Draining tract post TECA

Re: Draining tract post TECA

Malcolm Ness — Thu, 09 May 2013 11:57:29 GMT

TECA/LBO is increasingly regarded as a relatively routine, primary care practice surgical procedure but it is technically very challenging and in my opinion should only be contemplated by those who have significant surgical expertise plus some procedure-specific training.

There is much in the literature with peri-operative major complication rates of 25% being typical. There are relatively few reports following these cases over a longer period (2 years plus) and that is significant because para-aural abscessation as described in this case is a common late complication typically seen many months or even years after surgery. In our own cases, this occurs in about 2.5% cases but , like most referral practices we see a steady stream of cases operated elsewhere that would suggest a significant "learning-curve" effect exists resulting in some surgeons having substantial complication rates.

We have had no long-term success dealing with these cases medically - they need surgical revision.The revision surgery is challenging and involves identification and retrieval of the skin/epithelial tissue that was left at the earlier "sub-total ear canal ablation". The prognosis is a little guarded and the owner should be warned that a single revision surgery might not be curative.

Re: Draining tract post TECA

Hannah Wynne Richards — Thu, 09 May 2013 11:50:09 GMT

This sounds like one where I would volunteer to pay for referral (even if I didn't consider myself negligent in the first place) Call me a coward-you're right

Wynne

Re: Draining tract post TECA

David Mills — Thu, 09 May 2013 11:36:48 GMT

[quote user="John Flynn"]

[quote user="Anthony Dennison"]This is what I was starting to think. Will try and clear the infection a bit before going to surgery[/quote]

Easier to go back to surgery without clearing the infection in my opinion - that draining tract is your only clue as to path of dissection to take to get the epithelium. A deep swab at time of surgery and appropriate post-op antibiotics should be fine - also means you can hospitalise on eg gentamicin injections for few days while waiting for swab results - you might already have idea what infection likely to be in there.

I've never done this, but a colleague has twice and managed fine; I'd be concerned that I'd lost my usual anatomical landmarks and, together with the scarring, there'd be a bigger risk of facial nerve serious damage. I would wimp out and refer if that was an option, otherwise I'd have the owner well-warned about the increased risk of permanent facial nerve paralysis just in case...

[/quote]

I don't know how much experience ou have of the procedure, but as Mr Flynn says, be very careful with this. It is not a simple dissection and there is potential for catastrophic nerve damage. Almost certainly there was insufficient curretage/debridement of the epithelium. During the surgery you will be working down a deep, dark hole. Care with too eager debridement - there is a venous plexus within the bulla that you don't want to hit. Much of the discharge won't be infection so there is little point waiting. I would not use gentamicin - your normal antibiotics first line antibiotics - e.g. cefalexin - should be used pending culture.

Re: Draining tract post TECA

John Flynn — Thu, 09 May 2013 08:25:00 GMT

[quote user="Anthony Dennison"]This is what I was starting to think. Will try and clear the infection a bit before going to surgery[/quote]

Re: Draining tract post TECA

Anthony Dennison — Thu, 09 May 2013 07:43:01 GMT

This is what I was starting to think. Will try and clear the infection a bit before going to surgery

Re: Draining tract post TECA

Braden Collins — Thu, 09 May 2013 00:15:09 GMT

I believe one of the most common reasons for draining tracts post TECA is failing to remove all the epithelium from the tympanic bulla. That would be where I'd focus my attention with any revision Sx.

Re: Draining tract post TECA

Mark Hedberg — Wed, 08 May 2013 20:47:23 GMT

[quote user="Nicola Lawlor"]

I would also suspect revision surgery would be needed. Quite possibly some epithelial tissue still deep down there?

[/quote]

Almost certainly; while I'm no dermatologist; there's some focus of irritation/infection/atopy down there that's still providing a source of nastiness.

Re: Draining tract post TECA

Nicola Lawlor — Wed, 08 May 2013 19:53:59 GMT

I would also suspect revision surgery would be needed. Quite possibly some epithelial tissue still deep down there?

Re: Draining tract post TECA

Evelyn Barbour-Hill — Wed, 08 May 2013 18:47:07 GMT

Dunno but I fear it is going to need revision surgery. I'd be delighted to be proved wrong.