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Table of Contents
Year : 2021  |  Volume : 23  |  Issue : 3  |  Page : 95-99

Viability of ambulatory major ear surgery and patient satisfaction

Department of Otolaryngology, King Fahad Specialized Hospital, Dammam, Saudi Arabia

Date of Submission29-Sep-2020
Date of Acceptance30-Nov-2020
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Mudy Alafaleq
Department of Otolaryngology, Dammam Medical Complex Dammam, Eastren Province
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_46_20

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Background: Ambulatory ear surgery is expanding worldwide due to improvements in surgeries, and this has had a highly positive impact on both hospital and patient satisfaction. However, ambulatory major ear surgery remains controversial in our region due to a lack of research, which motivated us to conduct this study. The purpose of the research is to assess the safety of ambulatory major ear surgery and elaborate on the patient satisfaction rate. Methods: To assess complications, the readmission rate, and patient satisfaction with ambulatory major ear surgery, a prospective study of all such surgeries on pediatric and adult patients in a 1-year period in a tertiary hospital was carried out. Results: A total of 47 patients underwent ambulatory major ear surgery, and the results indicated an 89.4% discharge rate and 10.6% readmission rate, as well as high patient satisfaction. Conclusion: Our study showed a rather low complication rate and high patient satisfaction rate with ambulatory major ear surgery. This should encourage other hospitals in the Kingdom of Saudi Arabia to apply ambulatory ear surgery.

Keywords: Ambulatory ear surgery, cochlear implant, day surgery, patient satisfaction, tympanomastoidectomy

How to cite this article:
Alafaleq M, Alafaleq S, Alzahrani M. Viability of ambulatory major ear surgery and patient satisfaction. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:95-9

How to cite this URL:
Alafaleq M, Alafaleq S, Alzahrani M. Viability of ambulatory major ear surgery and patient satisfaction. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jul 2];23:95-9. Available from: https://www.sjohns.org/text.asp?2021/23/3/95/327569

  Introduction Top

In the past, major ear surgeries required admitting patients the night before. Inpatient limited capacity increases patient's susceptibility to disease progression while waiting for their surgery. Ambulatory ear surgery is an ear surgery performed in a day-case unit in which patients are discharged on the same day after recovery. It has become available in many countries due to surgeon/anesthesia expertise and technology development. Furthermore, it has a positive impact on both hospital and patient satisfaction. Saudi Arabia has been experiencing an expansion in population size. With this, medical and surgical needs have been increasing. Hearing impairment is a widespread condition in all ages that necessitates surgery to improve the quality of life. Major ear surgeries, such as cochlear implants and mastoid surgery, are well-suited procedures in the day surgery unit in the pediatric and adult populations.[3],[8] Studies have shown that the day surgery unit is more convenient than inpatient admission, while showing no difference in clinical outcomes between day-case patients and inpatients, along with a lower risk of infection and less expenses in terms of hospital accommodation cost for ear surgeries.[4],[5],[6]

Ambulatory major ear surgery remains controversial due to insufficient studies conducted in our region. This motivated us to conduct the present paper, which evaluates the complication and patient satisfaction rates related to such surgery.

  Methods Top

A prospective cohort study was performed for all ambulatory ear surgeries over 1 year, spanning from October 2018 to October 2019 in a tertiary care center. Patients were recruited from a specialized otology clinic and evaluated by the same physician. Institutional review board approval was obtained.

The patients underwent a preoperative evaluation and a preanesthesia assessment 1 week before admission. Then, each patient presented to the day surgery unit in the early morning. Experienced surgeons performed the surgeries, and the patients were discharged after oral intake, mobilized freely, anesthetist, and surgeon evaluation with instructions. Admission was considered only if any acute event, such as uncontrolled bleeding from the surgical site, nausea/vomiting, uncontrolled pain, or unstable vital signs, occurred to ensure patient safety. Data were collected postoperatively and 1 week later during follow-up by the physician. The questionnaire was filled in by the patients/parents to evaluate the satisfaction rate.

Questionnaire validation

The questionnaire was extracted from two similar types of research, which are as follows: (1) patient satisfaction following day surgery[10] and (2) the satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared with conventional hospitalization.[2]

Inclusion and exclusion criteria

The patients included in our study were adults and children undergoing any otological procedure, (1) aged 1–75 years, (2) who were willing to participate in day surgery procedures, (3) with good general condition, and (4) have accommodation within a 20-min ride from the hospital. Nonconsenting patients and those with a poor general medical condition were excluded.

