J Anaesth. 1998;81:754-756.

10. Fujii Y, Toyooka H, Tanaka H. Prophylactic anti-emetic therapy with granisetron,droperidol and metoclopramide in female patients undergoing middle ear sur-gery. Anaesthesia. 1998;53:1165-1168.

11. Fujii Y, Toyooka H, Tanaka H. Granisetron in the prevention of nausea and vom-iting after middle-ear surgery: a dose-ranging study. Br J Anaesth. 1998;80:764-766.

12. Fujii Y, Toyooka H, Tanaka H. Granisetron reduces the incidence of nausea andvomiting after middle ear surgery. Br J Anaesth. 1997;79:539-540.

13. Scuderi PE, James RL, Harris L, Mims GR. Antiemetic prophylaxis does not im-prove outcomes after outpatient surgery when compared to symptomatic treat-ment. Anesthesiology. 1999;90:360-371.

14. Dickins JR. Comparative study of otologic surgery in outpatient and hospital set-tings. Laryngoscope. 1986;96:774-785.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, NOV 2000 WWW.ARCHOTO.COM1348

©2000 American Medical Association. All rights reserved. on September 23, 2010 www.archoto.comDownloaded from