Clinical Study of Labyrinthine Fistula in Cholesteatomatous Chronic Otitis Media: A Tertiary Care Hospital-Based Retrospective Study in a South Indian Population

INTRODUCTION

Among the extracranial complications of cholesteatoma, the most common is labyrinthine fistula (LF). The causes are still poorly understood for cholesteatoma-induced labyrinthine fistula. Some of the possible factors described in the literature are the patient's age, duration of the disease, growth pattern of cholesteatoma, and disease aggressiveness. These affect the site of development of labyrinthine fistula. Cholesteatoma and its complications pose a great burden on the economic and health sector of developing nations.

AIM AND OBJECTIVE

 The objective is to estimate the incidence of labyrinthine fistula in cholesteatomatous chronic otitis media (COM) and analyze the clinical presentation and post-surgical improvement in hearing and vertigo in the study cohort.

MATERIALS AND METHOD

The study was conducted in the Department of Otorhinolaryngology. It involved retrospective data collection of case records between 2018 and 2022. All patients diagnosed with chronic otitis media (COM) with cholesteatoma were reviewed retrospectively in a tertiary healthcare center. Of the 324 cases reviewed, 21 had an LF.

RESULTS

The incidence rate of LF in our study was 6.48%. Sixteen (76.1%) patients were male, and five (23.9%) were female. The youngest patient was a 10-year-old male, and the oldest was a 51-year-old female. The mean ± standard deviation (SD) age was 34.09 ± 10.05 years. The left ear (76.1%) was affected more than the right ear. All cases were from rural areas, and 16 (76.1%) of them were farmers. Ear discharge (85%) was the most common symptom, followed by hearing loss (76%) and then vertigo (47%). A very peculiar risk factor of self-cleansing the ear was noticed in all patients. Out of the 21 patients who underwent surgery, it was observed that the lateral semicircular canal (LSCC) was the commonest site of the fistula. According to the Dornhoffer and Milewski classification, type II LF was the commonest type. In one patient with a type III LF, a foreign body (a piece of a twig) was found intraoperatively near the LSCC fistula site. Two patients had multiple fistulae. Six patients had associated mastocutaneous fistula, and one had facial nerve paralysis. All patients, except one, were free of vertigo following surgery. Postoperatively, the bone conduction thresholds were similar to the pre-surgical values in 12 of 16 (74%) patients.

CONCLUSION

 The incidence of LF is still higher in developing countries, predominantly in rural populations, where the habit of self-cleansing the ear is a common practice. The common symptoms of COM with LF are ear discharge, hearing impairment, and vertigo. All the cases had a habit of frequent self-cleansing of the external ear as an important risk factor. Therefore, implementing awareness programs on maintaining aural hygiene in rural health centers may reduce the incidence of cholesteatomatous LF, thereby preserving hearing and vestibular functions and improving the quality of life. However, the above statement needs further validation with large multicenter studies.

Co-existing Paraganglioma, Cholesteatoma, and Otomastoiditis With Overlapping Imaging Features: A Diagnostic Challenge

Head and neck paragangliomas are rare neuroendocrine tumors arising from the autonomic nervous system. Imaging hallmarks of paragangliomas of the head and neck include an enhancing soft-tissue mass in the carotid space, jugular foramen, or tympanic cavity on computed tomography; a salt-and-pepper appearance on standard spin-echo magnetic resonance imaging; and an intense blush on angiography. Imaging studies depict the location and extent of tumor involvement, help determine the surgical approach, and predict operative morbidity and mortality. However, an atypical presentation of paragangliomas, especially when co-existing with other middle ear pathologies that have overlapping imaging findings, can often be misleading. Here, we report a case of simultaneous occurrence of paraganglioma, cholesteatoma, and otomastoiditis in a young adult female.

Bone destruction in chronic otitis media is not mediated by the RANKL pathway or estrogen receptor-alpha

BACKGROUND

Chronic otitis media with or without cholesteatoma progresses with various degrees of bone resorption and remodeling. Estrogen mediates osteoprotective effects through the receptor activator of NF-κB ligand (RANKL) pathway, which is mainly mediated by estrogen receptor-alpha (ER-α).

