In this review of smoking-related issues and otologic surgery, we assess the newest research in an era of electronic (e-) cigarettes and debate for legalization of marijuana. With a steady accumulation of evidence over previous decades for smoking's negative effects on surgical complications and patient outcomes, largely from other surgical fields, our review addresses clinical data and physiologic evidence for its particular impact on otologic outcomes.
Smoking remains one of the greatest problems in medicine today. Numerous high-quality studies have shown a causal effect between smoking and heart disease, cerebrovascular disease, and chronic obstructive pulmonary disease – the three leading causes of death worldwide [1–3]. Other harmful conditions, such as alcohol dependence  and certain types of cancers occur in greater rates among smokers. Smoking is the number one preventable cause of premature death .
The relationship between smoking and otologic surgery has been less robustly studied. However, data exist in other fields of surgery on the negative impact of smoking on surgical complications and outcomes. A steady accumulation of evidence over the past few decades has suggested that smoking is associated with poorer otologic outcomes in many, but not all, situations. Although there have been no breakthrough studies in the past year, we assess the available literature with emphasis on newer research. Aside from clinical data, there is ample physiologic evidence that smoking should negatively impact otologic outcomes on a theoretical basis. This includes the local, regional, and systemic effects of cigarette smoke and its chemical contents.
Recently, there has been a trend from traditional paper-based cigarettes to electronic cigarettes that deliver purified nicotine via water vapor. Although this activity is too new for studies on its relationship to otologic surgery, there is great interest on whether this represents a positive or negative public health phenomenon. For example, while electronic cigarettes might lead to decreased rates of traditional cigarette smoking (which is probably more harmful), they may also cause an increased rate in nicotine use overall. Finally, the effect of marijuana on otologic surgery is becoming more relevant as several American states have recently legalized its use.
The Medline database was searched for titles/abstracts containing smok* and the following terms: otology*, Eustachian tube, tympanoplasty, ear surgery, mastoidectomy, mastoid surgery, staped*, stapes surgery, cochlear implant, skull base surgery, neurotolog*, translab*, retrosig*, middle fossa*, CSF leak. Additional studies of interest were obtained from references of relevant articles. Emphasis was given to recent studies, particularly within the last year. When data were not available or conclusive, recommendations were based on our subjective experience.
SMOKING AND TISSUE EFFECTS
The biologic effects of tobacco smoking on tissues of the ear are well known. These can be divided into three categories: local, regional, and systemic.
Local effects are those that directly influence the ear. Cigarette smoke affects goblet cells and, in turn, the quality and amount of mucus [6,7]. Middle ear ciliary function may also be adversely affected . Of note, mucociliary dysfunction is due to the toxic byproducts of tobacco combustion, rather than the nicotine chemical itself . Vasoconstriction, in contrast, is directly caused by nicotine consumption . Nicotine can also decrease blood perfusion to local flaps whereas carbon monoxide in smoke can reduce the carrying capacity of oxygen to the healing tissue.
Regional effects include alteration of Eustachian tube and adenoid function. Smoke-induced inflammation of the Eustachian tube could induce poor middle ear aeration. Dysfunction of the adenoid tissue could cause hyperplasia, further obstructing the Eustachian tube, and also harbor bacteria .
Systemic effects include lung dysfunction, particularly the development of chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease may lead to coughing and bucking on extubation, which could disrupt delicately arranged middle ear grafts. Finally, smoking may adversely affect the immune system, increasing the risk of postoperative infections .
In summary, cigarette smoking should negatively affect otologic outcomes because of a variety of biologic mechanisms from a theoretical standpoint. For higher-level evidence, we next assess clinical studies.
SMOKING AND OTOLOGIC SURGERY
Myringoplasty and tympanoplasty
The association between smoking and otologic surgery has been mostly examined for repair of tympanic membrane perforations. The success rate for graft healing in smokers seems dependent on the graft material. Several articles have shown inferior results with smokers when a thin, pliable material, such as fascia, is used.
