Introduction
Otological surgery of the external auditory meatus, tympanic membrane or middle ear commonly requires some form of ear packing. The principal purpose is to maintain mild pressure on the operating site, allow delivery of local antibiotics and aid normal wound healing. The overall use of ear packing has, however, been questioned in the past; nonetheless, the vast majority of otological clinics use some form of packing.Reference Borgstein, de Zwart and Bruce1 There is a lack of robust evidence comparing the efficacies of the different packs available, with the current English-language literature showing no significant difference between commonly used dressings, such as bismuth iodoform paraffin paste (BIPP), Pope otowicks, Silastic® sheeting and tri-adcortyl ointment.Reference Nakhla, Takwoingi and Sinha2, Reference Zeitoun, Sandhu, Kuo and Macnamara3 The choice of packing used is usually dictated by availability and the personal preference of the surgeon.
The most widely used form of ear packing is sterile ribbon gauze impregnated with BIPP. It may also be in the form of nylon tape or cotton balls, with or without Silastic sheeting. Less traditional methods of dressing include Pope otowicks, sponge balls (microspheres) and gelatin-based dressings, such as the absorbable haemostatic gelatin sponge (Spongostan). Most of these packing materials require a follow-up appointment post-operatively for removal, which often causes distress and pain to patients, especially children, who may subsequently require further general anaesthesia for pack removal. In addition, these materials are expensive to purchase and are frequently uneconomical to use due to the form in which they are manufactured. As a result, large quantities of expensive packing are wasted every time it is used, therefore incurring considerable financial costs.
We describe here the use of a packing material, the absorbable gelatin sponge, manufactured by Spiggle & Theis (Spiggle & Theis Medizintechnik GmbH, Overath, Germany; Figure 1). Its dissolvable nature means that no removal is required at follow up, while it also has the added benefit of being substantially cheaper compared to other commonly used forms of packing.
Fig. 1 Absorbable gelatin sponge cube.
Methods
The absorbable gelatin sponge comes in the form of a 10 × 10 × 10 mm ‘sugar cube’ and can be cut with scissors to the required size and shape during the final steps of the procedure. It may then be placed on the tip of a curved needle and inserted into the external ear canal. The number of sponge cubes required is dependent on the procedure and patient's anatomy, with the aim of achieving adequate support to any grafts in situ and also coverage of the operative site (Figure 2; gelatin sponge in ear). Once in place, the sponge cubes are moistened with a few drops of dexamethasone/framycetin/gramicidin (Sofradex®) ear drops, although in some cases they can be placed in the ear pre-soaked as the material holds together well. Patients are discharged with instructions to apply 3 drops, three times daily to the operated ear canal for two weeks. The first follow-up review takes place six weeks post-operatively and the operated ear canal is examined for any residue of packing, signs of infection, discharge and progress of wound healing. It is used in all our ear operations, including myringoplasty, mastoidectomy, atticotomy, canaloplasty, meatoplasty, tympanoplasty and stapedectomy.
Fig. 2 Gelatin sponge in the ear canal following atticotomy.
Results
Table I compares the cost of using four common packing materials for several procedures. The absorbable gelatin sponge costs £0.84 per 1 cm3 cube, compared to BIPP at £15.43 for 50 cm, Pope otowicks at £2.63 per wick and Spongostan Special at £10.14 for a 7 × 5 cm sheet. The cheaper per-unit price and the economical nature of its use mean that the absorbable gelatin sponge is a considerably cheaper form of packing for a range of otological procedures.
Table I Actual costs of packing, based on procedure and type of pack used
The numbers in brackets show the number of pack(s) required according to the procedure used.
Over the last three years, the absorbable gelatin sponge has been used exclusively in otological procedures by the lead otology consultant across our Trust, a regional ENT centre. During this time, a total of 492 procedures have been performed at the William Harvey Hospital, with 254 tympanoplasties, 109 atticotomies, 67 mastoidectomies, 53 stapedectomies and 9 meatoplasties. Of the few complications that developed in these patients, all were associated with the procedure itself; no adverse outcomes were directly associated with the use of the absorbable gelatin sponge.
Discussion
The major benefit of the absorbable gelatin sponge is that no removal is required in the out-patient clinic as the material dissolves completely within two weeks with the use of antibiotic ear drops. The ear drops are applied twice a day into the ear canal and onto the gelatin sponge, where they have a combined action. The gelatin sponge allows direct and even delivery of the topical antibiotic to the surgical site, while the ear drop acts as a medium into which the gelatin sponge can slowly dissolve. It takes up to two weeks for the gelatin sponge to fully dissolve away with twice daily use of common ear drops, such as Sofradex, which conveniently facilitates the standard two-week course of ear drops that we advise for our patients. Our experience at the out-patient review after this period is that no residue of the sponge can be found in the operated ear canal.
Another key benefit of using the absorbable gelatin sponge is cost. It is much cheaper compared to the higher cost of BIPP, Pope otowicks and Spongostan Special (Table I). The standard, and larger, sizes of the BIPP tapes (100 cm long) and Spongostan Special sheets (7 × 5 × 0.1 cm) result in large amounts of packing being discarded when a procedure requires only small amounts of packing material, whereas the smaller size and easy-to-manipulate nature of the absorbable gelatin sponge means that less material is wasted. In addition, the absorbable nature of the gelatin sponge avoids the risk of tissue ingrowth and adherence into the packing material, which can occur with BIPP and Pope otowicks, especially after prolonged in-situ use.
Conclusion
In summary, we advocate the use of the absorbable gelatin sponge, an effective and economical packing material, within routine otological surgical practice. Compared to other types of ear packing available, it is as effective with respect to surgical outcomes, kinder to patients and substantially cheaper. In these difficult times, where National Health Service resources are limited and all departments are required to make considerable cutbacks, we have demonstrated how, through the use of simple products, we can deliver an excellent and cost-effective service.
