ORIGINAL ARTICLE

Outpatient Tympanomastoidectomy
Factors Affecting Hospital Admission
Cliff A. Megerian, MD; Jackie Reily, MD; Frank M. OConnell, MD; Stephen O. Heard, MD

Background: Outpatient tympanomastoidectomy is common in many medical centers. However, failure of same-day discharge is often the result of postoperative nausea and vomiting (PONV). Many times this leads to hospital admission after tympanomastoidectomy, and it is often difficult to predict before surgery whether PONV will be an issue that impedes same-day discharge. Objective: To determine the clinical factors correlated with the incidence of PONV requiring hospital admission after chronic ear surgery by hypothesizing that the complexity of a particular case, as measured using a 10point scale, is predictive of surgical time or failure of sameday hospital discharge. Study Design: Retrospective medical chart review of

Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required hospital admission.
Results: One third of patients studied were safely discharged from the hospital the day of surgery, and 92% were discharged within 23 hours. The most common cause for observation admission to the hospital was PONV. The only variable in multivariate analysis that significantly correlated with PONV mandating hospital admission after tympanomastoid surgery was a history of motion sickness or PONV (odds ratio, 5.21; P=.02). Although severity of disease did not correlate with length of hospital stay, it directly correlated with length of surgery. Conclusions: A history of PONV or motion sickness is

103 patients having mastoidectomy with tympanoplasty for chronic otitis media over a 2-year period.
Methods: We recorded patient age, clinical data, surgical times, types of agents used for induction and maintenance of anesthesia, use of prophylactic antiemetic drugs, types and doses of analgesic agents, and PONV.

predictive of PONV and length of hospital stay. Routine planning for a 23-hour overnight observation stay seems warranted for all patients undergoing tympanomastoidectomy, despite severity of disease. Arch Otolaryngol Head Neck Surg. 2000;126:1345-1348 gical time, use of particular anesthetic agents, intraoperative antiemetic drug administration, and a history of PONV (or motion sickness) and the incidence of PONV-induced hospital admission after chronic ear surgery. We also sought to determine whether the complexity of a particular case, as measured on a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge.
RESULTS

I
From the Departments of OtolaryngologyHead and Neck Surgery (Dr Megerian), Anesthesiology (Drs OConnell and Heard), and Surgery (Dr Heard), UMass Memorial Medical Center and University of Massachusetts Medical School, Worcester; and Albert Einstein College of Medicine, New York, NY (Dr Reily).

N THE ERA of managed care, many

procedures that in the past typically involved an overnight hospital stay are being performed on an outpatient basis. This now includes tympanomastoid surgery. Despite the complexity of surgery, same-day hospital discharge is frequently possible. However, postoperative nausea and vomiting (PONV) is a common factor affecting patients after tympanomastoidectomy for chronic otitis media and therefore contributes to the need for postoperative hospital admission. 1,2 In this era of costcontainment, prevention of PONV and subsequent hospitalization assumes great importance. Identification of variables that correlate with PONV that necessitates admission might be useful in developing strategies to reduce the risk of PONV. We sought to determine whether a correlation existed with surgical complexity, sur-

A total of 103 consecutive tympanomastoidectomies involving 103 separate patients comprised the study group. Average patient age was 34.5 years (range, 2-73 years). Demographic data are detailed in Table 2. Revision surgery comprised approximately one third of the procedures, and nearly 60% of patients had cholesteatoma.
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Table 1. Severity of Disease Scale*

