Renewed Concept of Mastoid Cavity Obliteration with the Use of Temporoparietal Fascial Flap Injected by Injectable Platelet-Rich Fibrin after Subtotal Petrosectomy for Cochlear Implant Patients

Round 1

Reviewer 1 Report

1.   Case series with interesting "how I do it " technique description

2.  3 cases only and short followup one patient with 6 month followup and 2 with 12 months followup.

3.  Figure 5B not explained - needs to be explained

4.  Intraoperative figure to show how the cavity looks with the TPFF and Platelet rich Fibrin would be helpful.

Comments for author File: Comments.pdf

Author Response

Great thanks for the positive review. Figure 5 contains 2 adjacent CT scans to better show the condition of the ear prior to surgery. I've added an arrow pointing to the locations of the open cavity, but actually this scan is not necessary. If the reviewer wishes, I can leave only figure 5A. In fact, the number of cases we present is not very high, but these procedures are not performed very often compared to classic cochlear implantation performed usually in the ear without a chronic inflammation. The observation period is extended, for example, by waiting for reviews (2 months from submission), patients are under our constant control, no complications are observed. In our work, we used the most interesting intraoperative images that we managed to take, but when the next opportunity arises, we will take a photo of the cavity.

Reviewer 2 Report

This is a case control study analyzing outcomes of mastoid cavity obliteration with the use of  temporoparietal fascial flap injected by Injectable Platelet Rich Fibrin after subtotal petrosectomy for cochlear implant patients.

The objective of the study is presented clearly and the introduction section communicates the need for addressing outcomes subtotal petrosectomy for patients with deafness and recidivant or complicated otitis media chronica. The Materials and Methods section has clearly defined inclusion and exclusion criteria, should  cite CARE guidelines and add a flowchart accordingly. IRB approval and informed consent need to be addressed in this section.

The technique has been described in detail, and is reproducible, logical and easy to replicate in the clinical setting.

The manuscript has been written with great care and attention to detail and I would support publication pending minor revision as stated above. 

Author Response

Reviewer 3 Report

This manuscripts presents 3 cases of subtotal petrosectomy with mastoid obliteration using the temporoparietal fascia flap injected with Platelet Rich Fibrin (PRF) and cochlear implantation. This is a good review of cases describing the author's experience. I personally do not believe this is a novel approach since I have seen other Neurotologist performing this technique but without the IPRF injection, which is definitely novel from my understanding, or at least not reported yet. 

My major concerns are:

1. How did the authors followed this patient up, specially for monitoring of the cholesteatoma? 

2. Usually a 12 month period to follow up patients with cholesteatoma is very short since most studies follow these patient for about 5 years or so? Did the patient obtained an MRI one year after surgery to r/o recidivism?

3. How does the author know of the benefits of the IPRF, more than just literature reading? How did you confirm these were positive outcomes in your patients or if the IPRF actually caused changes in your TPFF? The three cases were one-stage procedure, if staged, the authors could have obtained a piece of the TPFF for histology and comparisons between the first and second surgery.

 4. To make this manuscript more valuable, the authors could select a couple of traditional cases performed with fat graft for example and compared post op images?

Author Response

Thank you very much for the positive review. I am fully aware that in the case of one-stage cochlear implantation in patients with profound hearing loss or deafness treated for extensive cholesteatoma destroying the structures of the ear, it is particularly important to precisely remove the pathology in order to minimize the risk of recurrence. In each of the described cases, we were convinced during the surgery that the cholesteatoma was completely removed, if this was not the case, we were always prepared to put a dummy electrode and perform the procedure in 2 stages. Of course, no surgeon can be 100% sure about the radical removal of cholesteatoma, which is why, of course, all patients are under our medical supervision. During this period, we did not observe the occurrence of severe symptoms in patients indicating a possible recurrence of cholesteatoma or the occurrence of complications. For this reason, we scheduled a follow-up MRI 1.5 T (Non-Echo Planar Diffusion-Weighted Imaging) 1.5 years after the procedure, bearing in mind that MRI scans are sometimes deteriorated by artifacts and had limited applicability on the CI side.

