External auditory canal closure in cochlear implant surgery

OBJECTIVE

To evaluate surgical techniques and complications associated with external auditory canal (EAC) closure in cochlear implant surgery.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center with a large cochlear implant program.

PATIENTS

Twenty-eight patients (8 adults and 20 children) underwent multichannel cochlear implantation with EAC closure. The follow-up periods ranged between 1 and 10 years. Closure of the EAC was performed in conjunction with implantation of ears with chronic suppurative otitis media or cochlear drill-out procedures for ossification, or for access to the cochlea in patients with abnormal temporal bone anatomy. A modified Rambo technique was used for EAC closure in all but one case.

INTERVENTIONS

Cochlear implantation with EAC closure and subsequent clinical and radiologic follow-up.

MAIN OUTCOME MEASURES

Postoperative complications or the development of cholesteatoma in the implanted ear.

RESULTS

Cholesteatoma developed in the implanted ear in two patients. Breakdown of EAC closure occurred in one of these patients. The details of these patients are reviewed.

CONCLUSION

Closure of EAC can be done with relatively low risk. Close and careful follow-up is required for early detection of a developing cholesteatoma.

Retinoic acid depletion induces keratinizing squamous differentiation in human middle ear epithelial cell cultures

OBJECTIVE

The pathogenesis of cholesteatoma behind an intact tympanic membrane remains controversial. Squamous metaplasia of the middle ear mucosa is thought to be a possible mechanism in such cases. However, to date, no definitive experimental results have proved this association. This study was undertaken to investigate whether normal human middle ear epithelial (NHMEE) cells undergo keratinizing squamous differentiation in a retinoic acid (RA)-deficient culture.

MATERIAL AND METHODS

We examined the morphological differences between RA-deficient and -sufficient cultures, and determined the expressions of the mucin gene and cornifin-alpha mRNAs as indicators of mucous and squamous differentiation, respectively.

RESULTS

Histomorphologically, the NHMEE cells differentiated into a keratinizing squamous epithelium in RA-deficient cultures. In addition, the expressions of mucin gene 5AC (MUCSAC) and MUC8 mRNAs were suppressed, and the expression of cornifin-alpha mRNA increased progressively as a function of differentiation in RA-deficient cultures.

CONCLUSIONS

This study shows that RA depletion induces keratinizing squamous differentiation in NHMEE cell cultures. This finding supports the hypothesis that middle ear cholesteatoma originates from metaplastic middle ear mucosa.

[Middle ear cholesteatoma: present-day concepts of etiology and pathogenesis]

Since J. Cruveilhier described cholesteatoma as the "pearly" tumor of the middle ear in 1828, the pathogenesis of cholesteatoma remained controversial. It is accepted that cholesteatoma may be congenital or acquired. Several pathogenic mechanisms have been proposed to explain the pathogenesis of congenital cholesteatoma. Proposed theories include ectopic epidermis rest, ingrowth of meatal epidermis, metaplasia and reflux of amniotic fluid. Four basic theories present the pathogenesis of acquired cholesteatoma: invagination of the tympanic membrane (retraction pocket cholesteatoma), basal cell proliferation, epithelial in-growth through a perforation (the immigration theory) and squamous metaplasia of middle ear epithelium. The aim of the article is to review the recent literature dealing with problems of the etiopathogenesis and classification of cholesteatoma.

Efficacy of surgical treatment of chronic otitis media

This article presents our results of surgical treatment of chronic otitis media (COM) and discusses its efficacy regarding the control of disease and hearing results. A retrospective chart review of 84 ears was performed. Forty-one ears with noncholesteatomatous COM underwent tympanomastoidectomy, 43 ears with cholesteatoma were managed according to the extension of the disease, closed mastoidectomy was indicated in 19 cases, and open mastoidectomy was performed in 24 ears. In the group without cholesteatoma, a stable ear with closed tympanic membrane was obtained in 85% of cases after the first procedure. The speech response threshold before and after surgery was 38 and 26 dB. In patients with cholesteatoma, a dry ear was achieved in 79% of cases on both techniques after the first intervention. The recurrence rate of cholesteatoma was 10% for the closed technique and 4% for the open technique. The mean preoperative and postoperative SRTs for the closed technique were 30 and 29 dB and for the open technique were 50 and 54 dB. The surgical treatment for COM can be a rewarding procedure if a correct technique is indicated. The surgery should be tailored regarding the clinical stage and intraoperative findings in each case.

[Retrospective results of radiation therapy of the eustachian tube in chronic otitis media]

BACKGROUND

The treatment results of symptomatic radiation therapy of the Eustachian tube in chronic otitis media had to be evaluated retrospectively.

PATIENTS AND METHODS

Between 1980 and 1997, 66 patients were referred for therapy. The median age was 58 years. In the clinical presentation, all the patients had a hearing impairment, 35 patients complained of pain, 21 had otorrhea. In their history, 20 patients indicated chronic recurrent infections. The complaints lasted for 4.7 years in the median, primary conservative (adstringentia, antibiotics) and surgical treatment (paracentesis, tympanic tubule, tympanoplastic) did not lead to lasting cure. In 40 of 66 patients, finally radiation therapy was done of both Eustachian tubes. With opposed fields and cobalt-60 photons a total dose of 6 Gy at single doses of 1 Gy, three times a week, was applied. Under the causes for exclusion of radiation therapy were non-acceptance of the patients (nine), prior radiation therapies (six) or spontaneous improvement after initial presentation in our department. The treatment results were evaluated by interviews of the patients and regular otorhinolaryngological examinations.