OBJECTIVES

The present study investigated the expression patterns of receptor activator of NF-κB (RANK), osteoprotegerin (OPG), RANKL, and ER-α in pathological tissue from patients with chronic otitis media to determine the roles of those factors in osteolytic mechanisms underlying the pathogenesis of chronic otitis media.

METHODS

Normal and pathological specimens from 18 patients with chronic otitis media were examined.

RESULTS

There were no significant differences in RANK, OPG, RANKL, or ER-α mRNA expression between normal and pathological specimens of epithelial tissue.

CONCLUSIONS

Our findings suggested that RANK, OPG, RANKL, and ER-α are not associated with the bone destruction in chronic otitis media; other cytokines may directly activate the osteoclasts in chronic otitis media.

Comparison of Endoplasmic Reticulum Stress Messenger Ribonucleic Acid Expression Between Chronic Otitis Media With and Without Cholesteatoma

BACKGROUND

We evaluated and compared the role of endoplasmic reticulum stress in chronic otitis media with cholesteatoma and chronic otitis media without cholesteatoma.

METHODS

The messenger ribonucleic acid expression of endoplasmic reticulum stress was measured and compared between chronic otitis media with cholesteatoma and chronic otitis media without cholesteatoma according to the presence or absence of bacteria, type of hearing loss, ossicle destruction, and facial canal dehiscence.

RESULTS

The expression of immunoglobulin heavy chain-binding protein messenger ribonucleic acid was higher in the chronic otitis media without cholesteatoma group than in the chronic otitis media with cholesteatoma group, and Protein kinase RNA (PKR)-like endoplasmic reticulum kinase and activating transcription factor 6 messenger ribonucleic acid expression were higher in the chronic otitis media with cholesteatoma group than in the chronic otitis media without cholesteatoma group.

CONCLUSION

Endoplasmic reticulum stress messenger ribonucleic acids were expressed in both chronic otitis media with cholesteatoma and chronic otitis media without cholesteatoma. The levels of expression of endoplasmic reticulum stress messenger ribonucleic acids differed according to clinical features, suggesting that different endoplasmic reticulum stress pathways are involved in the pathophysiology of different types of chronic otitis media.

The diagnostic utility of diffusion-weighted magnetic resonance imaging and high-resolution computed tomography for cholesteatoma: A meta-analysis

Objective

The purpose of this meta-analysis was to compare the efficiency of high-resolution computed tomography (HRCT) and diffusion-weighted magnetic resonance imaging (DWI) in guiding the diagnosis of middle ear cholesteatoma in clinical practice.

Materials and methods

Cochrane Library, Medline, Embase, PubMed, and Web of Science were searched for studies that evaluated the sensitivity and specificity of HRCT or DWI in detecting middle ear cholesteatoma. A random-effects model was used to calculate and summarize the pooled estimates of sensitivity, specificity, and diagnostic odds ratios. Postoperative pathological results were considered as the diagnostic gold standard for middle ear cholesteatoma.

Results

Fourteen published articles (860 patients) met the inclusion criteria. The sensitivity and specificity of DWI when diagnosing cholesteatoma (regardless of type) were 0.88 (95% confidence interval [CI], 0.80-0.93) and 0.93 (95% CI, 0.86-0.97), respectively, while those of HRCT were 0.68 (95% CI, 0.57-0.77) and 0.78 (95% CI, 0.60-0.90), respectively. Notably, the sensitivity and specificity levels of DWI were similar to those of HRCT (p = .1178 for sensitivity, p = .2144 for specificity; pair-sampled t tests). The sensitivity and specificity of DWI or HRCT for the diagnosis of primary cholesteatoma were 0.78 (95% CI, 0.65-0.88) and 0.84 (95% CI, 0.69-0.93), respectively, while that for recurrent cholesteatoma were 0.93 (95% CI, 0.61-0.99) and 0.94 (95% CI, 0.82-0.98), respectively.

