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Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 130-134

Patient-Related long-term outcome measures after mastoid surgery at a tertiary care center of North India: A retrospective analysis

Department of Otolaryngology Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission25-Jan-2022
Date of Acceptance06-Mar-2022
Date of Web Publication21-Sep-2022

Correspondence Address:
Prof. Naresh K Panda
Department of Otolaryngology Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_15_22

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Background: Long-term postsurgical follow-up in chronic otitis media (COM) is crucial in otologic practice for outcome assessment. Validated questionnaires for the same are robust alternatives when physical visits are not feasible such as the current COVID-19 pandemic and we present our findings of outcome assessment using COM outcome test (COMOT)-15 questionnaire through nonphysical mode. Materials and Methods: A retrospective analysis of a cohort of 112 patients of COM who underwent surgery by the single senior otology surgeon between 2009 and 2019 was done using COMOT 15 questionnaire through telephonic methods to circumvent the need of office visits. Results: Fifty out of 112 patients could be contacted and consented for the assessment and their COMOT-15 scores were obtained. The numbers of patients with any otologic symptoms and their need for consultations, except hearing loss were significantly less. One-third of the patients had mild to moderate residual hearing loss and its quality of life impacts, although the same neither was statistically significant nor required increased numbers of consultations. Conclusion: Bothering symptoms and the need for a frequent visit to the doctor is significantly less with adequate clearance of disease and mastoid obliteration in cases of canal wall down procedures. The residual mild-to-moderate hearing loss are not significant and manageable with day-to-day activities. Successful outcome of COM surgery needs long-term follow-up and evaluation by all practicing otologic departments and surgeons which can well be done through nonphysical modes in unprecedented situations like the current times.

Keywords: Chronic otitis media, chronic otitis media outcome test-15, long-term hearing outcome in chronic otitis media, outcome assessment in chronic otitis media

How to cite this article:
Patro SK, Panda NK, Rathod R. Patient-Related long-term outcome measures after mastoid surgery at a tertiary care center of North India: A retrospective analysis. Indian J Otol 2022;28:130-4

How to cite this URL:
Patro SK, Panda NK, Rathod R. Patient-Related long-term outcome measures after mastoid surgery at a tertiary care center of North India: A retrospective analysis. Indian J Otol [serial online] 2022 [cited 2022 Oct 7];28:130-4. Available from: https://www.indianjotol.org/text.asp?2022/28/2/130/356446

  Introduction Top

Surgery of the middle ear cleft, including mastoidectomy, has been a common yet challenging surgery for otology surgeons since the early days. In the early half of the 20th century, radical mastoidectomy was a commonly performed procedure for cholesteatoma and other infectious conditions of the middle ear cleft.[1],[2] The incidence of middle ear cleft infections and their complications, seen in earlier days,[3],[4],[5] have significantly reduced in recent times due to the increased reach of health care services, including vaccinations and antibiotics.[6],[7] However, even today, middle ear conditions are important in terms of the patient-related outcomes, cavity issues, recurrence, and recidivism of disease and hearing outcomes,[8] more so in a society where follow-up has not been given priority by the population once the acute and pressing issue resolves.[9],[10],[11] Hence, every otologic surgeon or surgical unit should review and audit the surgical outcomes to ensure that the health-care delivery in terms of mastoid surgeries gives better quality of life (QOL) to the patients being operated on with mastoidectomy.[12],[13]

The earlier radical mastoidectomy of the early half of the century was converted to less radical procedures such as modified radical mastoidectomy, attico-antrostomy, combined approach surgery described by Jansen[14] and recently leading to mastoid surgeries with visual augmentation techniques such as the use of endoscopes. The cavity issues led the surgeons to adapt to less radical procedures, combined approach canal wall up (CWU) procedures, and various cavity obliteration methods such as the Palva's flaps.[14] Few authors such as Mercke have also described en bloc osteoplasty and the traditional soft reconstruction of the posterior canal wall using conchal cartilages.[15] Today, CWU and canal wall down (CWD) are both established surgical methods, and each has strong advocates. In earlier studies, CWU was associated with a higher residual cholesteatoma frequency compared to CWD,[16] in contrast to the current literature. These all factors and surgical concerns affect the patient-related outcome measures in terms of cavity conditions, hearing, and other rare issues such as dizziness and effects of overall patient well-being and mental health.

Hence, we planned this study to retrospectively analyze the patient records to evaluate the patient-related outcome measures of patients operated with a mastoid surgery in the last 11 years to audit surgical results and know regarding QOL impacts of surgery and treatment in our patients. Given the ongoing pandemic, a questionnaire-based study was planned.

