[The study between temporal bone HRCT and operations in congenital abnormality of external and middle ear]

OBJECTIVE

We explore the deformity degrees of external ear, mastoid process, tympanic cavity and auditory ossicle by the HRCT features of bilateral and unilateral patients of congenital abnormality of external and middle ear for preoperative analysis and selection for surgical approaches.

METHOD

Twenty-nine patients were enrolled in our study, and HRCT were performed on all patients. There were 23 unilateral ears deformity (13 right and 10 left), 6 patients with bilateral ears deformity in the study group. Nineteen patients (19 ears) were treated with operations.

RESULT

The deformity degree of auricle was correlated with that of external auditory meatus, and mastoid process develops bad aeration extent with bad tympanic cavity development in 35 ears in our research. We got data of shortest distance from tympanic cape to atresia board in HRCT, (0.59 +/- 0.13)cm in comparison group, (0.45 +/- 0.19)cm in unilateral deformity group, (0.32 +/- 0.12)cm in bilateral deformity group, and there were significant differences compared the two deformity groups with the comparison group. There were 1 ear with normal auditory ossicle (2.86%), 5 ears with fixation of stapes foot board (14.29%), 3 ears with no auditory ossicle (8.57%); 26 ears with malleus and incus abnormality (74.29%). Abnormality of malleus was always concomitant with that of incus. Degeneration of malleus, the joint amalgamation of malleus and incus were discovered mostly in this research.

CONCLUSION

The deformity degree of auricle is correlated with that of external auditory meatus, and mastoid process develops bad aeration extent with bad tympanic cavity development in 35 ears in our research. The shortest distance from tympanic cape to atresia board in HRCT in unilateral ears deformity group are shorten 0.15 cm in that of comparison group. And that of bilateral ears deformity group are shorten 0.25 cm in that of comparison group. The main abnormality of auditory ossicle in our research present in both malleus and incus, and degeneration of malleus and the joint amalgamation of malleus and incus are main types.

Intraoperative CT-guided cochlear implantation in congenital ear deformity

CONCLUSIONS

Intraoperative computed tomography (iCT)-guided cochlear implantation is practical and effective for correct electrode placement in the cochlea of patients with congenital inner ear and/or complex middle ear malformation.

OBJECTIVES

The operation in patients with inner ear and/or complex middle ear malformation including abnormal facial nerve course is difficult. This study evaluated the efficacy of cochlear implantation under the guidance of iCT to insure correct electrode placement.

METHODS

This was a prospective interventional case series. Ten patients with severe to profound sensorineural hearing loss due to ear malformations were enrolled, and iCT was used to confirm the right placement of electrodes.

RESULTS

Intraoperative CT was performed three times in one patient, twice in two, and once in the others. Interruption of the surgical process for each iCT until resumption of surgery was 9.64 ± 0.63 min. iCT revealed incorrectly positioned cochlear implants in two patients, which were immediately corrected. There were no reoperations due to misplacement of electrodes. iCT helped locate the cochlea in the middle ear of one patient with an abnormal facial nerve course. The overall intervention rate based on iCT findings was 30%.

LEVEL OF EVIDENCE

level 4.

[Efficacy in patients with outer and middle ear deformities of using bone-anchored hearing aids]

OBJECTIVE

To evaluate the efficacy and satisfaction of bone-anchored hearing aids (BAHA) in patients with outer and middle ear deformities.

METHODS

Seven patients with bilateral microtia and aural atresia, and three patients with unilateral microtia and bilateral middle ear malformation were fitted with soft-band BAHA for a few months, followed by receiving unilateral BAHA implantation. Mean pure-tone thresholds and speech audiometry tests results were compared among patients without hearing aid, with soft-band BAHA, and with implanted BAHA. Scores from the BAHA users' questionnaires and Glasgow children's benefit inventory (GCBI) were used to measure patient satisfaction and subjective health benefit.