Conclusion

DWI and HRCT have similar levels of high sensitivity and specificity in detecting various cholesteatomas. Also, the diagnostic efficiency of HRCT or DWI for recurrent cholesteatoma is identical to that of primary cholesteatoma. Therefore, HRCT may be used in clinical settings to reduce the use of DWI and save clinical resources.

Lay summary

Data on the use of diffusion-weighted magnetic resonance imaging and high-resolution computed tomography in the diagnosis of cholesteatoma were obtained through a literature search. They were analyzed to guide the clinical diagnosis and treatment of cholesteatoma.

Level of evidence

NA.

Imaging guidance for cholesteatoma surgery using tissue autofluorescence

Significance

Cholesteatoma is an expansile destructive lesion of the middle ear and mastoid, which can result in significant complications by eroding adjacent bony structures. Currently, there is an inability to accurately distinguish cholesteatoma tissue margins from middle ear mucosa tissue, causing a high recidivism rate. Accurately differentiating cholesteatoma and mucosa will enable a more complete removal of the tissue.

Aim

Develop an imaging system to enhance the visibility of cholesteatoma tissue and margins during surgery.

Approach

Cholesteatoma and mucosa tissue samples were excised from the inner ear of patients and illuminated with 405, 450, and 520 nm narrowband lights. Measurements were made with a spectroradiometer equipped with a series of different longpass filters. Images were obtained using a red-green-blue (RGB) digital camera equipped with a long pass filter to block reflected light.

Results

Cholesteatoma tissue fluoresced under 405 and 450 nm illumination. Middle ear mucosa tissue did not fluoresce under the same illumination and measurement conditions. All measurements were negligible under 520 nm illumination conditions. All spectroradiometric measurements of cholesteatoma tissue fluorescence can be predicted by a linear combination of emissions from keratin and flavin adenine dinucleotide. We built a prototype of a fluorescence imaging system using a 495 nm longpass filter in combination with an RGB camera. The system was used to capture calibrated digital camera images of cholesteatoma and mucosa tissue samples. The results confirm that cholesteatoma emits light when it is illuminated with 405 and 450 nm, whereas mucosa tissue does not.

Conclusions

We prototyped an imaging system that is capable of measuring cholesteatoma tissue autofluorescence.

Middle ear cholesteatoma resection under general anesthesia in patients with congenital methemoglobinemia: A case report

RATIONALE

Congenital methemoglobinemia is a rare cyanosis cause that can be manifested in affected individuals. We report a case of congenital methemoglobinemia after middle ear cholesteatoma resection under general anesthesia.

PATIENT CONCERNS

The primary concern of the patient is to safely perform cholesteatoma resection of the middle ear to reduce the pain associated with years of surgery and to survive the perioperative period.

DIAGNOSES

Congenital methemoglobinemia type 1.

INTERVENTIONS

The patient underwent general anesthesia and cholesteatoma resection of the middle ear.

OUTCOMES

The patient successfully underwent cholesteatoma resection in the middle ear under general anesthesia and went through the perioperative period smoothly, and successfully returned to society.

LESSONS

For patients requiring general anesthesia complicated with rare methemoglobinemia, we improve the awareness of crisis and make comprehensive preparation and monitoring, learn the pathophysiological mechanism related to the disease, so as to protect the operation of methemoglobin patients under general anesthesia.

Micro RNAs and Circular RNAs in Different Forms of Otitis Media

The aim of this comprehensive review was to present the current knowledge on the role of microRNAs (miRNAs) in acute, recurrent, and chronic forms of otitis media. Special attention was focused on cholesteatoma of the middle ear. MicroRNAs modulate gene expression, which, in turn, influences the development and likelihood of the recurrence of acute and aggressive chronic middle ear inflammatory processes. Moreover, this study discusses the modulating role of a specific subgroup of noncoding RNA, circular RNA (circRNA). Recognizing the precise potential pathways and the mechanisms of their function may contribute to a better understanding of the molecular bases of middle ear diseases and identifying novel methods for treating this demanding pathology. Articles published between 2009 and 2022 were used in this analysis. In this review, we provide a complete overview of the latest progress in identifying the role and mechanisms of particular miRNAs and circRNAs in acute, recurrent and chronic forms of otitis media.