PATIENTS, MATERIALS, AND METHODS

Consecutive patients (n=103) with chronic otitis media who underwent tympanoplasty with mastoidectomy between February 1, 1995, and November 30, 1997, were evaluated. All procedures were performed by one otologic surgeon (C.A.M.) at UMass Memorial Medical Center in Worcester. Patients undergoing tympanoplasty without mastoid surgery or simple mastoidectomy were excluded. The surgical philosophy and operative technique have been described in detail in previous studies.3,4 A 1-stage mastoidectomy with tympanoplasty was used for all patients. The components of a canal wall-down procedure (primary and revision) included a postauricular incision, development of a Koerner flap, thorough exenteration of all mastoid cells (particularly those of the tegmen, tip, and sinodural angle), lowering of the facial ridge to the level of the facial nerve, canalplasty, a wide meatoplasty, and obliteration of the mastoid with bone pate or an inferiorly based musculoperiosteal flap followed by split-thickness skin grafting and tympanoplasty. The components of a canal wall-up mastoidectomy included a postauricular incision, development of a Koerner flap, thorough exenteration of all mastoid air cells, a posterior tympanotomy via the facialrecess,meatoplasty,canalplasty,andsplit-thickness skin grafting with tympanoplasty. After surgery, all patients received a mastoid dressing without a drain. The dressing was not removed until postoperative day 5 to 7, during the first outpatient visit. A retrospective medical chart review was used to collect clinical data about the study population, including age, sex, type of surgery and reconstruction (primary vs revision surgery), presence of cholesteatoma, length of surgery and anesthesia, types of anesthetic agents used, use of intraoperative antiemetic drugs, and a history of PONV or motion sickness. A 10-point severity of disease scale was generated that took into account preoperative and intraoperative characteristics that could add to the complexity of surgery and surgical and anesthetic time (Table 1). The severity of disease score was then generated for each patient via a review of clinical and surgical records. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required admission to the hospital. To minimize the exclusion of potentially important variables, the P value was set at .3 for the univariate analysis. Significant independent variables derived from the univariate process were then included in the multivariate analysis, where the P value was set at .05. Independent variables that had more than 2 identifiers included type of reconstruction, induction agent, inhalational agent, and severity of disease. For these variables with n identifiers, n1 design variables were created.5 Other data are presented as meanSD and were analyzed using the t test.

Preoperative Perforation/tympanosclerosis resulting in expected total drum replacement Frequent drainage ( 4/y) History of previous chronic ear surgery to affected ear Clinical evidence of cholesteatoma (examination or computed tomography) Age 70 y, current smoker, diabetic, immune dysfunction Intraoperative Cholesteatoma medial to incus Canal wall-down procedure Absent stapes superstructure Labyrinthine fistula or facial nerve involvement by cholesteatoma Granulomatous 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. (%) Sex Male Female Surgery performed Canal wall-up mastoidectomy Canal wall-down mastoidectomy Reconstruction performed Type I Type III Type IV Type V Tympanomastoid obliteration Primary procedures Revision procedures Chronic otitis media with cholesteatoma 54 (52) 49 (48) 50 (49) 53 (51) 44 (43) 46 (45) 8 (8) 1 (1) 4 (4) 68 (66) 35 (34) 61 (59)

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 ear mucosa (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 hospital the same day of surgery, and 95 patients (92%) were discharged within the 23-hour observation window; 61 patients (59%) were discharged within 23 hours and after an overnight stay. Eight patients (8%) were formally admitted to the hospital after surgery (stay 23 hours), all for monitoring of preexisting medical conditions (heart disease, mental retardation, pulmonary disorders, renal transplant, etc). The most common indications for 23hour hospital admission were PONV (65%) and afternoon surgery (19%). No other complications (wound infection, hematoma, or flap necrosis) were noted. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV severe enough to cause a 23hour hospital admission. The only variable in the univariate analysis (Table 3) and multivariate analysis (Table 4) that was significantly associated with this
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Table 3. Univariate Analysis*

Odds Ratio (95% Confidence Interval) 1.22 (0.55-2.71) 1.73 (0.70-4.29) 0.66 (0.30-1.46) 0.80 (0.36-1.79) 0.64 (0.29-1.41) 0.84 (0.37-1.87) 0.99 (0.45-2.16) 0.77 (0.34-1.72) 0.64 (0.05-7.51) 2.09 (0.54-8.06) 1.02 (0.44-2.36) 1.12 (0.39-3.28) 0.81 (0.36-1.82)

