Post-operative cholesteatomas and retraction pockets after obliterative surgery in ears without cholesteatoma

The frequency of post-operative cholesteatomas, epidermizations and retraction pockets in a series of 343 chronically infected ears (315 patients) without cholesteatoma at primary surgery was evaluated. The ears were operated on radically, exclusively by the Palva method, with removal of the bridge in 248 ears and preservation of it in 95 ears. Musculo-periosteal obliteration and seclusion of the aditus were performed in every case with a Palva flap and with a temporalis muscle-fascia graft. The primary operations took place over the period 1964-1972, and all the ears without cholesteatoma at primary surgery were included; they were followed up annually. The evaluation of this material was carried out in 1976-1979 and the follow-up time was on an average of 8.5 years (5-15 years). Cholesteatoma was found in six (6/343; 1.7 per cent), epidermization of the tympanum in four (4/343; 1.2 per cent), and retraction pockets without cholesteatoma in six (6/343; 1.7 per cent) of the ears. Preservation or removal of the bridge at operation did not cause any significant difference in the frequency of the post-operative complications mentioned (p greater than 0.05). Most of the complications were discovered after the first postoperative year.

Late changes in ear canal volumes after mastoid obliteration

In this study, preoperative and postoperative ear canal volumes of ears subjected to obliterative radical mastoidectomy were assessed. The measurements were performed using sterile saline solution both at the preoperative stage (V0) and at the early (one year, V1) and the late (five to 13 years, V2) postopertive stages. The mean V0 was 0.8 mL (SD, 0.2 mL; V1, 1.0 mL (SD, 0.3 mL); and V2, 1.2 mL (SD, 0.4 mL). The differences were highly significant. Clinically, the widening of the ear canals was mainly slight and appeared evenly in the epitympanic area and in the posterior ear canal wall.

Correlation of postoperative ear canal volumes with obliteration material and with volume of operation cavity

In this study the preoperative and early and late postoperative volumes of ear canals of 131 operated chronic ears were measured by filling the ear canals with saline solution. The ears were operated on using the Palva method of obliteration of the operative cavity and reconstruction of the ear canal after removing the posterior, bony canal wall at operation. The average preoperative ear canal volume (V0) was 0.8 ml, the early postoperative volume (V1) was 1.0 ml, and the late postoperative volume (V2) was 1.2 ml. There was significantly more widening of the volume of the ear canals in the ears with a larger (greater than 7 ml) operation cavity as compared to ears with smaller (3-7 ml) operation cavity (p less than 0.05). Widening of the ear canals was smaller in the 12 ears with obliteration of the surgical cavity with musculoperiosteal flap and anorganic bone (Ossar) as compared to the 119 ears obliterated with musculoperiosteal flap only, but the difference was not statistically significant (p greater than 0.05).

Role of atopic allergy in chronic otitis media. Evaluation based on serum IgE and nasal/aural cytologic findings in patients with operated chronic ears

Serum IgE levels and nasal/aural secretion eosinophils and basophils cells were studied in 84 patients with ear discharge despite previous radical operation, in 83 patients with postoperatively dry ears, and in 30 normal persons. Serum IgE values suggesting atopy (greater than 100 U/ml, PRIST) were more frequent (p less than 0.05) among patients with draining ears than among persons with healthy ears. Normal IgE concentrations showed reversed frequency distribution. Nasal secretion eosinophils and/or basophilic cells were also found more frequently (p less than 0.05) among patients with discharging ears than in other groups. Analogously, those with both serum IgE of greater than 100 U/ml and 'positive' nasal cytology more often had infected than dry (p less than 0.01) or normal (p less than 0.05) ears. Aural secretions showed eosinophils and/or basophilic cells in 14 (17%) patients; 11 of them had such cells in their nasal secretions too. It would seem that atopy is probably one cause of persistent therapy-resistant otitis media and it must be taken into account when considering the treatment of a chronic ear.

Late hearing results after paraffinplasty or silastic sheeting

The long-term hearing results are presented for 135 ears operated on radically. In 59 of the ears temporary paraffin filling of the tympanic cavity was employed after the removal of the tympanic mucosa ot operation. The filling material was removed, and the ossiculoplasty was performed about 6 months later. In 76 ears a one-stage operation with tympanoplasty and Silastic sheeting was employed. There were no statistical differences between the groups of ears mentioned according to hearing results early (1 year) or late (5-15 years) postoperatively or in the deterioration of the air-bone gaps after the first postoperative year (P greater than 0.05). The late change in the air-bone gap was significant in both groups (paraffin group: 6.1 dB; Silastic sheeting group: 5.7 dB; P less than 0.05). The total improvement of hearing late after surgery (as compared to the preoperative hearing) was significantly better in the paraffin group than in ears with Silastic sheeting (P less than 0.05). Paraffinplasty seems to be a suitable way to avoid tympanic adhesions.

Comparison of pre- and post-operative bacteriology of chronic ears

The over-all distribution of the pre-operative bacteria of 806 ears and the post-operative bacteria of 109 post-operatively moist or discharging ears correlated very well, the only clear difference being the detection of diphtheroid bacilli more often post-operatively than pre-operatively. When comparing the pre- and post-operative bacteriology of 109 post-operatively infected chronic ears which had undergone radical surgery and obliteration with Palva flaps (and which were drawn from a group of 806 ears originally operated on and followed yearly for 5-14 years) it was noticed that Pseudomonas aeruginosa and Proteus sp were cultured more often post-operatively than pre-operatively in the same ears. Statistically, other bacteria were not found to be significantly present in the same ears.

