Updated surgical experience with bone-anchored hearing aids in children

BACKGROUND

We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children.

METHODS

The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured.

RESULTS

Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life.

CONCLUSION

Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.

[Surgical treatment of diffused osteoradionecrosis of temporal bone in cases with nasopharyngeal carcinoma after radiotherapy]

OBJECTIVE

To investigate the effective treatment method of osteoradionecrosis (ORN) of temporal bone in the patients with nasopharyngeal carcinoma (NPC) after radiotherapy.

METHODS

Eight NPC patients (8 ears) with ORN of temporal bone accepted surgical treatment, 2 ears undergoing radical mastoidectomy, 2 ears undergoing extensive radical mastoidectomy, 5 ears undergoing radical mastoidectomy and obliteration with transferring local vascularized fascia flaps.

RESULTS

Five of the 8 ears (62.5%) achieved dry ear, including 4 ears undergoing radical mastoidectomy and obliteration with vascularized fascia flaps, and 1 ear undergoing radical mastoidectomy. Two of the 8 ears (25%) still had infection and were not fully epithelized, but without sequestration, including 1 ear undergoing mastoidectomy and obliteration with vascularized fascia flaps, and 1 ear undergoing extensive radical mastoidectomy. One of the 8 ears (12.5%) which had received radical mastoidectomy needed revision surgery because of re-sequestration.

CONCLUSION

The surgical treatment for diffused ORN of temporal bone by radical mastoidectomy and obliteration with local vascularized flaps is effective. The main objective of the surgery is get excellent drainage and prevention of complications.

Comparison of microtia reconstructive surgery with autograft versus homograft

BACKGROUND

Microtia is a congenital abnormality with low incidence but considerable morbidities. Reconstruction of the microtia deformity is a complex and difficult process that requires a proper planning. The primary technique of reconstruction employs patient's own rib cartilage. Irradiated homograft cartilages previously have been used in facial reconstruction but its application in microtia surgery has not been reported yet. This study is designed to compare the results of autograft versus homograft auriculoplasty.

METHODS

Between 1992 - 2002, 23 patients underwent auricular reconstructive surgery by the senior author in our department. Autograft implantation was performed in one stage but homograft auriculoplasty was done in two stages.

RESULTS

Auricular deformity was right-sided in 13, left-sided in 8, and bilateral in 2 cases. Implanted graft was autograft in 9 patients and homograft in 14 patients. During mean follow-up of 4 years, cartilage graft resorption was detected in two cases, one in autograft and one in homograft group (P > 0.05). No postoperative infection was observed. Status of postauricular sulcus was optimal in 85.7% of homograft and 77.8% of autograft groups (P > 0.05). The satisfaction score of the patients and/or parents was excellent in 66.7% of autograft and 92.9% of homograft groups (P < 0.01).

CONCLUSION

Based on better satisfaction score, equivalent aesthetic appearance, and absence of complications such as scaring and pain on the chest wall, homograft auriculoplasty is an appropriate option for reconstructive surgery in patients with microtia.

Surgical Management of Lesions of the Internal Carotid Artery Using a Modified Fisch Type A Infratemporal Approach

OBJECTIVE

To report seven cases of vascular repair of the internal carotid artery (ICA) using a modified Fisch type A infratemporal approach and a venous grafting.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

PATIENTS

We have analyzed the clinical presentation, paraclinical assessment, and postoperative results regarding the vascular repair and the facial and auditory function from seven consecutive patients. All patients have been operated on by a multidisciplinary team of ENT and vascular surgeons.

RESULTS

The study includes four men and three women, aged from 21 to 62 years old. Six patients suffered from vascular traumatic injury after motor vehicle accident (n = 5) or cervical manipulation (n = 1) and one patient presented an atheromatous stenosis. All benefited from a vascular repair with a venous grafting through a modified Fisch Type A infratemporal approach. No death and no new stroke were noted (mean follow-up, 34 mo). The postoperative angiographies showed six functional grafts and one asymptomatic thrombosis. Six immediate postoperative facial palsy occurred but recovered to Grade I or II within 6 months. There was one traumatic injury of the facial nerve and one postoperative anacusis. For the six other patients, the reconstitution of the external auditory canal and ossicular chain allowed to limit the hearing loss to a mean air-bone gap of 22.5 dB (range, 15-35 dB).

CONCLUSION

The lesions of the intrapetrous aspects of the ICA remain the subject of debates regarding the indication for a vascular repair. For young or in good health patients, the infratemporal approach provides a safe and reliable access to the horizontal segment of the ICA, offering to the vascular surgeons optimal conditions for the vascular repair.

