Acute and acute-on-chronic mastoiditis (a five-year experience at Groote Schuur Hospital)

One hundred and thirty patients with acute-on-chronic mastoiditis were managed by the ENT Department of Groote Schuur Hospital between 1980 and 1984 inclusive. Seventy-four patients had cholesteatomas, of whom 78.4 per cent had intracranial extension and 44.6 per cent had intradural extension of the infection. In contrast, of the 56 patients without cholesteatomas, only 23.2 per cent had intracranial extension of the infection. These may be rare conditions in some privileged parts of the world but their lethal potential requires all ENT surgeons to be competent in their management.

Lateral sinus pathology (22 cases managed at Groote Schuur Hospital)

One hundred and thirty patients with acute and acute on chronic mastoiditis were managed at Groote Schuur Hospital between 1980 and 1984. Twenty-two (16.9 per cent) had pathology of the lateral (sigmoid) sinus and 19 of these patients had cholesteatomas. Nine patients (40.9 per cent) had concomitant intradural sepsis and there were two deaths. The modern literature is reviewed and the pathology, presentation and management of lateral sinus pathology is discussed. This condition is rare and clinical features may range from subtle signs to gross toxaemia, torticollis and evidence of septic embolization. The otolaryngologist must be competent in diagnosing and treating this condition in all forms of its wide spectrum of presentation.

Middle ear tissue mass and audiometric data from otologic care of infants with cleft palate

Routine early myringotomy in patients with cleft lip, cleft palate, or both revealed polypoid tissue masses as well as otitis media with effusion. Changes in middle ear mucosa usually associated with chronic middle ear dysfunction were observed in the early months (2 to 8) of life.

Cholesteatoma in the pediatric age group

The diagnosis and management of cholesteatoma in children remains controversial. In the past 15 years, the senior author (S.C.P.) has treated 320 patients with cholesteatoma. Patients 18 years and younger composed 40% (125) of the overall group and are the basis for this report. The patient data were compiled using the history, physical examination, audiograms, radiographs, patient questionnaires, surgical findings, and postoperative observations. The surgical treatment selected was determined by the extent of disease, the configuration of the mastoid, and a clinical assessment of eustachian tube function. A middle ear tympanotomy approach was used in 17% of the patients, a canal wall up procedure in 31%, and a canal wall down procedure in 52.3%. The average clinical follow-up was 3.9 years, with the range being from 3 months to 13.5 years. Hearing was maintained or slightly improved in a majority of cases. Residual disease occurred in 8% of patients, and recurrent disease in only 3%.

Middle-ear cholesteatoma in children--an Indian perspective

A study of the clinical presentation of acquired aural cholesteatoma in 51 Indian children is presented. An attempt has been made to assess the impact of this chronic ear disease in terms of the morbidity it incurs upon the paediatric population. The preponderance of bilateral presentation in cholesteatomatous otitis media (24.5 per cent) and the associated sensorineural or mixed hearing loss (in 25.4 per cent of the ears) is emphasized, to reflect the alarming audiological disability in the afflicted child. An attempt has been made to correlate the otoscopic profile with the extent of disease, osteitic damage and co-existing complications. It was noted that, in Indian children, mesotympanic choleasteatoma was more often associated with large defects of the pars tensa (viz. marginal, subtotal and total perforations--54.4 per cent) than with postero-superior retraction pockets (37.2 per cent) or purely attic defects (7.8 per cent). Further analysis revealed this common otoscopic presentation to be a more active process, occurring in predominantly cellular mastoids and associated with extensive disease. Based on this study, a more aggressive canal down tympanomastoid approach is advocated for children presenting with this otoscopic profile.

Bilateral congenital cholesteatoma: a cause or result of chronic otitis media with effusion?

Bilateral congenital cholesteatoma in children is unusual, and our experience with a case arising in a 6-year-old boy is described. Various theories of the origin of this disease are briefly reviewed. The possibility that this entity may be more common than previously realized, and its relationship to eustachian tube obstruction and middle ear effusions, are also discussed.

Complicated cholesteatomas: CT findings in inner ear complications of middle ear cholesteatomas

Patients with facial palsy and middle ear disease, which may be chronic but clinically occult, may have a cholesteatoma with extension medially along the facial canal. In two patients, axial computed tomographic (CT) scans demonstrated involvement of the medial petrous bone. Patients with vertigo and chronic middle ear disease may have a cholesteatoma with a "fistula" between the middle and inner ears. Although the fistula usually involves the lateral semicircular canal, the cholesteatoma may pass through the oval window. In two patients, coronal CT scans showed extension to the oval window in one and through it in the other.

Acute mastoid abscess and cholesteatoma

A 10-year review of acute mastoid abscess treated surgically in Belfast revealed a total of 24 cases, 12 of which were found to have an underlying cholesteatoma. The surgical management of these 12 cases is outlined but despite a desire to maintain an intact canal wall, 9 of them to date have ended up with an open cavity. The danger of conservative management and the possible association between acute mastoid abscess and cholesteatoma, especially in developed countries, is stressed.