  Materials and Methods Top

Study setting

Department of Otolaryngology and HNS of our hospital.

Study type

A retrospective review and cross-sectional questionnaire-based patient-related outcome measurement.

This study was exempted from the requirements of Institutional Ethics Committee approval as the study did not involve any kind of human or animal intervention or management was only a review of the currest status and audit of the surgical outcome of cases operated wirh mastoid surgery and did not involve any kind of financial concerns. Hence, prior approval was not required for the study.

Surgical procedure

An insideout mastoidectomy of all cases diagnosed with chronic otitis media (COM) of squamous type was performed. The procedure consisted of an atticoantrostomy and following the disease eventually aiming to remoe the entire disease. Onliteration of the cavity with conchal cartilage with preserved perichondrium was also done. A temporalis fascia graft was used to line the cavity. Cartilage tympanoplasty with conchal cartilage harvested during the time of underataking meatoplasty was performed.


All patients who were operated on between 2009 and 2019 were contacted for questionnaire-based evaluation.

The questionnaire used: COM outcome test (COMOT) 15 [Supplementary material 1] was used to evaluate the current status of patient-related functions pertaining to otitis media.[17]

The results were analysed and presented [Table 1].
Table 1: Symptoms severity of patients as per the chronic otitis media outcome test score

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Statistical analysis

Measures of central tendencies, dispersion, and quartiles were determined for the individual and total scores to understand the severity of the otologic symptoms encountered by the patients in their day-to-day life. This was done by using statistical software (SPSS v20.0, IBM Corp, Armonk, NY, USA).[18]

  Results Top

Our retrospective chart review resulted in 112 patients operated on in the last 11 years from 2009 to 2019. Attempts were made to establish contact with the patients for assessment and current status evaluation through telephone and postal mail. However, we could establish contact with only 53 patients due to changes in phone numbers or addresses. Of the 53 patients, one patient expressed inability to convey the current status and fill the proforma due to language and technical reasons and two patients had died due to other comorbid conditions unrelated to the ear pathology. Hence, a total of 50 patients complied with the study questionnaire. The responses were collected, tabulated, and analyzed.

For all the 15 questions and parameters of the COMOT scale, the data were significantly skewed. The responses in the COMOT scale did reveal better overall surgical outcome and patient satisfaction. Median and percentile values were observed to find the response of the majority of the patients for each symptom score in the range from 1 to 5 and the total score of the COMOT test questionnaire from 15 to 75.

For the symptoms of ear discharge, earache and ear pressure/heaviness, the median values were zero and 80th percentile values were 1, 0.80, and 1, respectively, for ear discharge, earache, and pressure/heaviness in the ear. For the symptoms of tinnitus and headache, the median, 75th and 80th percentile all were zero. For symptoms pertaining to hearing loss such as hearing loss, distant hearing, listening in a noisy background, hearing when people are speaking simultaneously and hearing impacts leading to confusion, all patients had a median of zero. However, the 75th and 80th percentiles range between 2 and 3, suggesting mild-to-moderate residual hearing loss in patients of mastoidectomy. Similarly, the QOL impacts of otologic disease such as sadness due to hearing loss, embarrassment due to hearing loss, fear of progression, and overall impact on QOL were all having median of zero and 75th and 80th percentile values ranging between 2.80-4, suggesting that majority of patients had a moderate QOL impact due to their disease more specifically due to the residual hearing loss. However, when the need for a visit to the doctors' office due to the otologic disease was estimated, the 80th percentile was at 1, suggesting that the mild-to-moderate residual hearing loss and QOL impacts of disease were manageable with day-to-day life and did not warrant a frequent visit to the doctors' office for the patients [Table 1].

Out of the total COMOT score of 75, the median score was 4, suggesting that 50% of the patients had no complaints with their ear pathology or symptoms. The 75th and 80th percentile scores were 26 and 30.20 implying that 80 per cent of the patients had a score <30 out of 75 in the COMOT scoring.

  Discussion Top

The primary goals of mastoid surgery include complete removal of the disease from the middle-ear cleft and mastoid, address the hearing loss, including preservation and residual hearing, and reconstruction of the ossicular chain for restoration of the lost hearing and attempts to prevent recurrence of the disease. The three goals are unmet at times, and recurrences and recidivism of disease are known. Hence, surveillance and audit of the surgical outcomes become essential in otologic practice, especially when long-term surgical outcomes and their impact on patients QOL are of concern. The recurrence rates and bothering tableoperative patient-related outcomes are reported to range from 7% to as high as 57% in literature.[19] Literature also suggests that the overall long term recurrence rates are similar in both CWU and CWD procedures,[20] which contrasts with a few recent studies suggesting higher recurrence rates in CWU procedures.[21] Most of the procedures performed in our hospital were CWD procedures with mastoid obliteration, with only a handful of CWU procedures performed for minimal disease. The long-term recurrence rates are around 8% in cases of CWD mastoidectomy with obliteration.[22] Hence, regular follow-up becomes significant.