In a retrospective study from 1970 involving 86 participants who underwent myringoplasty with either temporalis fascia or, less commonly, vein, smokers had a 44% graft take rate (i.e., presence of an intact tympanic membrane on follow-up) versus 96% for nonsmokers. Patients with coinciding trauma and infection had the lowest take rate overall (33%), and all of these participants happened to be smokers .
In another study using temporalis fascia grafts, smokers had a comparable rate of graft healing problems with nonsmokers in the first 6 months postoperative. However, after 6 months, there was a higher risk of perforation or atelectasis of the graft in smokers (60%) versus nonsmokers (20%) .
The nicotine metabolite cotinine has been used as a more accurate measure of active smoking than history alone. In patients with a serum cotinine level higher than 17.5 ng/ml, temporalis fascia grafts were significantly less likely to succeed (52%) than in patients with cotinine levels lower than 17.5 ng/ml (77%) .
A more sophisticated study of temporalis fascia grafts using multivariate analysis found smoking to be a significant risk factor for graft failure, with a large odds ratio of 11.4 . Because of suboptimal results with fascia in both smokers and some nonsmokers, many contemporary otologists employ cartilage for tympanic membrane reconstruction.
Cartilage possesses a number of advantages compared with temporalis fascia. First, because of its rigidity, cartilage does not easily deform and is resistant to recurrent retraction. Second, cartilage has low nutrient requirements, thereby allowing a scarcer blood supply during healing to the surrounding tympanic membrane. Both qualities would seem uniquely suited for smokers. For example, smoking exacerbates Eustachian tube dysfunction, leading to negative middle ear pressure, and a tendency for graft material to retract. In addition, nicotine also causes vasoconstriction, which may adversely affect blood supply and graft healing.
A recent study examined ‘butterfly’ inlay cartilage myringoplasty, where the cartilage is circumferentially scored and placed into the tympanic membrane perforation. In multivariate analysis, smoking was the only independent factor for increased graft failure (odds ratio 8.16) . Despite the discouraging result, this was the only study in our review that showed worse graft survival in smokers when using cartilage.
A series of contrasting studies cite cartilage as an incredibly resilient and durable material that essentially negates the injurious effects of smoking. However, several of these studies also include a mastoidectomy, which makes it less clear whether it is the cartilage or the mastoidectomy responsible for the improved outcomes. Cartilage tympanomastoidectomy is discussed in the subsequent section.
In the previously mentioned study that used cotinine levels as a biomarker for smoking, cartilage grafting in patients with suprathreshold cotinine had a success rate of 89% compared with only 25% with temporalis fascia .
A similar result was obtained using a perichondrium-cartilage island graft. Smokers had an 80% success rate compared with 93% in nonsmokers, a nonsignificant difference [18▪]. (A similar ratio was found between smokers and nonsmokers with temporalis fascia grafting, however with lower success in both groups.)
Finally, a recent study examined taste function with whole-mouth gustatory testing after myringoplasty. There was no difference in taste before or after surgery between smokers and nonsmokers .
A large review of 329 smokers and more than 1000 nonsmokers or former smokers examined a variety of outcomes after otologic surgery. The vast majority of procedures performed were tympanomastoidectomies; however, the tympanic membrane grafting material was not specified. Smokers were significantly more likely to have cholesteatoma present, and on revision, more extensive disease. They were also significantly more likely to require canal wall down procedures, ossicular reconstruction, or revision surgery. Furthermore, smokers had worse hearing outcomes. Although this study made no attempt to control for severity of disease at surgery, it provides evidence that overall, smoking leads to worse otologic outcomes. Interestingly, former smokers who quit for less than 5 years have similar outcomes to smokers, whereas those who quit for more than 5 years were similar to never-smokers .
In a study focused on cartilage tympanoplasty and tympanomastoidectomy, graft take was equivalently high in both smokers (93%) and nonsmokers (91%). Hearing improvements were also similar . Even more dramatic equivalence was obtained in a similar study that showed 100% take rate with cartilage in both smokers and nonsmokers .