RESULTS

The mean pure-tone thresholds of the patients were (64.8 ± 5.9) dBHL for those without hearing aid, (30.2 ± 3.7) dBHL for those with soft-band BAHA, and (20.3 ± 3.9) dBHL for those with implanted BAHA. The average decline in pure-tone threshold was (36.2 ± 8.0) dBHL for those with soft-band BAHA, and an additional decline of (12.2 ± 3.4) dBHL was achieved with implanted BAHA. The average gains in speech discrimination scores (SDS) were (3.00 ± 1.07)% for those without hearing aids and (89.39 ± 5.83)% for those with implanted BAHA in sound field of 45dBHL. SDS were (57.55 ± 10.30)% for those without hearing aids and (91.19 ± 4.16)% for those with implanted BAHA in sound field of 65dBHL. The average gains in SDS were (88.21 ± 6.86)% and (38.04 ± 7.56)% tested with 45dBHL and 65dBHL respectively. Sound reception thresholds (SRT) without hearing aids were (63.1 ± 5.9) dBHL and (24.7 ± 3.5) dBHL for those with implanted BAHA. The average gains in SRT was (39.6 ± 6.2) dBHL. The BAHA application questionnaire demonstrated excellent patient satisfaction. The general benefit score was 35.59 ± 14.35.

CONCLUSION

BAHA remains one of the most reliable methods of auditory rehabilitation and improves quality of life for patients with ear deformities.

[Survey of quality of life scale for patients with congenital ear malformation]

OBJECTIVE

To explore the congenital ear malformation (CEM)-specific quality of life (QOL) and examine the effects of total ear reconstruction surgery for QOL of CEM patients.

METHODS

A self-composed QOL scale was used for 129 patients with congenital external and middle ear malformation. All patients were requested to fill in the QOL scale before and 1 month after ear reconstruction surgery.

RESULTS

The level of QOL varied according to the degree of ear malformation. The total QOL score of patients with unilateral and bilateral CEM was 28.5 ± 18.4 and 51.6 ± 23.6, respectively. The total QOL score of patients pre- and post-operation was 21.0 ± 14.0 and 14.2 ± 9.7 respectively. Physiological functions, psychological status and social interactions of the patients were of statistical significance after ear reconstruction surgery compared to that of at pre-operation.

CONCLUSION

Congenital ear malformation-specific QOL scale can show sensitively the changes of QOL of CEM patients. And ear reconstruction surgery is beneficial for the patients.

[A case of congenital (juvenile) otosclerosis]

The present paper reports a case of congenital (juvenile) otosclerosis. This pathology is known to occur in 10% of the patients and cause severe hearing impairment. Precise diagnostics of the activity and extent of the otosclerotic process based on the results of functional multispiral computed tomography (MSCT) enables the practicing surgeons to identify indications for the surgical intervention, choose the adequate method and time for its performance, and make prognosis of its outcome. This inference is confirmed by the clinical observation described in this communication.

[The use of functional multispiral computed tomography for differential diagnostics of otosclerosis and congenital malformation of the internal and middle ear (a case report)]

This paper reports a rare clinical observation of congenital malformation of the internal and middle ear diagnosed with the help of functional multispiral computed tomography (fMSCT). The patient presenting with conductive hearing loss was suspected to have otosclerosis. However, the use of fMSCT made it possible to arrive at a more precise diagnosis, that is congenital malformation of the internal and middle ear that clinically manifested itself as the conductive loss of hearing. It was decided to refrain from the surgical intervention: first, because its efficacy in this case was considered to be doubtful and second, it was fraught with the high risk of development of postoperative complications.

Continuity of the incudostapedial joint: a novel prognostic factor in postoperative hearing outcomes in congenital aural atresia

CONCLUSION

Mean incudostapedial joint (ISJ) angulation of atretic ears was statistically wider than ISJ angulation of non-atretic ears. Postoperative hearing results in the narrow tympanoplasty type II (T2) subgroup were better than those in the wide T2 subgroup. In cases of abnormally wide ISJ angulation, we recommend that partial ossicular reconstruction (POR) be used as a surgical means of achieving hearing improvement.

OBJECTIVE

To report the results of ISJ angulation in patients with congenital aural atresia and its effects on postoperative hearing improvement.

METHODS

Patients undergoing canaloplasty with T2 (149 ears) and canaloplasty with POR (32 ears) were enrolled. The T2 group was dichotomized according to an ISJ cut-off of an angle of 120° into the 'narrow' T2 and 'wide' T2 subgroups. The pre- and postoperative air-bone gap (ABG) and ABG change were analyzed.

