Otogenic pneumocephalus

Fifty-four previously reported cases of otogenic pneumocephalus were analyzed in addition to five new cases which are presented in detail. Forty-one males and 18 females were included with 95% of the patients being over 12 years of age. The most common presenting symptom was headache, and the ventricular system was the intracranial space most commonly involved. Tension pneumocephalus was present in 40 (66%) cases. Trauma (36%) was the most common etiologic factor, while otitis media (30%), otologic surgery (30%), and congenital defects (2%) accounted for the rest. The overall mortality was 12% with all patients succumbing to causes other than pneumocephalus. Because of its lack of specific symptoms, pneumocephalus was usually unsuspected and the diagnosis made only after radiographic evaluation. Despite its rarity, pneumocephalus has to be considered whenever the dura is violated, especially if associated with a CSF leak. Management depends on the degree of tension, symptomatology, and underlying cause. When associated with trauma or surgery, bedrest and close monitoring may suffice, although needle aspiration or re-exploration may be needed. When secondary to otitis media or a congenital defect, control of any infection and repair of the defect are mandatory.

Hearing and otologic disorders in children with Down syndrome

Hearing impairment and otologic problems have been reported to be prevalent among individuals with Down syndrome. This study was designed to determine whether children with Down syndrome have a higher prevalence of auditory abnormalities than do children with other forms of mental retardation. Hearing, impedance, and otoscopic examinations were performed on 30 children with Down syndrome and 30 children without Down syndrome matched for CA and IQ. Results indicated that the children with Down syndrome had a significantly higher prevalence of hearing impairment and otologic disorders.

Reading disability and middle ear disease

The association between specific reading disability and middle ear disease was investigated in a longitudinal study of 962 children followed from age 5 to 11. No significant differences were found in the prevalence of middle ear abnormalities between the reading disabled group (n = 49) and the remainder.

Metronidazole uptake in the cholesteatomatous membrane in chronic otitis media

Previous investigations have demonstrated a good uptake of metronidazole in the middle ear mucosa. We have now presented a trial study in which there was also a significant uptake of metronidazole in the cholesteatomatous membranes of patients with chronic otitis media.

Mini-myringoplasty in the treatment of tympanic atelectasis

Mini-myringoplasty is an outpatient procedure developed to simultaneously lateralize the tympanic membrane and provide middle ear ventilation in patients who have developed atelectasis. This paper describes the operative procedure and reports on 50 consecutive cases in which these objectives were achieved. Patients experience a minimum of discomfort. Restoration of the normal tympanic membrane configuration and improvement in hearing are noted within a few days.

Medical aspects of synchronized swimming

Synchronized swimming is a low-injury competitive aquatic sport for all ages. It requires flexibility, kinesthetic awareness, and aerobic conditioning, with the ability to function anaerobically as well. Few acute injuries occur during participation in the sport, but overuse injuries are becoming more common as synchronized swimmers participate in longer, more strenuous workout programs. Most common among these injuries are knee pain associated with the eggbeater kick and shoulder pain associated with sculling. Synchronized swimmers are also prone to otitis externa ("swimmer's ear") and chemical conjunctivitis. Stress-related symptoms are common.

Venous lakes of the ears

Venous lakes of the ears and telangiectasias of the ears and cheeks were seen in older men living in Texas who were known to have had long-term sun exposure. Even though these are benign changes, these patients should be checked routinely for possible skin malignancies, especially basal cell carcinomas.

[Differential diagnosis of tinnitus and vertigo. A review]