Most of the above studies have examined graft incorporation (take rate), which is a measure of successful surgical healing. Dornhoffer followed patients with cholesteatoma for a mean of 8 years who underwent a retrograde (inside-out) mastoidectomy followed by cartilage reconstruction. This longer follow-up period should allow the assessment of long-term tympanic membrane health, rather than simply postoperative healing. The disease recurrence rate for smokers was 32% compared with 6% for nonsmokers. The rate of all complications (recurrence, need for intubation, perforation, need for second look because of poor hearing) was 79% for smokers compared with 16% for nonsmokers. Although statistics were not reported for the smoking data, the differences are certainly large .
In conclusion, cartilage seems to be a better reconstructive material for smokers as evidenced by graft integration rates approaching that of nonsmokers. Long-term data (i.e., beyond the healing period) are more limited, but smokers who have cholesteatoma may have complications at a higher rate.
Other otologic surgery
There is a paucity of studies on the risk of smoking related to otologic surgery for indications other than tympanic membrane perforation, chronic otitis media, or cholesteatoma. For patients without Eustachian tube dysfunction, the risk of smoking-induced middle ear dysfunction is less relevant. The primary concerns relate to poorer healing after raising tympanomeatal and other flaps as well as bucking/coughing during awakening from anesthesia.
For example, in stapedectomy, an elective procedure with a low level of tolerance for error, heavy coughing during extubation could potentially displace the prosthesis. In cochlear implantation, wound-healing complications (i.e., breakdown, infection) are a primary postoperative concern. With many surgeons using smaller incisions that do not extend beyond the postauricular sulcus, this may be less of an issue today. However, it is still prudent for surgeons to recommend that patients abstain from perioperative smoking when skin flap issues are possible.
SMOKING AND NEUROTOLOGIC SURGERY
Studies of smoking and neurotologic/related cranial surgery are uncommon. In a retrospective review of patients who underwent elective neurosurgery, multivariate analysis identified cigarette smoking as a significant predictor of surgical site infection (odds ratio 2.20) . In neurotologic cases, smoking cessation is advisable when wound healing can be problematic. Relevant procedures may include the translabyrinthine approach (which involves an abdominal fat graft), auditory brainstem implantation (with similar concerns as discussed above with cochlear implantation), and in patients who had or will undergo regional radiation. Finally, in two studies that examined the rate of cerebrospinal fluid leak, smoking was not associated with an increased risk [25,26].
SMOKING CESSATION AND PERIOPERATIVE MORBIDITY
The preoperative period represents a unique and opportune time period to discuss smoking cessation with patients. The most discussed effects of smoking are chronic conditions or diseases caused by long-term exposure. To the unmotivated patient, these nebulous, faraway risks may not provide a strong enough stimulus to quit. For a patient about to undergo surgery, quitting may offer real, immediate benefits. It is the surgeon's responsibility to impart this urgency to the patient. Surprisingly, less than a quarter of surgeons consistently counsel about how to quit .
In addition to surgical complications related to smoking, a greater concern is perhaps the risk of perioperative systemic morbidity and mortality as a result of the stress of surgery. Perioperative smoking cessation measures lower this risk.
The strongest evidence comes from the nonotologic literature. In a randomized controlled trial from Denmark, patients who underwent knee or hip replacement were assigned to cessation counseling along with nicotine replacement therapy (NRT) versus a control group. The cessation/NRT group had fewer overall complications (18%) versus the control (52%), including fewer cardiac complications (0 versus 10%, respectively, although marginally significant) . In another randomized trial with a similar design, the relative risk reduction for all complications (wound as well as systemic) was 49% . Although general and orthopedic surgeries tend to be higher risk than ear surgery, one could extrapolate that there should be an analogous, even if smaller, risk reduction for otology.
Direct physician-to-patient counseling makes a difference. Smokers are more likely to quit when advised by a health professional . However, the choice of which pharmacologic adjuvants to prescribe preoperatively is less clear. NRT along with counseling increases short-term smoking cessation. Varenecline, a nicotine receptor antagonist, has been shown to improve long-term cessation; however, a randomized controlled trial did not show an effect on early quitting or surgical complications [31▪,32].
Traditional cigarette smoking involves combustion, or burning, of tobacco rolled within paper. The resulting smoke contains nicotine and a variety of other chemicals. The smoke passes into the pharynx, is inhaled into the lungs, and then is absorbed into the bloodstream.