Prognostic role of EAONO/JOS, STAMCO, and ChOLE Staging for Exclusive Endoscopic and Endoscopic-Microscopic Tympanoplasty

OBJECTIVE

The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging.

STUDY DESIGN

Retrospective study.

SETTING

Monocentric study in a tertiary referral center.

METHODS

One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging.

RESULTS

The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p = .031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p = .046).

CONCLUSION

EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma.

A Rare Combination of Acquired Lymphangioma of the External Auditory Canal and Cholesteatoma in the Middle Ear Cavity

Lymphangioma (LM) is a rare but benign tumor derived from lymphatic malformation, which is extremely rare in the auditory canal or middle ear cavity. We presented a case of acquired lymphangioma of the external auditory canal combined with cholesteatoma in the middle ear cavity. To our best knowledge, this is the first case of combined lesions of lymphangioma and cholesteatoma in English literature.

Inside-Out Transcanal Endoscopic Mastoidectomy: Literature Revision

Introduction  Recently, there have been significant advancements in transcanal endoscopic ear surgery (TEES). The combination of rigid and thin otoendoscopes with high-definition cameras enabled a less invasive transcanal access to the middle ear and a clearer view of the surgical field. Several surgeons have recently published studies about cholesteatoma resection via transcanal endoscopic surgery, even in cases where the disease has extended to the mastoid, requiring transcanal endoscopic mastoidectomy. Objectives  To analyze the currently available literature on transcanal endoscopic inside-out mastoidectomy, and to determine its efficacy as a surgical technique by evaluating the disease's relapse/recurrence rate. Data Synthesis  Initially, the titles and abstracts of articles identified were analyzed. At this stage, 117 articles were analyzed, 97 of which were excluded for not meeting the inclusion criteria. The 20 remaining articles were further evaluated. The articles were classified on the basis of five levels of scientific evidence. Final Comments  The analysis of the studies showed that the transcanal endoscopic approach is effective in providing access to the attic or antrum, especially in cases of sclerotic mastoids. There was only one study with grade A recommendation, which showed the efficacy of endoscopic ear surgery in the treatment of cholesteatoma. Furthermore, there were three studies with grade B recommendation, showing less relapse/recurrence after TEES. More studies with grade A and B recommendations are needed to better evaluate the effectiveness of TEES, especially compared with that of traditional microscopic surgery.

Recurrence in cholesteatoma surgery: what have we learnt and where are we going? A narrative review

Treatment of cholesteatoma is surgical and has historically encompassed two main techniques: canal wall up (CWU) and canal wall down (CWD) tympanoplasty. Follow-up for cholesteatoma is still debated and can be either radiological or with second-look surgery. MRI with diffusion weighted sequences has proved to have high sensitivity and specificity in detecting recurrent or residual disease. Specifically, non-echo planar imaging DWI (non-EPI DWI) has been shown to be superior to other imaging techniques, allowing, in some cases, to avoid second-look surgery. Both residual and recurrence rates are higher in CWU compared to CWD procedures. Endoscopic ear surgery (EES) has become popular with the advantage of “looking around corners”. The endoscope is used in addition to a microscope or exclusively to reduce cholesteatoma recurrence. In addition, it has been demonstrated that mastoid obliteration and the use of potassium titanyl phosphate laser (KTP) can reduce cholesteatoma recurrence, with better functional outcomes. A synthetic sulphur compound (MESNA) may have an interesting role in the overall improvement in recurrence and residual cholesteatoma disease. This narrative review critically appraises the factors associated with the risk of recurrent cholesteatoma.