Tinnitus and vertigo, two common neurological complaints, often challenge the physician's ability with respect to possible etiology. Objective tinnitus can result from an abnormally patent eustachian tube, from tetanic contractions of the muscles of the soft palate, or from vascular abnormalities within the head or neck. Subjective tinnitus refers to lesions involving the external ear canal, tympanic membrane, ossicles, cochlea, auditory nerve, brainstem, and cortex. As many as 50% of patients with tinnitus do not exhibit associated hearing loss; in these patients, the cause of the tinnitus is rarely identified. An illusion of movement is specific for vestibular system disease--a peripheral or central location depending upon associated audiologic and neurologic symptoms, respectively. However, a presyncopal, light-headed sensation is most commonly associated with diffuse cerebral ischemia: in the young patient, this may be caused by a hyperventilation syndrome; in the aged individual, this can result from diffuse atherosclerotic cerebrovascular disease and decreased cardiac output. Postural and gait imbalance associated with acute vertigo indicates a unilateral peripheral vestibular or a central vestibular lesion; if vertigo is absent, either a cerebellar, proprioceptive, or bilateral peripheral vestibular lesion is likely. Transient oscillopsia suggests unilateral peripheral vestibular lesions. Permanent oscillopsia indicates a bilateral peripheral vestibular lesion or--in the absence of severe vertigo--brainstem or cerebellar damage.

Pure-tone and acoustic immittance screening of preschool-aged children: an examination of referral criteria

Seventy-five 3- and 4-yr-old children participated in a hearing screening program that included both pure-tone and acoustic immittance measures. ASHA's guidelines for acoustic immittance screening were modified to include a rescreening of all children failing the immittance test. Results were then compared to those projected from the existing ASHA criteria and two other screening protocols. Our findings revealed a higher incidence of otologic abnormalities in preschoolers compared to school-aged children and a higher incidence of false positives, even when immittance rescreening was provided. Pure-tone audiometry was ineffective as a means of identifying otologic abnormalities. A comparison of the immittance screening protocols indicated that the ASHA guidelines are likely to result in an excessive number of false-positive medical referrals. Recommendations are made for procedural modifications aimed at improving the efficiency of this procedure.

Acute mastoiditis: a review of 34 patients

A review of 34 patients presenting with acute mastoiditis was undertaken. Prior treatment was noteworthy for lack of medical or surgical drainage at the time of initial otitis media. Typical findings, in hospital, included postauricular edema and tenderness, displaced auricle, and distorted tympanic membrane. X-rays were not diagnostic, nor were they helpful in determining who was a surgical candidate. Treatment was individualized. Patients with obvious subperiosteal abscesses, and those who did not respond rapidly to enteric antibiotics, underwent early mastoid surgery. The remaining patients received enteric antibiotics, had drainage established, and were carefully followed. Most resolved without mastoid surgery. Patients with a history of antecedent ear disease were examined separately from those without such history. The former group required mastoid surgery more often than the latter and had poorer outcome.

Surgery in elderly patients with chronic otitis media

The results of surgery in 75 ears in patients over 60 years of age affected by chronic otitis media were compared with the results of surgery in 693 ears in patients under 60 years of age affected by chronic otitis media. Results in the elderly patients were found to be as good as those in the younger patients. No severe complications of surgery occurred in the patients over 60 years of age. The authors recommend that surgery should be undertaken on ears of elderly patients affected by chronic otitis media on the basis of the same indications as in younger patients.

Squamous cell carcinoma of the middle ear. A 25-year retrospective study

Squamous cell carcinomas of the middle ear cleft are highly unpleasant tumors which pose many problems for the otologist. We have retrospectively reviewed the hospital notes of 21 patients (22 ears) who presented with this disease in order to try to clarify those features which are of prognostic significance. We confirmed that a history of chronic suppuration with or without cholesteatoma predisposes the patient to tumor development and that, in the presence of continuing otorrhea, patients are not protected by mastoid surgery. These patients have been treated with conservative surgery and radiotherapy without en bloc resection of the temporal bone and, in these circumstances, the histological grade of the tumor at presentation appears to bear a direct relationship to survival.

Computed tomography of local complications of temporal bone cholesteatomas

The preoperative temporal bone CT scans of 13 patients with surgically proven acquired cholesteatoma were retrospectively reviewed for bony erosions and for extension beyond the temporal bone. A correlation with the clinical and surgical findings was also carried out. The CT findings are discussed and illustrated as well as some pitfalls in the evaluation of bony erosions. The appearance of "autoantrectomy" caused by a dry, self-cleaning, well ventilated cholesteatoma is also discussed and illustrated.