Sigmoid Sinus Diverticulum

OBJECTIVE

Tinnitus represents a bothersome symptom not infrequently encountered in an otology practice. Tinnitus can be the harbinger of identifiable middle or inner ear abnormality; but more frequently, tinnitus stands alone as a subjective symptom with no easy treatment. When a patient complains of tinnitus that is pulsatile in nature, a thorough workup is indicated to rule out vascular abnormality. We report of a new diagnostic finding and method of surgical correction for select patients with pulsatile tinnitus.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care, academic referral center.

PATIENTS

Among patients seen for complaints of unilateral or bilateral pulsatile tinnitus, five were identified with diverticula of the sigmoid sinus. All patients had normal in-office otoscopic, tympanometric, and audiometric evaluations. Patients with paragangliomas or benign intracranial hypertension were excluded. Auscultation of the pinna or mastoid revealed an audible bruit in most patients. All patients underwent computed tomographic angiography of the temporal bone. In all cases, this finding was on the side coincident with the tinnitus.

INTERVENTION

Three of five patients underwent transmastoid reconstruction of the sigmoid sinus.

MAIN OUTCOME MEASURE

Patients were evaluated clinically for presence or absence of pulsatile tinnitus after reconstructive surgery.

RESULTS

All patients electing surgical reconstruction had immediate and lasting resolution of the tinnitus.

CONCLUSION

Surgical reconstruction can provide lasting symptom relief for patients with pulsatile tinnitus and computed tomographic evidence of a sigmoid sinus diverticulum.

[Modification of postoperative cavity plastic reconstruction in sanation operations on the ear]

A technique of plastic reconstruction of the mastoid compartment with cutaneoperiosteofascial flap is described for rapid and complete epidermization of the postoperative cavity in open sanation operations in epitympanitis and epimesotympanitis with cholesteatoma. Good morphological and functional results were achieved in 32 patients operated by the above technique.

[Effects of middle-ear surgical interventions of different types on peripheral audio reproduction part of the acoustic analyzer in patients with otitis media purulenta chronica]

Different operations on the middle ear were performed in 86 patients with otitis media purulenta chronica (OMPC). Mean bone hearing thresholds in the high-pitched area (10,000-16,000 Hz) were determined and suprathreshold tests were made in 86 patients on day 10 and 6 months after surgery. Minimal changes seen only in early postoperative period occurred in canal wall up operations with tympanoplasty of type I-II. Canal wall down type of surgery had a negative effect on the function of the cochlear receptor system in the early postoperative period. All "open" types of ear surgery, even with tympanoplasty, provoked hearing deterioration with maximum elevation of the hearing thresholds in the high-pitched area (10,000-16,000 Hz). Middle ear surgery without forming a new tympanic cavity results in progressive deterioration of the peripheral part of the hearing receptor system.

Histopathology of the vestibular end organs after intratympanic gentamicin failure for Meniere's disease

CONCLUSION

To our knowledge, this is the first report of the histopathology of the vestibular end organs following intratympanic gentamicin for intractable Meniere's disease. There was relative sparing of the utricular macula, compared with the cristae ampullares. However, the utricular macula exhibited severe hair cell loss. Clinically, the patient has been free from vertigo spells for 3 years following labyrinthectomy.

OBJECTIVE

To describe the histopathology and morphometry of the vestibular end organs from a 59-year-old Meniere's patient who underwent transmastoid labyrinthectomy for recurrent vertigo after failed intratympanic gentamicin.

MATERIALS AND METHODS

Light and transmission electron microscopy were utilized; with unbiased stereology-physical fractionator for type I, type II hair cell, and supporting cell counts. Comparison with end organ histopathology in a 56-year-old with Meniere's disease without gentamicin treatment was carried out.

RESULTS

Histopathological analysis of the semicircular canal cristae ampullares showed severe atrophy of the neuroepithelium with undifferentiated cells, and fibrosis and edema of the stroma. The utricular macula had some remaining type I and type II vestibular hair cells, and nerve fibers and terminals within the underlying stroma. Morphometric measures were obtained from the utricular macula: 2000 type I and 500 type II hair cells, representing 7.3% of type I hair cells and 4.9% of type II hair cells compared with normative controls, and 24 000 supporting cells were obtained.