  Results Top

Forty-seven patients underwent ambulatory major ear surgery over 1 year. Their age ranged between 2 and 66 years; the mean age was 15.8 years (standard deviation = 17.2). Most patients were in the pediatric age group, and it can be seen that the mean age was lower for unilateral and bilateral cochlear implant than it was tympanomastoidectomy, with a significant difference (P = 0.000). Gender distribution was as follows: 40.4% females and 59.6% males [Table 1]. Forty-two patients (89.4%) were discharged successfully, whereas five patients (10.6%) required inpatient admission [Table 2].
Table 1: Demographic data

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Table 2: Causes of readmission: Nausea/vomiting, emergency department, intravenous

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In terms of the surgical procedures, 12.5% underwent unilateral confidence interval (CI), 11.1% underwent bilateral CI, and 13.3% underwent tympanomastoidectomy. There was no significant relationship between the type of surgery and readmission (P = 0.799, Chi-square = 1.09). Surgeries were classified as cochlear implant (16 unilateral and 9 bilateral), tympanomastoidectomy (15 patients), and other surgeries (tympanoplasty, subannular tube insertion, stapedotomy, and BAHA). The mean surgery duration was 2.6 h; this was higher for bilateral CI compared with other types of surgery, and the difference was significant [P = 0.000; [Table 3]].
Table 3: Surgeries classification

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Question about the first night at home revealed that a total of 74.5% of the patients were at least satisfied. Furthermore, 72.3% were satisfied with staying with family on the same day of surgery, 89.4% were satisfied with the doctor's discharge instruction, 87.2% were satisfied for pain control, and likewise, 87.2% were satisfied with having a surgery appointment sooner through day surgery. In terms of the conditions of the day surgery room, 85% of the patients were satisfied. In the overall evaluation of the day surgery experience, 82.9% of the patients were satisfied. More details on the questionnaire results are given in [Table 4], whereas the binary results are listed in [Table 5]. The relationships between the questionnaire results and type of surgery were studied and showed no significant relationship.
Table 4: Questionnaire results

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Table 5: Binary questionnaire results

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  Discussion Top

Many previous studies have presented the positive outcomes of major ear surgery as day surgery and emphasized the safety of the procedure. Uziel[3] reported no difference in complication rates between admission and day surgery cases. However, Patel et al.[1] analyzed data from the American College of Surgeons and showed that patients with asthma or a central nervous system abnormality had a high likelihood of admission. In our study, only patients with good health status were included. Patel et al.[1] and Jain et al.[7] reported that readmission is highly associated with bilateral CI patients due to the long operation time. So, in our study The mean operation time was 3.6 hrs for nine patients of bilateral Cochlear Implant and only one patient was readmitted <24 hrs from surgery due to nausea and vomiting. However, we also experienced readmission for two unilateral CI patients; one had postauricular hematoma that needed to be evacuated <24 h after surgery and the other patient had minor wound dehiscence which managed conservatively with Steri-Strips application. Ralli et al.[4] reported that complex chronic suppurative otitis media with cholesteatoma undergoing tympanomastoidectomy are more likely to be admitted overnight has a higher risk of postoperative pain requiring IV opioids, as well as nausea and vomiting. We had 15 cases of cholesteatoma who were managed with different mastoidectomy techniques and only one adult was readmitted 1 week after surgery due to wound dehiscence. Powell HR et al[9], Rowlands et al[13] concluded that pediatric middle ear surgery can be safely performed with no association between the anesthesia duration and admission rate. Moreover, it is a working system that needs all staff participants to ensure the patient's safety upon discharge. Hasan et al.[12] observed pediatric day-case tympanomastoidectomy and reported that 92% of the patients were discharged safely. Admissions were higher in patients with cholesteatoma related to postoperative nausea and vomiting and need for IV opioids. In contrast, Megerian et al.[14] mentioned the predictive value of postoperative nausea and vomiting related to patients' history of previous postoperative nausea and vomiting or motion sickness rather than the complexity or length of ear surgery. Dickins JR et al.[16] compared inpatient hospitalization to day-case ear surgery, and the results showed no difference in terms of complications if the patient was living near the hospital. We only included patients who lived within a 20-min ride from the hospital to ensure the accessibility in case of complications occurred. Dornhoffer and Manning[15] found that unplanned admissions were higher in pediatric than adult patients, at 5.7% versus 2.3%, as well as a more prolonged duration of the procedure of >2 h. In our study, it was observed that, of the five patients who were readmitted, four were in the pediatric age group.