Table 4. Multivariate Analysis*

Odds Ratio (95% Confidence Interval) 1.56 (0.53-4.56) 0.32 (0.06-1.89) 0.64 (0.11-3.66) 0.09 (0.01-1.03) 0.87 (0.04-20.40) 2.14 (0.46-9.89)

Variable Severity of disease score 0-5 vs 6-10 Age 50 y Sex Presence of cholesteatoma Removal of canal wall History of previous ear surgery Anesthetic time 200 min Induction agent Propofol vs thiopental Etomidate vs thiopental Volatile agent vs thiopental Use of nitrous oxide Fentanyl dose 2 g/kg Use of intraoperative antiemetic drugs Type of reconstruction III vs I IV vs I TMO vs I History of postoperative nausea and vomiting or motion sickness Maintenance inhalational agent Halothane vs isoflurane Desflurane vs isoflurane Sevoflurane vs isoflurane

Estimate 0.20 0.55 0.41 0.22 0.45 0.18 0.01 0.26 0.45 0.74 0.02 0.12 0.21

P
.63 .23 .31 .59 .26 .66 .97 .52 .72 .28 .96 .83 .61

Variable Age 50 y Removal of canal wall Type of reconstruction III vs I IV vs I TMO vs I Induction agent (volatile agent vs thiopental) History of postoperative nausea and vomiting after any procedure or motion sickness Maintenance inhalational agent (desflurane vs isoflurane)

Estimate 0.44 1.13 0.44 2.36 0.13 0.76

P
.41 .21 .61 .05 .93 .33

1.65

.02

5.21 (1.36-19.88)

0.84

.20

2.31 (0.64-8.36)

0.46 1.24 1.72 1.38

.25 .13 .13 .01

1.59 (0.72-3.53) 0.29 (0.06-1.47) 5.56 (0.58-53.02) 0.25 (0.09-0.74)

*TMO indicates tympanomastoid obliteration. P .05.

0.53 1.04 0.87

.45 .06 .46

1.69 (0.42-6.86) 2.83 (0.94-8.51) 0.42 (0.04-4.29)

*TMO indicates tympanomastoid obliteration. P .05.

PONV was a history of previous PONVor motion sickness. No correlations were observed for use of nitrous oxide, time of anesthesia and surgery, extent of surgery, use of intraoperative antiemetic drugs, and PONV. The severity of disease score correlated well with length of surgery but not with length of hospital stay or PONV. Surgical time for patients with severity of disease scores between 1 and 5 was 150.5 51.5 minutes, and surgical time for those with scores between 6 and 10 was 169.238.4 minutes (P = .049).
COMMENT

The major finding of this study is that PONV was the principal reason for admission to a 23-hour observation unit, and a history of PONV or motion sickness was the only variable that predicted PONV severe enough to require hospital admission. In addition, it seems that the length or complexity of surgery is not predictive of the need for hospital admission. The incidence of PONV in patients undergoing ambulatory surgery is approximately 35%.6 However, for patients undergoing otologic surgery, the incidence of nausea, vomiting, or retching can be as high as 80%.7 Most studies that have used perioperative antiemetic drugs to reduce the high incidence of PONV in this patient population have included a diverse group of surgical procedures (eg, tympanoplasty, stapedectomy, ossiculo-