Congenital Aural Atresia

OBJECTIVES/HYPOTHESIS

To review the short- (<1 yr) and long-term (>1 yr) surgical and hearing outcomes for congenital aural atresia and to analyze the stability of surgical results over time.

STUDY DESIGN

Retrospective chart review of 45 patients (54 ears) who underwent surgery for congenital aural atresia during a 5-year period at a tertiary care institution.

METHODS

Preoperative and postoperative speech reception thresholds, air-bone gaps (ABGs), and pure-tone averages were compared and further analyzed for outcome stability over time. The complication rate was reviewed and compared with results from similar studies.

RESULTS

Approximately 50% of patients achieved a speech reception threshold of 30 dB or better both in the short and long term. The average improvement in ABG was 22 dB, resulting in a postoperative ABG of 30 dB or less in three of four patients. Short- and long-term outcomes were not significantly different. Patients with an intact ossicular chain did not seem to have a significant advantage in hearing when compared with patients with a prosthetic reconstruction prosthesis. We report a low incidence of meatal stenosis compared with other similar reviews and describe surgical modifications that may attribute to this outcome.

CONCLUSION

Overall, the mean hearing outcome for this group collectively did not significantly degrade over time and compared favorably with other series. However, there was significant variability among individual patients. The safety of this procedure and the demonstrated hearing improvement makes it a reasonable option in patients with congenital aural atresia with favorable anatomy.

[Clinical study on external ear reconstruction using expanded postauricular flap and medpor framework]

OBJECTIVE

To explore the feasibility of applying porous high density polyethylene (Medpor) as framework for auricle reconstruction of congenital or acquired auricular defects.

METHODS

From February 1999 to February 2004, 61 patients suffering from congenital or acquired auricular defects underwent auricle reconstruction with Medpor framework after expanding postauricular skin. Among them, there were 38 males and 23 females, aging from 5 to 61 years. In 40 cases of congenital microtia, two sides were involved in 1 case and one side in 39 cases. In 21 cases of traumatic auricle damage, two sides were involved in 6 cases and one side in 15 cases. The operation was performed by two stages. First stage: the expander was implanted underneath postauricular skin or soft tissue such as notrophic scar tissue for the traumatic auricle defect. Second stage:the expander was removed and auricle reconstruction was performed by placing Medpor framework between the expanded skin/scar flap and the underlying fascial flap.

RESULTS

Sixty-one patients obtained successfully reconstructed auricles. During a follow-up of 6 months to 5 years and 1 month (mean 2.8 years), the results were excellent and good in 49 cases (80.3%), fair in 7 cases (11.5%) and poor in 3 cases (4.9%), 2 cases (3.3%) underwent replacement of Medpor framework with autogenous costal cartilage after 6 months of operation.

CONCLUSION

Medpor framework would be applied safely, simply and reliably in condition that auricular framework is unfit or reluctant to undergo auricle reconstruction by using autogenous costal cartilage.

Auditory Midbrain Implant

HYPOTHESIS

The lateral suboccipital approach is a well-established route for safe removal of vestibular schwannomas in neurofibromatosis Type 2 (NF2) patients. The goal of this study was to assess if this approach can be extended to a lateral supracerebellar infratentorial approach to enable insertion of an auditory midbrain implant (AMI) penetrating array along the tonotopic gradient of the inferior colliculus central nucleus (ICC).

BACKGROUND

The AMI is a new auditory prosthesis designed for penetrating stimulation of the ICC in patients with neural deafness. The initial candidates are NF2 patients who, because of the growth and/or surgical removal of bilateral acoustic neuromas, develop neural deafness and are unable to benefit from cochlear implants. The ideal surgical approach in NF2 patients must first enable safe removal of vestibular schwannomas and then provide sufficient exposure of the midbrain for AMI implantation.

METHODS

This study was performed on formalin-fixed and fresh cadaver specimens. Computed tomography scan and magnetic resonance imaging were used to study the heads of the specimens and for surgical navigation.

RESULTS

The lateral suboccipital craniotomy enabled sufficient exposure of the cerebellopontine angle and internal auditory canal for tumor removal. It could then be extended to a lateral supracerebellar infratentorial approach that provided good exposure of the dorsolateral aspect of the tentorial hiatus and mesencephalon for implantation of the AMI along the tonotopic gradient of the ICC. This approach did not endanger the trochlear nerve or any major midline venous structures in the quadrigeminal cistern.

CONCLUSION

This modified lateral suboccipital approach ensures safe removal of large vestibular schwannomas and provides sufficient exposure of the inferior colliculus for ideal AMI implantation.