Digital image enhancement may improve sensitivity of cholesteatoma detection during endoscopic ear surgery

OBJECTIVES

This study investigates the possible benefits and limitations of the digital image enhancement systems provided by Storz Professional Image Enhancement System (SPIES) during endoscopic ear surgery (EES) for cholesteatoma. An increased detection of cholesteatoma residuals during the final steps of endoscopic surgery using DIE technology was hypothesized.

DESIGN

Cross-sectional study.

SETTING

Tertiary referral hospital.

METHODS

A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image-enhancing modalities (Clara, Spectra A, Spectra B), were generated. Fifty-one experienced ear surgeons participated to the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. The answers were compared with the histopathological reports.

RESULTS

Clara showed the highest accuracy in cholesteatoma detection, followed by Spectra A and lastly Spectra B. In contrast, Spectra B showed the highest sensitivity and Clara the highest specificity, while Spectra A was placed in the middle for both values. Using the Spectra B modality, most responses agreed across the two time points. Ear surgeons assessed the usefulness, as well as preference among image modalities for cholesteatoma surgery, in the following order: Clara, Spectra B, Spectra A.

CONCLUSION

Digital enhancement technologies are applicable to EES. After complete cholesteatoma removal, Spectra B showed the highest sensitivity in the detection of cholesteatoma residuals as compared with Clara and Spectra A. Thus, Spectra B may be recommended to avoid missing any cholesteatoma residuals during EES.

Morphopathogenesis of Adult Acquired Cholesteatoma

Background and Objectives. The aim of this study was to compare the distribution of proliferation markers (Ki-67, NF-κβ), tissue-remodeling factors (MMP-2, MMP-9, TIMP-2, TIMP-4), vascular endothelial growth factor (VEGF), interleukins (IL-1 and IL-10), human beta defensins (HβD-2 and HβD-4) and Sonic hedgehog gene protein in cholesteatoma and control skin. Methods. Nineteen patient cholesteatoma tissues and seven control skin materials from cadavers were included in the study and stained immunohistochemically. Results. Statistically discernible differences were found between the following: the Ki-67 in the matrix and the Ki-67 in the skin epithelium (p = 0.000); the Ki-67 in the perimatrix and the Ki-67 in the connective tissue (p = 0.010); the NF-κβ in the cholesteatoma matrix and the NF-κβ in the epithelium (p = 0.001); the MMP-9 in the matrix and the MMP-9 in the epithelium (p = 0.008); the HβD-2 in the perimatrix and the HβD-2 in the connective tissue (p = 0.004); and the Shh in the cholesteatoma's perimatrix and the Shh in the skin's connective tissue (p = 0.000). Conclusion. The elevation of Ki-67 and NF-κβ suggests the induction of cellular proliferation in the cholesteatoma. Intercorrelations between VEGF, NF-κβ and TIMP-2 induce neo-angiogenesis in adult cholesteatoma. The similarity in the expression of IL-1 and IL-10 suggests the dysregulation of the local immune status in cholesteatoma. The overexpression of the Sonic hedgehog gene protein in the cholesteatoma proves the selective local stimulation of perimatrix development.

Higher degree of keratinization correlated with severe bone destruction in acquired Cholesteatoma

BACKGROUND

Acquired cholesteatoma is characterized by hyper-keratinized squamous epithelium and bone destruction. However, direct evidence for hyper-keratinized epidermis promoting bone destruction is lacking.

AIMS/OBJECTIVES

To determine whether higher degree of keratinization correlated with severe bone destruction and further offer direct evidence for keratinocyte-inducing osteoclastogenesis.

MATERIALS AND METHODS

Histological changes and clinical relevance were analyzed in human-acquired cholesteatoma. Animal models were established by implanting autologous epidermis with different degrees of keratinization. The severity of bone resorption and the number of osteoclasts were compared in different keratinized groups. An in vitro coculture system was developed to mimic the progress of keratinocyte-inducing osteoclastogenesis.