The benefits of IPRF are described in literature, and our cases confirmed its beneficial role in tissue healing. This is a very good idea that we will use when we get the opportunity to assess the temporal muscle before and after the injection. We will try to do this when the opportunity arises.

We made the decision to treat the patients with use of TPFF on the basis of previous experience in blind sac closure surgeries with the use of fat, during which we sometimes observed tissue inflammation, leakage from the wound, and always in a longer period of observation after the procedure, fat absorption manifested by collapse in the area of the planum mastoideum The photo was added (Fig 8). For this reason, we decided to implement our invent technique in the case of CI in SP.

We have corrected the manuscript in accordance to reviewer question.

Round 2

Reviewer 3 Report

I really appreciate the author's efforts to address all of the issues. I do agree that this manuscript is a good description and presentation of cases using TPFF for mastoid obliteration in cases of cholesteatoma undergoing a subtotal petrosectomy with cochlear implantation as a one stage procedure. This manuscript should be considered a good review of cases and a starting point to further study this approach. However, the current design and data presentation cannot conclude that the IPRF+ is of real benefit since there is not post procedure assessment to evaluate its benefits. Therefore, I find the title and the conclusions to be somewhat misleading to the reader.

I also agree, that maybe performing a punch biopsy of the muscle after injection might be an overkill that will lead to extra unnecessary procedure to the patient, however, other type of data should be presented to support the use of the presented technique. For example, the authors should consider waiting until the follow up MRIs of these patients are complete and consider comparing these images to those of patients that underwent the traditional obliteration with fat in addition to post operative images of the postauricular incisions.

No major concerns.

Author Response

Dear Reviewer,

Thank you for your insightful review of our work and comments. The usage of IPRF has its significant clinical utility. In our studies we use the IPRF+ to:

1. Improve the healing- in all presented cases we achieved good and fast healing.
2. Decrease a risk of infection – there was no tissue infection after all the performed procedures.
3. Get adequate obliterative tissue volume- what was confirmed by CT.

In our opinion MRI might be useful rather for exclusion of residual cholesteatoma and not for comparison of different tissues used to obliterate cavity. Additionally, we have attached a photo showing the atrophy of tissues in the retro- auricular- area 12 months after SP with fat obliteration (Fig. 8), which we did not observe in the other presented patients, as shown in the Figure 4.

The advantages of using IPRF now are presented in the revised introduction.

Round 3

Reviewer 3 Report

Dear authors. Than you for your revised version and attempting to address the concerns. I see the value of the case report, however,  I still believe that the statements the authors are making in favor of the use of the proposed technique cannot be supported by the findings of the case series. Only 3 cases with a maximum follow up of 3mo the are being reported. These can be used as a start point to continue collecting data and serve a description of the procedure, but not to make conclusions. Authors should rephrase their conclusion and avoid statements using words like “our study confirmed”, “our study e o strayed”. An “n” of 3 is not representative. Instead, authors should use words like “our findings correlate with what has been reported in other studies”, “our literature review and our experience with this small group of patients suggest that…”, etc.. avoid stating that there is “better healing”, what are the parameters that are being used to state this? How do you define “better healing”…

Author Response

Dear esteemed reviewer,

I extend my sincere appreciation for your insightful comments. It is true that the described group of patients is not large, however, motivated by the notably positive outcomes observed thus far, and drawing upon the experiences set by other scholars who have explored diverse applications of Temporoparietal Fascial Flap (TPFF) and Injectable Platelet-Rich Fibrin (IPRF), we have made the decision to disseminate our implemented treatment approach through publication. It is imperative to underscore that Cochlear Implant (CI) procedures within the context of chronic otitis media with cholesteatoma are not as ubiquitously performed as they are in cases of other manifestations of sensorineural deafness. The subjects delineated in our study continue to undergo vigilant monitoring, with the observational timeframe currently spanning from 6 to 15 months. The affirmative feedback received thus far serve as a compelling impetus for the continued implementation of the surgical treatment paradigm explicated in our study. In response to your astute suggestion, we have duly revised the narrative employed in the conclusion section, and these modifications have been highlighted in red for your perusal. Once again, I express my gratitude for your constructive feedback.

Best regards,

Aleksander Zwierz