RESULTS

Mean ISJ angulation of non-atretic ears was 93.06 ± 13.21° and that of atretic ears in the T2 group was 118.39 ± 19.60° (p < 0.001). Mean short- and long-term postoperative ABGs were better in the narrow T2 subgroup than in the wide T2 subgroup (p = 0.01 and 0.03, respectively). The short-term postoperative ABG and ABG change in the POR showed superior results to those of the wide T2 subgroup (p < 0.001 and 0.041, respectively).

[Sectional anatomical analysis of auricular and middle ear malformation in patients with microtia]

OBJECTIVE

To analyze the sectional anatomical features of auricular and middle ear malformation in patients with microtia so as to improve the clinical classification and the instruction of surgery.

METHODS

From Jun. to Dec. 2009, 36 cases with microtia were selected in the center of auricular reconstruction in Plastic Surgery Hospital, including 22 cases of unilateral microtia and 14 cases of bilateral microtia. 22 patients with unilateral microtia were studied with the contralateral healthy ears as controls. Spiral CT was performed for high-resolution scan of the temporal bone. The coronal, sagittal and 3D reconstruction images were created with Mimic software. Several distances and degrees were measured.

RESULTS

The patients were classified by Max classification. The anteroposterior diameter and the vertical diameter of tympanic cavity were (7.75 +/- 1.92) mm and (14.66 +/- 4.75) mm for type I; (6.17 +/- 2.56) mm and(14.35 +/- 5.12) mm for type II; (6.31 +/- 3.40) mm and (9.97 +/- 4.36) mm for type III (P = 0.001). The mastoid pneumatization degree for type I, II, III were 13.33%, 13.64%, 30.77% in sclerotic type, 13.33%, 18.18%, 7.69% in diploe type, 0, 9.09%, 38.46% in composite type, 73.33%, 59.09%, 23.08% in pneumatic type (chi2 = 24.11, P = 0.002). The cover of fenestra vestibuli by facial nerve was 21.43%, 47.62%, 54.55% (chi2 = 23.44, P = 0.002) for type I, II, III. There was a statistical difference between the microtia group and the control group.

CONCLUSIONS

According to the Max classification, the middle ear malformation changed along the auricular malformation. The anatomical variations was complicated in type II microtia, which should be sub-classified.

[Congenital malformations of the ear--state-of-the-art review]

The rehabilitative treatment of the children presenting with congenital malformations of the external and middle ear requires the use of up-to-date technologies for diagnostics, surgical interventions, and prosthetic treatment in combination with genetic counseling. Many problems related to these issues remain unresolved despite recent progress in this field.

[Development and evaluation of a quality of life scale specific to patients with congenital external and middle ear malformation]

OBJECTIVE

To develop a quality of life scale for patients with congenital external and middle ear malformation, and to explore its reliability and validity.

METHODS

The initial quality of life scale for patients with congenital external and middle ear malformation was constructed based on quality of life scales from home and abroad. A total of 140 patients with congenital external and middle ear malformation had been recruited in the study. After pretest and item sifting, the quality of life scale was constructed, and its reliability and validity were evaluated.

RESULTS

Eighteen-item quality of life scale for patients with congenital external and middle ear malformation was constructed, which included three parts: physiological function, psychological status and social interaction. The retest reliability was 0.878; split-half reliability coefficient and Cronbach's alpha coefficient were 0.927 and 0.899, respectively. The results of factor analysis showed satisfactory construct validity. The reliability and validity of this scale was consistent with the demands of psychometrics.

CONCLUSION

Congenital external and middle ear malformation quality of life scale is believable and effective, which can be used for clinical practice.

Application of the Vibrant Soundbridge in bilateral congenital atresia in toddlers

CONCLUSION

The Vibrant Soundbridge offers an excellent audiologic rehabilitation for toddlers with microtia and atresia. It provides direct stimulation of the cochlea and straightforward adaption to the given anatomical structures. The 'posterior atresia incision' preserves the physical integrity of the tissue layers around the ear remnant, which is essential for an aesthetic auricular reconstruction.