plasty, mastoidectomy, and tympanomastoidectomy). The results of these studies are difficult to extrapolate to the tympanomastoidectomy surgery population because these patients often need continuous suction irrigation, a caloric vestibular stimulant that is not often used during other middle ear surgical procedures. In this series, there were no cases of iatrogenic inner ear injury such as unexplained sensorineural hearing loss, labyrinthine penetration, or disruption of the stapes footplate, and preoperative bone lines were preserved in all patients. Therefore, PONV was uniformly ascribed to a combination of anesthetic adverse effects and the stresses on the ear during surgery, including prolonged exposure, caloric and suction irrigation, and highspeed drilling of perilabyrinthine bone. Of interest is the observation that the prophylactic administration of antiemetic drugs did not seem to have an effect on the incidence of PONV necessitating hospital admission. Several randomized, prospective clinical trials8-12 have demonstrated that prophylactic use of 5-hydroxytryptamine-3 (5-HT3) receptor antagonists reduces the incidence of PONV in patients undergoing middle ear surgery by 30% to 50%. In this study, no 5-HT3 receptor antagonists were used prophylactically, although other antiemetic agents were administered intraoperatively to 44% of patients. The majority of patients in our study received droperidol. Other studies10 have reported rates of 42% for PONV when droperidol is used in a preemptive fashion, a rate similar to the 50% we observed in this study. Use of prophylactic antiemetic drugs, including 5-HT3 receptor antagonists, seems to be ineffective in patients with a history of motion sickness or previous PONV. Honkavaara8 reported that patients with a history of motion sickness who underwent middle ear surgery received no benefit from intraoperative administration of the 5-HT3 receptor antagonist ondansetron hydrochloride. The whole concept of antiemetic prophylaxis for outpatient surgery has been called into question recently. Scuderi et al13 found that intraWWW.ARCHOTO.COM

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operative use of antiemetic agents in a diverse group of patients had no effect on the time to hospital discharge, rate of unplanned hospital admissions, return to normal activity, or patient level of satisfaction with control of PONV. These authors, however, had no instance of hospital admission because of intractable PONV. Whether these findings can be extrapolated to the patient undergoing tympanomastoidectomy remains to be determined. The high rate of overnight observation for patients in this study indicates that a better method (eg, administration of 5-HT3 receptor antagonists with or without dexamethasone9) to provide prophylaxis for PONV is needed, and this could result in fewer 23-hour hospital admissions. A substantial proportion of our patients (33%) were discharged directly from the postanesthesia care unit. To our knowledge, this is one of the first studies to examine the potential for same-day discharge for patients undergoing tympanomastoidectomy. Dickins14 reviewed his colleagues 9-year experience with 1750 otologic surgical procedures in inpatient and ambulatory settings. There were 221 tympanomastoidectomies, of which 58% were ambulatory. These patients were discharged from the postanesthesia care unit to a motel unit on a different floor of the clinic. The incidence of PONV was not reported. No patient who was discharged from the postanesthesia care unit had to be readmitted to the hospital, an observation that indicates that selective discharge from the postanesthesia care unit to home is safe. The severity of disease scale was devised to take into consideration preoperative and intraoperative findings or maneuvers that could contribute to the need for prolonged surgery or anesthetic time, including granulomous degeneration of the middle ear, the absence of stapes suprastructure requiring ossiculoplasty or type IV tympanoplasty, cholesteatoma, or a cholesteatoma coursing medial to the incus. We sought to determine whether the complexity of surgery by virtue of the severity of disease scale or length of surgery could affect PONV and subsequent admission to the hospital. This could be helpful in surgical planning and patient counseling and in obtaining preoperative approval for a hospital stay. None of the factors related to surgical complexity seemed to predict the need for hospital admission due to the presence of PONV. Although the complexity of diseases characterized on the 10-point scale had significant correlation with length of surgery, length of surgery itself had no correlation with need for hospital admission.
CONCLUSIONS

23-hour overnight observation in patients undergoing tympanomastoidectomy. The severity of disease as measured on a 10-point scale is predictive of surgical time but not length of hospital stay or PONV. Antiemetic drug prophylaxis without 5-HT3 receptor antagonists has no effect on the incidence of PONV requiring hospital admission. Further research is required to determine whether use of 5-HT3 receptor antagonists can reduce PONV in a cost-effective fashion in this patient population. Until that time, patients should be counseled about the possibility of postoperative observation admission to the hospital, especially when a history of PONV or motion sickness is present. Accepted for publication February 2, 2000. Reprints: Cliff A. Megerian, MD, Department of OtolaryngologyHead and Neck Surgery, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655 (e-mail: Megeriac@ummhc.org).
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Tympanomastoid surgery can safely be performed on an outpatient basis. Most patients (92%) can be discharged the day of surgery or within a 23-hour observation window. However, a history of PONV or motion sickness is correlated with the incidence of PONV and the need for

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