Bacteria in the middle ear and ear canal of patients with secretory otitis media and with non-inflamed ears

Aerobic and anaerobic semiquantitative bacteriological cultures were taken from 110 mucoid middle ear effusions and the respective ear canals of 74 patients with secretory otitis media (SOM). Additionally, mucosal pieces from 20 non-inflamed middle ears and swabs from the ear canals were cultured similarly. Bacteria were found in 35 effusions and 65 ear canals with SOM; in both sites the most frequent species were S. epidermidis and S. aureus, and the species distributions were not significantly different in the sites. Ten effusions grew bacteria not culturable in the respective ear canal samples. Anaerobes were found in one effusion only. Nine non-inflamed middle ears revealed bacteria; the species distribution was no different from SOM, and four of the bacteria were not found in the ear canal of the same ear. In conclusion, there may be bacteria in the middle ear in the absence of inflammation and in SOM, but the role of viable bacteria seems to be nil in an established secretory otitis media.

Atlantoaxial subluxation. An unusual complication after local anesthesia for tonsillectomy

After tonsillectomy, atlantoaxial subluxation occurred in two patients. Operations had been performed with the use of local anesthesia, and it was assumed that, during the injection of anesthetics, bacteria infected the prevertebral space. The initial symptoms of the prevertebral space infection were neck pain and stiffness; the movements of the neck were minimal, and opening of the mouth caused pain due to spasm of the deep cervical muscles. Both patients had persistent fever. The roentgenographically observed subluxation developed in one to two months after tonsillectomy. One of the patients was treated only with antibiotics; the other patient required atlantoaxial spondylodesis. Healing of the subluxation lasted about six months in both cases.

Ultrastructural morphology of mucoid effusion in secretory otitis media

The ultrastructural morphology of 19 mucoid middle ear effusions in 14 children with secretory otitis media was studied. Phagocytosing neutrophil granulocytes were the most common inflammatory cells, and ingested bacteria were present in some of them. The next in frequency were macrophages and lymphocytes. Monocytes and polyblasts were also present in most specimens. No plasma cells, eosinophil granulocytes or mast cells were seen. Epithelial cells were common, and great numbers of free and phagocytosed mucus granules were found. Considerable numbers of all the celltypes were in various stages of disintegration. Thus, it seems that the effusion in secretory otitis media is primarily of inflammatory origin, and the dissolution of the cells with liberated cellular contents, together with the secretion of the mucosa, contributes to the formation of the effusion.

Bacteria in chronic maxillary sinusitis

Sixty-one chronically inflamed maxillary sinuses produced 131 bacterial strains from mucosal pieces that were taken during a Caldwell-Luc operation and cultured aerobically and anaerobically. Sinus secretions showed only 62 and nasal secretions 106 bacterial strains. Fourteen mucosal strains, including 11 Haemophilus influenzae, grew heavily. None of 24 mucosal anaerobes showed heavy growth. Of 52 antral mucosae with culturable bacteria, 37 disclosed mixed and 15 pure growth. The bacteriological characteristics of the diseased sinus and the nose did not correlate. The duration or extent of the disease, the macroscopic appearance of the diseased sinus, or the presence or absence of allergy were unrelated to bacteriological findings, except that H influenzae was concentrated in purulent sinuses. Intraoperative culture of antral mucosa seems to give the most reliable picture of the bacteriological condition in chronic maxillary sinusitis.

T lymphocytes in the effusions of secretory otitis media

Smears were made from 39 middle ear effusions in 29 children with secretory otitis media (SOM) and stained with acid alpha-naphthyl acetate esterase (ANAE) to demonstrate T lymphocytes. The effusions showed on the average 21% of the lymphocytes to be ANAE positive, while simultaneously drawn peripheral blood revealed the proportion of ANAE positive cells to be 53% (P less than 0.001, the Student's t-test). Our finding suggests that T cell dependent defence mechanisms may be locally disturbed in SOM.

T cells as marked with acid alpha-naphthyl acetate esterase staining in secretory otitis media

Non-specific acid alpha-naphthyl acetate esterase (ANAE) activity of the lymphocytes was investigated in smears made of middle ear secretions and peripheral blood from 61 children with secretory otitis media. On the average, 20.1% (right ear) and 2.1% (left ear) of the lymphocytes in the ear samples showed distinctive ANAE-positive spots in their cytoplasms, by the method used. The mean percentage of ANAE-positive cells in the blood was 47.8 and it was significantly (P less than 0.001) higher than the respective percentages of the ear samples. In normal childrne, 54.9% of the lymphocytes, on the average, were ANAE-positive. This difference in blood between patients and control group was significant (P less than 0.001). Consequently, the present study suggests that the relationship of T- and non-T-lymphocytes, as a marked with ANAE, are disturbed in children suffering from secretory otitis media. The importance of this finding and the validity of the method are discussed.

Mycotic flora in tonsils and adenoids. A microbiological and histological evaluation

The tonsils of 147 patients with chronic tonsillitis and the adenoids of 134 children with recurrent respiratory infections were cultured for fungal organisms and studied microscopically. A control group consisted of 68 healthy persons. Positive cultures were obtained in 64% of patients with chronic tonsillitis, in 21% of children treated with adenoidectomy, and in 69% of the control group. Candida albicans, Saccharomyces sp. and Aspergillus were the most common organisms. The histological investigations revealed no evidence of pathogenecity in these organisms. They were found in the tonsillar crypts, and no granulomatous inflammation was seen surrounding them.