RESULTS

The matrix of cholesteatoma was composed of a thicker stratum corneum than normal skin. The stratum corneum thickness and the expression of Keratin 10 positively correlated to the severity of bone destruction. Animal models revealed that the bone destruction induced by a higher keratinized epidermis was more severe. Osteoclasts were detected in bone erosion areas, and the number of osteoclasts increased with the keratinization degrees of the graft. In vitro studies showed that keratinocytes directly promoted monocytes differentiating into osteoclasts.

CONCLUSIONS AND SIGNIFICANCE

In acquired cholesteatoma, the degree of keratinization correlated with disease severity, and keratinocytes directly promote osteoclastogenesis.

A Role for Mast Cell-Mediated Antibodies in the Formation of Cholesteatoma and Cholesteatoma-Induced Bone Erosion

The study aimed to evaluate the effects and relationships between mast cells in the matrix, mast cell enzymes tryptase and chymase, epithelial proliferation, microvascular density, and bone destruction in cholesteatoma. Thirty-five biopsies diagnosed with cholesteatoma and seven healthy skin tissues taken from the retro-auricular region for control were evaluated. Immunohistochemical studies were performed with CD117, CD34, Ki-67, chymase, and tryptase antibodies, in a single session for all cases and the control group. The relationship between erosion size and antibody load was determined. The mean cholesteatoma epithelium Ki-67 was higher than the control group (p < 0.001). CD117-positive mast cells, chymase-positive mast cells, tryptase-positive mast cells, and microvessel density were significantly higher in the cholesteatoma matrix compared to the control group (p < 0.002, p < 0.001, p < 0.005). In the group with bone erosion scores of two and above, immunohistochemical markers tended to be higher. A positive correlation was found between CD117 and chymase, tryptase, and microvessel density; between tryptase, chymase, and microvessel density; and between chymase and microvessel density. CD117-positive mast cells and chymase-positive mast cells stimulate angiogenesis, increase the epithelium's proliferative capacity in the cholesteatoma matrix, and form cholesteatoma. The increased proliferation of cholesteatoma epithelium and increased vascular density in the matrix exacerbate bone erosion.

Use of artificial intelligence for the diagnosis of cholesteatoma

Objectives

Accurate diagnosis of cholesteatomas is crucial. However, cholesteatomas can easily be missed in routine otoscopic exams. Convolutional neural networks (CNNs) have performed well in medical image classification, so we evaluated their use for detecting cholesteatomas in otoscopic images.

Study Design

Design and evaluation of artificial intelligence driven workflow for cholesteatoma diagnosis.

Methods

Otoscopic images collected from the faculty practice of the senior author were deidentified and labeled by the senior author as cholesteatoma, abnormal non-cholesteatoma, or normal. An image classification workflow was developed to automatically differentiate cholesteatomas from other possible tympanic membrane appearances. Eight pretrained CNNs were trained on our otoscopic images, then tested on a withheld subset of images to evaluate their final performance. CNN intermediate activations were also extracted to visualize important image features.

Results

A total of 834 otoscopic images were collected, further categorized into 197 cholesteatoma, 457 abnormal non-cholesteatoma, and 180 normal. Final trained CNNs demonstrated strong performance, achieving accuracies of 83.8%-98.5% for differentiating cholesteatoma from normal, 75.6%-90.1% for differentiating cholesteatoma from abnormal non-cholesteatoma, and 87.0%-90.4% for differentiating cholesteatoma from non-cholesteatoma (abnormal non-cholesteatoma + normal). DenseNet201 (100% sensitivity, 97.1% specificity), NASNetLarge (100% sensitivity, 88.2% specificity), and MobileNetV2 (94.1% sensitivity, 100% specificity) were among the best performing CNNs in distinguishing cholesteatoma versus normal. Visualization of intermediate activations showed robust detection of relevant image features by the CNNs.

Conclusion

While further refinement and more training images are needed to improve performance, artificial intelligence-driven analysis of otoscopic images shows great promise as a diagnostic tool for detecting cholesteatomas.

Level of Evidence

3.

Facial Palsy Secondary to Cholesteatoma: A Case-Series of 14 Patients

BACKGROUND

To evaluate patients with middle ear cholesteatoma presenting with facial palsy (FP).