OBJECTIVES

Patients with bilateral aural atresia require immediate auditory stimulation to ensure normal speech development. We present an operative technique that allows safe restoration of hearing before aesthetic reconstruction.

METHODS

A 6-year-old boy presented with bilateral microtia and osseous atresia. A hairline incision was performed through all layers and was followed by a subperiostal preparation towards the atresia plane. The fused malleus-incus-complex was removed and the transducer was crimped to the stapes suprastructure on both sides.

RESULTS

Speech performance is nearly normal in both quiet and noise conditions. The surgery did not affect the tissues that are important for the later ear reconstruction.

[Analysis of correlation between congenital auricular deformities and middle ear malformations]

OBJECTIVE

To explore the potential value of knowing the relationship between congenital auricular deformities and middle ear malformations.

METHODS

A total of 86 patients with congenital auricular deformities and middle ear malformations, including 51 males and 35 females, were admitted from January 2008 to December 2009 to the Eye Ear Nose and Throat Hospital of Fudan University. Fifty-eight patients had unilateral deformities (R:L = 34:24), while 28 were bilateral. One hundred and fourteen ears with congenital auricular deformities were included. High-resolution CT (HRCT) data was obtained from each patient. The auricular deformities were classified into three grades using the Marx H classification system. The modified Jahrsdoerfer grading system was used to score the malformations using HRCT data. The correlation between the grades of auricular deformities and scores of middle ear malformations was analyzed using Spearman rank correlation analysis.

RESULTS

The Marx H grades of congenital auricular deformities were 12 patients with grade I, 25 patients with grade II and 77 patients with grade III, while their corresponding Jahrsdoerfer scores were 7.8 ± 2.4, 6.8 ± 2.6 and 6.0 ± 2.8, respectively. The statistical analysis suggested a trend of negative correlation between the Marx H grades of auricular deformities and the Jahrsdoerfer scores of middle ear malformations (r = -0.2386, P = 0.0106).

CONCLUSION

There was a trend to a negative correlation between congenital auricular deformities and middle ear malformations.

Combined aesthetic and functional reconstruction of ear malformations

BACKGROUND

Surgery for major malformations of the outer and middle ear involves aesthetic as well as functional aspects. Whereas reconstruction of the auricle with autogenous rib cartilage is well established and has shown favorable results, functional repair using classic reconstructive techniques is possible only in a limited group of patients and the outcome is often unsatisfactory. Active middle ear implants (MEI) offer a promising alternative to reconstructive surgery.

METHOD

Fifteen patients with ear malformations underwent implantation of an active middle ear implant (Soundbridge), with or without concomitant reconstruction of the auricle. The vibrating element, the floating mass transducer (FMT), was coupled either to the round window, stapes, oval window or incus, according to each individual's anatomical middle ear situation. Aesthetic as well as functional outcomes were evaluated.

RESULTS

Implantation could be integrated into aesthetic reconstruction of the auricle without complications. In 14/15 patients, a satisfactory functional result could be achieved (< 30 dB pure-tone audiometry). Neither facial nerve palsy nor inner ear hearing loss was observed after implantation.

CONCLUSION

The versatile form of the FMT of the Soundbridge allows for adaptation of the coupling procedure to the individual anatomical situations. Implantation of a Soundbridge MEI is a valuable option for functional reconstruction of the malformed ear, which may offer more consistent and reliable results than classic reconstructive surgery.

The Markham-Stouffville hospital experience with malleovestibulopexy

OBJECTIVE

To analyze the hearing results of malleovestibulopexy (MVP) technique in the special situations encountered in revision stapedotomies and congenital middle ear malformations.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral stapes surgery center, community hospital.

METHODS

Audiometric results of 1369 stapedotomies performed in Markham-Stouffville Hospital during a period from 1991 to 2006 were reviewed. The results of 24 MVP procedures employed for revision stapedotomy or for congenital conductive hearing loss were included.

MAIN OUTCOME MEASURES

Air-bone gap (ABG) closure, air conduction (AC) gain, speech reception threshold (SRT) improvement.

RESULTS

Significant improvement in AC, ABG and SRT was demonstrated postoperatively. ABG closure within 20 dB was achieved in 61% of cases. One patient had transient postoperative vertigo. None of patients developed sensori neural hearing loss (SNHL) due to the surgery.