Spindle cell carcinoma of the external auditory meatus with intracranial extension: histological, immunohistochemical and electron microscopic evaluation

We present a case of squamous spindle cell carcinoma of the external auditory meatus in a 38-year-old man. The tumour was extended to the inner ear, the temporal bone, the middle cranial fossa and the meningo-cerebral tissue. The surgical intervention of temporo-occipital craniotomy removed most of the neoplasia. At pathologic examination, the tumour showed an undifferentiated spindle cell pattern. Immunohistochemistry with a large antibody panel found a weak positivity only to EMA. The diagnosis was made when the electron microscopy showed rare junctional structures and tonofilaments.

Ceruminous gland carcinoma of the external auditory canal presenting as chronic otitis media

OBJECTIVE

Ceruminous neoplasms of the external ear canal are rare. Classification, clinical behavior, and management of these tumours are controversial. We report a case of carcinoma originating from the ceruminous glands of the external ear canal (EAC), operated based on a diagnosis of chronic otitis media with polyp.

CASE REPORT

A 48-year-old man presented with left ear discharge and hearing loss. Clinical examination showed a well-circumscribed polypoid mass limited to the EAC. There was no history of bloody ear discharge or radiological findings of bony erosion suggestive of malignancy. Our preliminary diagnosis was chronic otitis media with polyp formation. Tympanoplasty was performed. Histopathology revealed a ceruminous carcinoma, and an additional operation involving lateral temporal bone dissection was performed, followed by 60 Gy radiation therapy.

CONCLUSION

Ceruminous carcinomas should be considered in the differentialdiagnosis of middle and external ear pathologies in cases of soft tissue mass in the EAC.

An otoneurosurgical approach to non-pulsatile and pulsatile tinnitus

OBJECTIVE

Most treatments proposed for tinnitus are non-surgical, to such an extent that it is sometimes forgotten that a certain number of patients with tinnitus may benefit from a surgical solution. The aim of this paper is to review the possible otoneurosurgical approaches in tinnitus treatment, treating the tinnitus causally or symptomatically.

METHODS

A Pubmed search on the words "surgery", "tinnitus" and "pulsatile" was performed and compared to the authors' personal experience with surgical approaches for alleviating tinnitus. The most relevant different pathologies presenting as pulsatile and non-pulsatile tinnitus are given and possible otoneurosurgical approaches for these identities summarised.

RESULTS AND DISCUSSION

Non-pulsatile tinnitus can be the clinical expression of vestibular schwannomas and other cerebellopontine angle lesions, arachnoid cysts, Ménière's disease, otosclerosis, brain tumours along the auditory pathways, Chiari malformations and microvascular compressions of the vestibulocochlear nerve. Symptomatic improvement of non-pulsatile tinnitus can also be obtained by electrical stimulation of the cochlea, auditory nerve or cortex. Pulsatile tinnitus can present as a venous hum resulting from benign intracranial hypertension, Chiari malformation and a high jugular bulb. Arterial-pulse-synchronous tinnitus can be caused by benign intracranial hypertension, arteria carotid stenosis, glomus tumours, vascular lesions of the petrous bone and skull base, ateriovenous malformations, aneurysms, and vascular loops inside the internal auditory canal.

CONCLUSION

Before people are told "to learn to live with their tinnitus" a thorough exploration of possible cause and potential surgical treatments should be provided for patients presenting with incapacitating tinnitus.

Ossicular necrosis following head injury

PROBLEMS/OBJECTIVES

The aim of this study is to report on ossicular necrosis in the middle ear occurring shortly after head injury.

METHODOLOGY

Our sample included 3 males and 2 females aged 9 to 37 years who complained of unilateral hearing loss after a head trauma that had occurred 3 to 6 months previously. The tympanic membranes were intact, and a CT-scan did not show fracture of the temporal bone. Audiometry showed a unilateral conductive hearing loss in all cases.

RESULTS

On tympanotomy exploration, 4 of the 5 patients had a necrosis of the lenticular process of the incus and one patient had a necrosis of the posterior and anterior crura of the stapes. Additionally, the incus was displaced at the incudomalleolar joint towards the promontory in two patients. The long process of the incus was surgically aligned and adjusted to the head of the stapes through interposition of either temporal fascia or a bone chip. At the 2-year-postoperative follow-up, the pure tone audiometry showed that the preoperative air-bone gap was almost closed with a mean of 11.8 dB.