MATERIAL-METHODS

A total of 14 subjects (10 males and 4 females), with a mean age of 42.5 years, were included in our study. The majority of patients presented with incomplete FP (House-Brackmann HB II-IV, 11 cases) and the remaining 3 patients had complete facial paralysis (HB V-VI). A canal wall down mastoidectomy was performed in all the patients, followed by partial facial nerve decompression.

RESULTS

At the one-year follow-up, eleven (78.5%) patients demonstrated satisfactory recovery to HB I-II. Facial function recovered to HB grade I-II in 9 (100%) patients who were surgically treated within one month, and in 2 (40%) patients who underwent surgery after one month. The tympanic segment of facial nerve was the most common site of involvement (8 patients). The multiple regression analysis showed that a higher preoperative HB grade combined with a gradual than sudden onset of FP more likely resulted in worse postoperative HB grade.

CONCLUSION

Early surgical removal of cholesteatoma associated with FP is more likely to result in good facial nerve recovery (78.5% of cases), when it is performed within one month from the onset of FP. According to the literature, the tympanic segment of the facial nerve was more frequently damaged (77.7%), followed by the mastoid segment (22.9%), labyrinthine segment (11.1%), and geniculate ganglion (11.1%). Labyrinthine fistula, mainly of the lateral semicircular canal, can be expected in cases of facial nerve dehiscence. The canal wall down mastoidectomy combined with partial decompression surgery was the most preferred surgical treatment for the FP secondary to cholesteatoma.

Novel candidate genes for cholesteatoma in chronic otitis media

Cholesteatoma is a rare and benign disease, but its propensity to cause erosive damage through uninhibited growth can be detrimental to hearing and health. Prior reports indicated a genetic component to pathogenesis in at least a subset of patients. In this study, we aimed to identify rare DNA variants in affected patients. The salivary DNA of six patients whose middle ear tissues were obtained during tympanoplasty/mastoidectomy surgeries were submitted for exome sequencing. Tissue samples from the same patients were previously submitted for mRNA sequencing and analyzed for differentially expressed genes (DEGs). From the generated exome sequence data, rare predicted-to-be-damaging variants were selected within previously identified DEGs, and the candidate genes within which these rare variants lie were used for network analysis. Exome sequencing of six DNA samples yielded 5,078 rare variants with minor allele frequency <.001. A total of 510 variants were predicted to be deleterious and 52 were found to lie within previously identified DEGs. After selecting variants based on quality control measures, 12 variants were identified all from one pediatric patient. Network analysis identified ten significant cellular pathways, including protein transport, viral process, regulation of catalytic activity and cell cycle, and apoptotic and rhythmic processes. We hypothesize that the candidate genes identified in this study may be part of key signaling pathways during the mucosal response to middle ear infection. The occurrence of multiple rare variants may play a role in earlier onset of cholesteatoma formation in chronic otitis media.

[Bacterial microbiota in exacerbation of chronic purulent otitis media in children]

OBJECTIVE

To study current spectrum of bacterial pathogens that cause exacerbation of chronic suppurative otitis media (CSOM) in children, who live in Moscow region, and to investigate sensitivity of isolated strains to various antibacterial drugs.

MATERIAL AND METHODS

The results of microbiome's bacterial cultivation of purulent discharge from tympanic cavities collected from 269 children with CSOM aged from 1.5 to 18 years for the period from 2017 to 2021 yr. were analyzed. The majority of examined subjects (70.6% from 190 children) had CSOM with cholesteatoma.

RESULTS

Monoculture was received in 62.5% of examined patients, bacterial associations - in 25.7%, bacterial-fungal associations - in 2.6%, and there was no growth in 9.2% of subjects. Staphylococcus aureus, which was found in 36.1% of children, dominated among agents. Pseudomonas aeruginosa was the second most frequently diagnosed agent, revealed in 12.3% of patients. Candida spp. (7.1%) was prevalent in bacterial-fungal associations. The article presents the results of isolated strains' sensitivity to antibacterial drugs. The high resistance to oxacillin, cefoxitin and antipseudomonal drugs was found among strains collected from children with CSOM and cholesteatoma.