In contrast to previous studies, Qureshi et al.[11] assessed the safety of ambulatory major ear surgery but did not consider the patient satisfaction rate concerning major ear surgery but did not consider the patient satisfaction rate concerning major ear surgery, our study combined both perspectives. The limitations of our study are the small sample size and the involvement of only one hospital; more patients at different institutions need to be studied to obtain more reliable results.

  Conclusion Top

Our study showed promising results with a low complication rate and highly satisfied patients in the context of ambulatory major ear surgery. The results should encourage other hospitals in the Kingdom of Saudi Arabia to offer such surgery.

Statement of ethics

The study was approved by the Institutional review board, and informed consent was obtained from study participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Patel TA, Nguyen SA, White DR. Clinical indicators of admission for pediatric cochlear implant procedures. Ann Otol Rhinol Laryngol 2018;127:470-4.   Back to cited text no. 1
Badaoui R, Rebibo L, Kirat K, Alami Y, Hchikat A, Cosse C, et al. Satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared to conventional hospitalization: A prospective non-randomized study. J Anesth 2018;32:227-35   Back to cited text no. 2
Uziel A. Day-case otological surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2017;134:249-51.   Back to cited text no. 3
Ralli G, Nola G, Taglioni A, Grasso M, Ralli M. Day-case management of chronic suppurative otitis media with cholesteatoma with canal wall down technique surgery: Long-term follow-up. Audiol Res 2017;7:187.   Back to cited text no. 4
Derks LS, Wegner I, Smit AL, Thomeer HG, Topsakal V, Grolman W. Effect of day-case unilateral cochlear implantation in adults on general and disease-specific quality of life, postoperative complications and hearing results, tinnitus, vertigo and cost-effectiveness: Protocol for a randomised controlled trial. BMJ Open 2016;6:e012219.   Back to cited text no. 5
Mawby TA, Kaleva AI, Ramsden JD. A UK experience of daycase cochlear implant surgery. Cochlear Implants Int 2014;15:109-11.  Back to cited text no. 6
Jain U, Chandra RK, Smith SS, Pilecki M, Kim JY. Predictors of readmission after outpatient otolaryngologic surgery. Laryngoscope 2014;124:1783-8.   Back to cited text no. 7
O'Neill JP, Young O, Conlon B. Major otology day case surgery: Viable, cost efficient and safe. Ir J Med Sci 2011;180:841-4.   Back to cited text no. 8
Powell HR, Rowlands RG, Lavy JA, Wright A. Day-case pediatric middle ear surgery: from myringoplasty to bilateral cochlear implantation. Int J Pediatr Otorhinolaryngol 2010;74:803-6.   Back to cited text no. 9
Lemos P, Pinto A, Morais G, Pereira J, Loureiro R, Teixeira S, et al. Patient satisfaction following day surgery. J Clin Anesth 2009;21:200-5.   Back to cited text no. 10
Qureshi AA, Padgham ND, Jiang D. Day-case major ear surgery: Is it viable? J Laryngol Otol 2006;120:5-9.   Back to cited text no. 11
Hasan RA, LaRouere MJ, Kartush J, Bojrab D. Ambulatory tympanomastoid surgery in children: Factors affecting hospital admission. Arch Otolaryngol Head Neck Surg 2004;130:1158-62   Back to cited text no. 12
Rowlands RG, Harris R, Hern J, Knight JR. Major ear surgery in a paediatric day care unit. J Laryngol Otol 2002;116:791-3.   Back to cited text no. 13
Megerian CA, Reily J, O'Connell FM, Heard SO. Outpatient tympanomastoidectomy: Factors affecting hospital admission. Arch Otolaryngol Head Neck Surg 2000;126:1345-8.   Back to cited text no. 14
Dornhoffer J, Manning L. Unplanned admissions following outpatient otologic surgery: The University of Arkansas experience. Ear Nose Throat J 2000;79:710, 713-7.  Back to cited text no. 15
Dickins JR. Comparative study of otologic surgery in outpatient and hospital settings. Laryngoscope 1986;96:774-85.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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