Tuberculous otitis media as a secondary infection to chronic otitis media with cholesteatoma

A series of six cases of tuberculous otitis media is reviewed. All patients had a history of chronic otorrhea and were operated on with a presumptive diagnosis of chronic otitis media with cholesteatoma. Postoperatively the diagnosis of tuberculosis was established by histologic examination of the granulation tissue from the middle ear and mastoid. We believe that any patient with a long history of discharging ears needs histologic examination, as tuberculous otitis might be the cause of infection. We report our findings in these patients and discuss the possibility of penetration of tuberculous mycobacteria into the ear and mastoid. In our opinion, the tuberculosis is secondary to established ear infection.

Otopathology in cranial facial dysostosis

Thirty patients with Crouzon's disease were evaluated longitudinally for type, incidence, and progression of otopathologic changes. The spectrum of otopathologic manifestations included otitis media with effusion, tympanic membrane atelectasis, tympanic membrane perforation, cholesteatoma, and grade I microtia. The frequency of ear disease progressed from 37% during infancy to 62% in older patients. The degree and type of hearing loss were also analyzed. Radiographic cephalometric measurements of the nasopharynx and temporal bone illustrated growth disturbances of the nasopharyngeal dimensions that worsened with increasing age. Our findings suggest that patients with Crouzon's disease are at risk from birth for otitis media with effusion and its sequelae and that the consequent incidence and severity of otopathologic changes increase with age.

Lethal cholesteatoma

Aural cholesteatoma is a disease entity well known to the otologic community. Complications of cholesteatoma, although uncommon, are not usually life threatening. We present two cases in which a unique and hitherto unreported pathway of spread of a cholesteatoma is noted. The cholesteatoma, after originating in the ear, entered the diploë and spread insidiously between the inner and outer tables to distal parts of the skull. Osteomyelitis, in concert with the cholesteatoma, destroyed large areas of the skull in both patients. One patient died of his disease. The other patient was operated on and is alive but has unresectable disease and purulent drainage from three separate cranial fistulas.

Incidence of occlusion due to impacted cerumen among mentally retarded adolescents

The incidence of occlusion of the external auditory canal due to impacted cerumen was determined for 44 mentally retarded subjects in comparison with 44 nonretarded subjects. Otoscopic data were taken by qualified personnel for both groups and subjected to statistical analysis. Results confirmed that retarded adolescents have a significantly higher incidence of occlusion of the external auditory canal due to impacted cerumen than do nonretarded adolescents. Routine otoscopic examinations should be performed on the former group to ameliorate loss of hearing due to impacted cerumen.

Hereditary congenital cholesteatoma. A variant of branchio-oto dysplasia

A mother and daughter both presented at age 5 years with the triad of right-sided congenital cholesteatoma, right preauricular pits, and bilateral sensorineural hearing loss. Twenty-six years apart, both were treated with middle ear exploration and removal of a cholesteatoma that filled the sinus tympani, facial recess, and middle ear. The sensorineural hearing losses were nonprogressive, and the preauricular pits were asymptomatic. These two cases may represent a unique variant of branchio-oto dysplasia. The mechanism of formation of these anomalies and the possible modes of inheritance are conjectural. This triad, however, supports genetic predisposition rather than aberrant epithelial rests during morphogenesis as a possible cause in congenital cholesteatoma.

Surgical treatment of stenosis of the external auditory canal

Analysis of the outcomes of reconstruction for stenosis of the ear canal in 20 patients revealed that the key step in the procedure after the stenotic meatus and ear canal skin have been removed (in the process accomplishing a wide meatoplasty) is widening the posterior bony canal wall until some mastoid cells are encountered. After the tympanic membrane has been deepithelialized, the bony canal should be lined with two separate pieces of split-thickness skin grafts and protected with Silastic sheeting and packing. Average follow-up of 3 1/3 years revealed that 2 ear canals have restenosed, 2 have partially restenosed, and 18 have healed. Of the 22 ears, 15 have had hearing improved to within 25 dB SRT or better, 5 have moderate hearing improvement, and 2 have no improvement. There were no complications.

Conductive hearing loss in the elderly

With a steadily increasing proportion of the population in the geriatric age group, otolaryngologists are frequently confronted with conductive hearing losses in elderly patients. An evaluation of audiometric data from an out-patient audiology clinic over a six-month period revealed 13.4% of our geriatric patients presented with significant conductive components to their hearing loss. Advances in anesthetic management and medical therapy have broadened the indications for surgery in this age group. Recent evidence suggests that the results of surgery in the elderly patient are identical to those in younger age groups, and careful attention to associated medical problems can keep the complication rate at an acceptable minimum. In the appropriately selected elderly patient, surgical correction of a conductive hearing loss may well be the preferred option.