CONCLUSION

S. aureus (36.1%) and P. aeruginosa (12.3%) remain the most common causative agents for exacerbation of chronic suppurative otitis media in children. Pathogenic fungi are not isolated separately, and Candida spp. (6.7%) dominates in bacterial-fungal associations. It is generally recognized and confirmed by our research, that topical fluoruquinolones (ciprofloxacin) are the most effective drugs for exacerbation of chronic suppurative otitis media treatment. Systemic antibiotics, of which fluoruquinolones (ciprofloxacin) are the most effective, are recommended in severe exacerbation, severe and destructive forms of chronic suppurative otitis media.

[Anatomical factors of temporal bone residual cholesteatoma: our experience]

The article describes clinical cases of invasive cholesteatoma of the temporal bone pyramid, leading to a massive destruction of the surrounding structures. Paying attention to the importance of knowing the microsurgical anatomy of critical structures of temporal bone (the anterior bony plate (cog), the tensor tympani fold and the tendon, the tympanic orifice of the eustachian tube, the pretympanic recess, tympanic sinuses) bearing a significance and helping to improve the removal of the invasive cholesteatoma.

[Partial sequestration of the labyrinth in a child with chronic suppurative otitis media with cholesteatoma]

A clinical case of a 16-year-old child with chronic suppurative otitis media with cholesteatoma complicated by partial labyrinth sequestration is presented. The case describes is a rare disorder. Computed tomography of temporal bones consistent with intraoperative data was decisive in establishing the diagnosis and the surgery extent.

The Impact of Chronic Suppurative Otitis Media with and without Cholesteatoma in Patients from Northeastern Romania

Quality of life is a widely used concept that tends to become an important part of clinical management. The present study performs an analysis of the impact of suppurative chronic otitis media with and without cholesteatoma on quality of life, using the COMQ-12 questionnaire. It was applied to a group of 40 healthy people and to 40 patients before surgery, and the answers to the questions were analyzed and correlated with socioeconomic factors. After the confirmation of the diagnosis based on clinical and imaging information, the patients completed the COMQ-12 questionnaire. It was observed that the chronic ear problems had negative impacts of varying degrees on daily and long-term activities. The evaluation and analysis of information can be used in setting therapeutic targets.

Effectiveness and Safety of Attic Exposition-Antrum Exclusion versus Canal Wall-Up in Patients with Acquired Stage Ib and II Cholesteatoma Affecting the Attic and Tympanic Cavity

This study aims to test the effectiveness and safety of exteriorization surgery comprising atticotomy and obliteration of the additus ad antrum, also referred to as attic exposition-antrum exclusion (AE-AE) surgery. This surgery combines otoendoscopy with surgical microscopy for the treatment of acquired pars flaccida cholesteatoma in stages Ib and II (according to the classification of the Japan Otological Society) present in the attic and the tympanic cavity. We reviewed a historical cohort of 65 patients. Of the total, 21 were treated with canal wall-up tympanomastoidectomy (CWU). Patients in whom the AE-AE technique was performed had residual and recurrence rates of 0% and 9.1%, respectively, compared with 28.6% and 9.5%, respectively, for those treated with CWU. In the AE-AE procedure, surgery is performed in one stage compared with the two stages in CWU, to address the risk of residual cholesteatoma. Auditory thresholds were higher in the CWU group compared with the AE-AE group in the pre-surgery (53 ± 16 vs. 44 ± 15 dB; p = 0.039) and post-surgery (52 ± 18 vs. 42 ± 16 dB; p = 0.042) evaluations but not in pre-post-surgery comparisons for either the AE-AE technique (p = 0.89) or the CWU technique (p = 0.96). We conclude that AE-AE is an effective and safe technique for the treatment of acquired stage Ib and II cholesteatoma present in the attic and tympanic cavities.