CONCLUSIONS

It is possible that the head injury resulted in ossicular displacement in the middle ear with disturbance of the local vascular supply. Due to the tenuous blood supply to the lenticular and long processes of the incus, this portion of the ossicular chain, including the stapes suprastructure, may become more vulnerable to an ischemic process and subsequent necrosis shortly after the head trauma.

How we do it: diagrammatic recording of tympanomastoid procedures

Accurate documentation of the operative findings of tympanomastoid procedures is essential for effective patient management and to satisfy the growing demands of clinical audit. Due to the three-dimensional complexity of the middle ear, it is difficult to represent graphically. Consequently, most surgeons only describe subjectively their operative, otological findings. We present for the first time a simple middle ear template which provides an objective tool to improve the recording of tympanomastoid procedures.

The Z-Meatoplasty for Modified Radical Mastoidectomy in Children

OBJECTIVE

To determine the effectiveness of the Z-meatoplasty technique for enlargement of the external auditory meatus of children undergoing modified radical mastoidectomy.

DESIGN

Case series.

SETTING

Pediatric otolaryngology practice in an academic setting.

PATIENTS

Consecutive sample of children (< or =18 years old) who had undergone modified radical mastoidectomy performed by the author from 1995 to 2005.

INTERVENTION

Z-meatoplasty technique used as part of modified radical mastoidectomy.

MAIN OUTCOME MEASURE

Development of postoperative stenosis of the external auditory meatus that required additional surgery.

RESULTS

A total of 28 children and 29 ears were treated with modified radical mastoidectomy during the study period. The Z-meatoplasty was used in 24 ears, and 3 (12.5%) required revision meatoplasty for meatal stenosis. Twenty-one ears (87.5%) treated with Z-meatoplasty had excellent healing and cosmesis without stenosis, during a mean follow-up period of 40 months.

CONCLUSION

The Z-meatoplasty is an effective technique for use during modified radical mastoidectomy to treat children with cholesteatoma.

How we do it: Switching from mechanical perforation to the CO2laser; audit results of primary small-fenestra stapedotomy in a district general hospital

The use of laser for stapedotomy was introduced in our department in the year 2002, and since then has taken over the mechanical technique. A total of 85 patients who had undergone primary stapedotomy with either technique are reported with regards to effectiveness and rate of side effects. Although footplate complications were reduced with the laser, short-term hearing outcomes were similar between the two techniques. In four occasions, the surgeon had to switch back to the mechanical technique unexpectedly. Stapedotomy will continue to be performed with the laser in our department, bearing in mind the occasional need for the older technique.

Virtuosity with the Mallet and Gouge: The Brilliant Triumph of the “Modern” Mastoid Operation

The development of mastoid surgery can be traced through the past 4 centuries. Once used as a means of evacuating a postauricular abscess, it has evolved to become a method for gaining entry into the middle ear for diagnostic purposes, to control chronic ear disease, or for otologic and neuro-otologic procedures. Earlier works led the way to the Wilde postauricular incision, which gave rise to Schwartze mastoidectomy. Stacke's technique of mastoidectomy was practiced for some time before Bondy, Heath, and Bryant introduced the modified radical mastoidectomy. By the 1930s, the mastoidectomy had evolved into a generally accepted otologic procedure. Endowed with a rich history, the future of mastoid surgery promises to be equally momentous.

Eustachian Tube Function and the Middle Ear

Eustachian tube dysfunction has been linked to causing middle ear pathology. One of the sequelae seen is tympanic membrane retraction. Concern occurs when this physiological state becomes chronic, leading to adhesive otitis media followed by debris collection and fulminate cholesteatoma. This chapter explores the role the eustachian tube plays in regulating middle ear and mastoid aeration, the causes of eustachian tube dysfunction, and the treatment of this disorder.

Endolymphatic sac revision for recurrent intractable Meniere's disease

Meniere's disease can be observed uniquely in revisions of the conservative surgical procedure for endolymphatic sac enhancement, which preserves the labyrinth, unlike destructive procedures. Genetic anatomic abnormalities in patients lead to malabsorption of endolymph and symptoms of Meniere's that are reversed by endolymphatic sac enhancement, but disabling symptoms eventually may recur in a few cases and require revisional surgery. We observe developing pathophysiologic conditions intraoperatively and have modified our techniques to accommodate the redeveloped pathogenesis we observe and avoid complications found with earlier techniques. This conservative treatment allows patients (many of whom may develop bilateral Meniere's) to retain capacity to accept cochlear implants should they become advisable later.