CONCLUSION

When surgical options for middle ear reconstruction are limited due to stapes immobility combined with absent or eroded incus, MVP offers a useful alternative enabling good hearing results. In our experience, the laser-assisted MVP technique is associated with low risk of postoperative SNHL and vestibular symptoms. This method offers a valuable adjunct to standard middle ear reconstruction techniques.

Narrowing critical regions and determining penetrance for selected 18q- phenotypes

One of our primary goals is to help families who have a child with an 18q deletion anticipate medical issues in order to optimize their child's medical care. To this end we have narrowed the critical regions for four phenotypic features and determined the penetrance for each of those phenotypes when the critical region for that feature is hemizygous. We completed molecular analysis using oligo-array CGH and clinical assessments on 151 individuals with deletions of 18q and made genotype-phenotype correlations defining or narrowing critical regions. These nested regions, all within 18q22.3 to q23, were for kidney malformations, dysmyelination of the brain, growth hormone stimulation response failure, and aural atresia. The region for dysmyelination and growth hormone stimulation response failure were identical and was narrowed to 1.62 Mb, a region containing five known genes. The region for aural atresia was 2.3 Mb and includes an additional three genes. The region for kidney malformations was 3.21 Mb and includes an additional four genes. Penetrance rates were calculated by comparing the number of individuals hemizygous for a critical region with the phenotype to those without the phenotype. The kidney malformations region was 25% penetrant, the dysmyelination region was 100% penetrant, the growth hormone stimulant response failure region was 90% penetrant with variable expressivity, and the aural atresia region was 78% penetrant. Identification of these critical regions suggest possible candidate genes, while penetrance calculations begin to create a predictive phenotypic description based on genotype.

[Effect of surgical reconstruction of congenital aural atresia via the mastoid antrum approach: analysis of 48 cases]

OBJECTIVE

To assess the effect of surgical reconstruction of congenital aural atresia via the mastoid antrum approach and investigate method for preventing postoperative atresia of the reconstructed aural canal.

METHODS

From 2000 to 2008, aural canal reconstruction and tympanoplasty was performed via the mastoid antrum approach. In 48 patients with congenital aural atresia (54 ears, including 45 ears of type II, 9 ears of type III). All the patients were followed-up for 18 months to assess the therapeutic effect.

RESULTS

The mastoid antrum was located uneventfully for all the 54 ears, all showing ossicular chain anomalies involving most frequently the malleus and the incus followed by the upper structures of the stapes. Facial nerve abnormalities were seen in 23 ears (42.6%). Hearing improvement to over 20 dB was achieved in 45 ears (83.3%) and to over 25 dB in 25 ears (46.2%) one year later.

CONCLUSION

The mastoid antrum approach for surgical reconstruction of congenital aural atresia is safe and reliable. Maintenance of the width of the aural canal and prevention of lateral healing of the transplanted tympanic membrane are crucial in the treatment of congenital aural atresia.

Hearing evaluation in newborns with congenital aural malformation

OBJECTIVES

Over 5 years, 68,472 newborns were screened through a newly implemented universal newborn hearing screening program. In 15 cases, atresia of the external ear canal was found. The aim of this study was to estimate the hearing status of these newborns using transiently evoked otoacoustic emissions (TEOAEs) and auditory brainstem responses (ABRs).

METHODS

TEOAEs were performed during the first days after birth in the normal ears of all newborns. Diagnostic ABR audiometry was performed in 10 newborns.

RESULTS

Unilateral involvement occurred in all newborns studied. TEOAEs were present in all the contralateral ears. Normal ABRs were recorded from the healthy ear, whereas a conductive hearing loss, of approximately 50-60 dB, was found in the involved ear. In long-term follow-up, a satisfactory level of hearing, language, and speech development was found in 9 of the newborns; it was too early to come to definite conclusions in 4 newborns and 2 newborns were lost in follow-up.

CONCLUSIONS

In this study, all newborns with aural atresia had normal function in the contralateral ear. Yet, a comprehensive assessment of hearing is essential as early intervention is necessary in the rare case of bilateral hearing impairment.