Missing stapes and stapes-replacing prosthesis

Our study of 205 ears with missing stapes, secondary to some type of chronic ear disease, showed that only 40% of such ears are suitable for ossiculoplasty. The remaining 60% are unsuitable because of a fixed footplate, severe atelectasis, hearing better than 25 dB (these patients do not need the operation), or poor discrimination. A new stapes replacement prosthesis (SRP), which we term Tabor, is described for use where indicated. The prosthesis has two parts: The lower part (or base) is made of a broad inorganic, biocompatible material (Teflon). This part fits and covers most of the footplate, ensuring maximal stability. The upper part of the prosthesis is made of autograft or homograft bone--usually a malleus head--the contact of which with the drum prevents extrusion. In twelve out of fourteen ears insertion of this prosthesis was successful; the average postoperative air conduction went from 56 dB to 29 dB, leaving an average air-bone gap of 16 dB. The bone conduction also improved, from an average of 20 dB to 13 dB.

Causes of failure of mastoidectomy for chronic otitis media

The operative findings of 66 patients who underwent revision mastoid surgery for recurrent chronic otitis media were analyzed for the causes of failure of the primary procedures. Recurrent cholesteatoma was found in 41% of the canal wall down and 70% of the canal wall up procedures requiring revision. Additional causes of failure included granulation tissue in unexenterated cells, particularly in the tegmental cells (41% of all cases and 64% of cases without cholesteatoma) and cells of the sinodural angle (38% of all cases and 58% of cases without cholesteatoma). The need for thorough exenteration of cells, particularly the tegmental cells and cells of the sinodural angle, mastoid tip, and facial recess, and the importance of lowering the facial ridge in canal wall down procedures were stressed. Following these principles, the success rate in creating a dry ear in 48 patients who had undergone from one to three previous mastoid procedures was 85% (mean follow-up three years).

Intracranial complications of ear disease in a pediatric population with special emphasis on subdural effusion and empyema

Between the years 1963 to 1982, 84 consecutive cases of intracranial complications of ear disease in pediatric patients were diagnosed and treated at the North Carolina Baptist Hospital. This group consisted of 65 patients with otitic meningitis, four with otitic brain abscess, four with otitic hydrocephalus, three with lateral sinus thrombosis, three with otitic subdural empyemas, and five with an otitic subdural effusion of fluid. The advent of antibiotics has drastically altered the natural history of middle ear infections. We present these 84 cases to review diagnostic problems and therapeutic options, and to offer a plea for continued awareness of the middle ear as a potential source of central nervous system complications.

Cholesteatoma surgery in children

We recently reviewed the records of 1024 operations for aural cholesteatoma, of which 181 were in children. Our surgical management was the same as for adults. Complications of the disease (labyrinthine fistula, facial paralysis, total sensorineural impairment, and meningeal complications) were less common in patients under 16 years of age. This appears to be related to duration of disease rather than to age. The disease in children tends to be more difficult to eradicate. Staging the operation is required more frequently and there is a higher incidence of residual disease at planned second-stage operations. Postoperative serous otitis media, though infrequent, was more common in those patients 16 years of age and older than in children. Persistence of this middle ear fluid, requiring a ventilation tube, was more common in younger children. The functional results of reconstructive middle ear surgery were the same in adults and children.

Subarachnoid space: middle ear pathways and recurrent meningitis

Congenital bony abnormalities of the inner ear may result in a communication between the middle ear and the subarachnoid space. Patients with this anomaly often present with recurrent meningitis associated with acute otitis media or with middle ear fluid. This article presents three cases of recurrent meningitis with open middle ear--subarachnoid space connections. The first two cases involve a cerebrospinal fluid leak into the middle ear via the oval window, both patients having a Mondini-type of inner ear deformity. The pathway in the third case opened into the middle ear along the horizontal portion of the facial nerve. Computed tomography (CT) scanning with metrizamide and differential density calculations helped to identify the abnormal pathway and to confirm that the leak has been closed postoperatively. Use of the CT scanner in these cases can be helpful in planning the surgical closure and in postoperative follow-up.