In contrast, electronic cigarettes (e-cigarettes) do not produce smoke. Instead, purified nicotine (and often flavor additives) within a solution is heated to produce water vapor. This water vapor is then inhaled. Unlike traditional cigarettes, there is no smoke produced from the combustion of tobacco and paper. Because it is the tobacco combustion products rather than the nicotine itself believed to be responsible for most of the deleterious and carcinogenic effects of smoking, electronic cigarettes are probably safer [33,34▪] (Fig. 1). Many e-cigarette users state that they are ‘vaping’, rather than ‘smoking’ because water vapor, not smoke, is produced.
Nicotine-replacement products, such as gum and transdermal patches, have been available for years; however, e-cigarettes seem the most promising solution because they mimic many of the habits and social rituals associated with smoking. This minimizes the behavioral modifications necessary to quit. However, the superiority of e-cigarettes as a tobacco cessation tool awaits more convincing data [34▪,35▪].
The risk of e-cigarettes before or after otologic surgery is probably similar to that of nicotine gum and patches. In terms of local effects, nicotine itself does not adversely alter ciliary function or mucus production [9,36]. However, one relevant pharmacologic effect of nicotine will remain, namely vasoconstriction. For integration of free fascia grafts, e-cigarettes may still reduce blood flow to the graft site, possibly decreasing the take rate. Although studies are needed to substantiate this theory, cartilage may be preferred because of its lower metabolic requirements. The regional effect of Eustachian tube inflammation should be minimal with e-cigarettes. Finally, systemic effects of tobacco smoking, such as lung dysfunction leading to coughing/bucking on extubation, should also be less of a concern with e-cigarettes.
Compared with traditional cigarette smoking, e-cigarettes seem to have a strong theoretical advantage for the perioperative period. Therefore, it seems reasonable to encourage cigarette smokers who will not quit to switch to e-cigarettes before surgery.
Recommending e-cigarettes walks a fine line, however. The long-term health effects of inhaling nicotine vapor are unknown and may not be known for decades. The nicotine content can vary widely and regulation is nascent. Because e-cigarette vapor may be colorless and odorless (or pleasantly scented), it is possible to use e-cigarettes in locations where smoking is unacceptable. Even more concerning, e-cigarette cartridges may contain sweetly flavored vapors that appeal to children [35▪]. The latter two features may eventually propel e-cigarette use to far surpass that of traditional cigarettes. A final concern is whether e-cigarettes might serve as a gateway to traditional cigarettes or illicit substances. Answers are not currently available, but the modern otologist must be prepared to counsel patients on these issues.
MARIJUANA AND SURGERY
In the United States, marijuana is the most commonly used illicit substance . As several states have recently legalized its use and others are debating its legalization, the perioperative consequences of marijuana smoking are increasingly important to assess. In our review, we found no studies on marijuana use and surgical outcomes. Like tobacco and nicotine, marijuana contains a variety of substances aside from the active chemical tetrahydrocannabinol. Marijuana smoke may affect the respiratory tract and is associated with respiratory complications . In otologic surgery, in which a smooth emergence from anesthesia without bucking and coughing is important, advising patients against smoking in any form seems prudent.
Smoking can adversely affect otologic surgical outcomes from both a theoretical/mechanistic standpoint as well as based on data from clinical studies. The strongest data demonstrate inferior results for tympanoplasty in smokers when temporalis fascia is used as the graft material. However, most studies show a similar short-term result when cartilage is used in smokers. For this reason, we recommend cartilage as the preferred grafting material in patients with a significant smoking history.
We also recommend preoperative smoking cessation counseling and, if needed, NRT. Electronic cigarettes represent a new alternative to tobacco cigarette smoking by delivering nicotine in water vapor, thus eliminating any combustion products. Other than the vasoconstrictive effects of nicotine, e-cigarettes are likely safer than smoking traditional cigarettes before and after otologic surgery. However, their efficacy and safety compared with NRT is currently unknown.
The authors thank Mary Kemper for editing the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
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