The pandemic led us to plan the study using a patient-related outcome-based questionnaire, the COMOT 15, which included 15 questions about the ear-related QOL. In our series, the numbers of patients with any symptoms of otologic disease and the need for a visit to the doctor's office, except hearing loss were significantly less. However, in terms of hearing loss and its QOL impacts, the patients had mild-to-moderate residual hearing loss, although it was not statistically significant. The total COMOT scores in the series were also significantly less, with the 75th percentile score was 26 out of 75, suggesting that three-fourths of the patients had less than one-third of the severity scores. The symptoms of residual hearing, which was a major symptom in our patients, were less than the results described in literature as 43%–60% of patients with a long-term hearing threshold of more than 30 decibels.[23],[24],[25],[26] This can be explained from the surgical technique, which includes ossiculoplasty and cartilage tympanoplasty in the mastoid surgeries in our institute, which has a better outcome than cases with loss of stapes supra structure or myringo-stapediopexy.[27] The number and need for frequent visits to the doctor's clinic for bothering Otologic symptoms were also significantly less in the current series. The major drawbacks of this study is it being a retrospective with limited number of patients that could be reachable to obtain questionnaires' scores.

  Conclusion Top

Routine follow-up and long term surveillance of patients operated with mastoid surgery are critical in otologic practice. Bothering symptoms and the need for a frequent visit to the doctor is significantly less with adequate clearance of disease and mastoid obliteration in cases of CWD procedures. There remains a mild to moderate degree of hearing loss in one-third of the patients in the long term follow up; however, its QOL impacts are not significant, and it is manageable with day-to-day activities of the patients. All otologic surgeons should practice long-term surveillance of patients of mastoid surgery to evaluate and improve the surgical outcomes. Hence, we do infer that:

  1. Long-term follow-up of patient undergoing otologic surgery is mandatory
  2. Validated questionnaires such as COMOT-15 can be utilized for longterm and retrospective objective outcome analysis
  3. Questionnaires are robust to keep up patient follow-up during global exigencies such as the current COVID-19 pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

[TAG:2]Supplementary Material[TAG:2]

  References Top

Sonnenschein R. The development of mastoidectomy. Ann Med Hist 1936;8:500-10.  Back to cited text no. 1
Peters EA. Radical mastoidectomy-persistent discharge-healing by means of massive flap. Proc R Soc Med 1924;17:77.  Back to cited text no. 2
Brown LG. Right chronic temporo-sphenoidal abscess. Wagner's osteoplastic craniotomy and drainage. Radical mastoidectomy five months later. Proc R Soc Med 1931;24:633-4.  Back to cited text no. 3
Tod H. Septic infection of the lateral sinus accidentally injured during the operation of mastoidectomy. Proc R Soc Med 1919;12:62-76.  Back to cited text no. 4
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Siampara L, Mann SB, Panda NK, Mehra YN. Audiovestibular profile in unilateral chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg 1997;49:107-11.  Back to cited text no. 11
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Shah AK, Patel S, Pawde A. Surgical outcome of mastoid cavity obliteration using postauricular composite bone with periosteum flap. Indian J Otolaryngol Head Neck Surg 2019;71:115-9.  Back to cited text no. 13
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Mercke U. The cholesteatomatous ear one year after surgery with obliteration technique. Am J Otol 1987;8:534-6.  Back to cited text no. 15
Kapur TR. Causes of failure of combined approach tympanoplasty in the treatment of acquired cholesteatomas of the middle ear and the mastoid. J Laryngol Otol 1995;109:710-2.  Back to cited text no. 16
Baumann I, Kurpiers B, Plinkert PK, Praetorius M. Development and validation of the chronic otitis media outcome test 15 (COMOT-15). Measurement of health-related quality of life in patients with chronic otitis media. HNO 2009;57:889-95.  Back to cited text no. 17
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Trinidade A, Skingsley A, Yung MW. Mastoid obliteration surgery for cholesteatoma in 183 adult ears – A 5-year prospective cohort study: Our Experience. Clin Otolaryngol 2015;40:721-6.  Back to cited text no. 22
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