RESULTS

There were no side effects noticed. 28 of 40 (70%) patients reported a significant improvement that could be verified by objective otorhinolaryngological examinations. In the group of 26 nonirradiated patients, 22 could be interviewed indicating in 16 cases (72%) that the complaints were unchanged and chronic otitis media was lasting. In a subgroup analysis concerning the duration of otitis media radiation therapy proved more effective in an acute and subacute stadium of disease of up to 5 years duration, while the patients resistant to radiation therapy were entirely in a chronic stage of disease exceeding 5 years duration.

CONCLUSIONS

Radiation therapy is an effective tool for symptomatic improvement of the therapy-resistant chronic otitis media. A dose of 6 Gy seems to be sufficient to achieve an antiinflammatory effect. Radiotherapy should be applied earlier after initial conservative and surgical treatment.

Revision surgery for chronic otitis media: recurrent-residual disease and hearing

The aim of this study was to determine the effect of surgical approach, intact canal wall (ICW) or canal wall down (CWD), upon the success of revision surgery for chronic otitis media (COM). A retrospective analysis of 367 patients (including 65 children aged <15 years) who underwent revision tympanoplasty because of persistent disease was performed. Single-staged tympanoplasty was performed, preserving the canal wall when present. Hearing was reconstructed with allograft incus. Follow-up ranged from one to 15 years. Hearing was determined by pre- and post-operative air-bone gaps. Post-operative re-perforation, aural discharge and/or cholesteatoma rates were similar for CWD and ICW. Cholesteatoma could present following the revision, even though it was not apparent at surgery. Following tympanoplasty, the final hearing was not significantly affected by the surgical approach or presence of cholesteatoma. Improvement in hearing was adversely affected by cholesteatoma or an absent stapes suprastructure. Revision ICW and CWD operations were both successful in controlling signs of COM. Cholesteatoma is a peripheral risk in COM and may become apparent after revision surgery.

Bone resorption in chronic otitis media: the role of the osteoclast

Most of the pathology associated with cholesteatoma is the result of osteoclast-mediated bone resorption in the middle ear. Cytokines, prostaglandins, nitric oxide, neurotransmitters and growth factors are associated with chronic inflammation and have been implicated in cholesteatoma-induced bone resorption. Although many different factors are known to regulate osteoclast activation, there is a final common pathway of osteoclast differentiation and resorption. Recent advances in molecular techniques and the increasing availability of genetically altered mice have provided valuable insight into the molecular mechanism of osteoclastic bone resorption. This review focuses on osteoclast biology, lessons from genetically altered mice, and their contribution to our understanding of cholesteatoma-induced bone resorption.

Chronic silent otitis media

Otitis media occurs along a continuum. For example, otitis media with effusion characterized by fluid pathology can lead to chronic otitis media plus chronic mastoiditis, characterized by the presence of intractable tissue pathology such as cholesteatoma, cholesterol granuloma or granulation tissue. The literature defines chronic otitis media as having a tympanic membrane perforation and otorrhea. Amongst many other sequelae, which can result from the continuum, an important common one is chronic silent otitis media. This overlooked entity which includes pathology beneath an intact tympanic membrane is commonly seen in our human temporal bone laboratory and in patients. The clinical pathological correlates of this important disease are discussed herein.

High incidence of complications encountered in chronic otitis media surgery in a U.S. metropolitan public hospital

OBJECTIVES

To examine the incidence and nature of complicating factors in surgery for chronic otitis media (COM) in a metropolitan public hospital in the United States.

METHODS

A retrospective review was performed over 2 years in a metropolitan public hospital to identify cases of surgery for chronic ear disease with the following complicating factors: intracranial or extracranial abscess, labyrinthine fistula, dural dehiscence with or without associated encephalocele or meningocele, or extensive involvement of the facial nerve by cholesteatoma with or without paralysis.

RESULTS

Thirty-three of 90 consecutive operations for COM (37%) met criteria for complicated chronic otitis media (CCOM). The majority (85%) of patients had cholesteatoma involvement. Most patients (73%) were managed by an extended modified radical mastoidectomy. An additional 31 procedures were required in these 33 patients for control of complications. There was no iatrogenic sensorineural hearing loss or facial paralysis.

CONCLUSIONS

The incidence of CCOM in this large, U.S. metropolitan public hospital is similar to that observed in developing nations. CCOM significantly complicates chronic ear surgery and substantially increases the use of resources. Maintaining functional hearing is possible, but difficult, and should be considered secondary to prevention of further complications and eradication of disease. Access to health care and proper follow-up are crucial in prevention of CCOM.

[Labyrinthine fistula caused by chronic suppurative otitis media]

OBJECTIVE

To study the clinical feature and surgical management of labyrinthine fistula caused by chronic suppurative otitis media (CSOM).

METHOD

A retrospective study of 450 patients with CSOM who underwent radical mastoidectomy between the years 1992 to 1999 in Department of Otolaryngology, Xijing Hospital was conducted.

RESULT

20 patients (4.4%) with labyrinthine fistula caused by CSOM were found. The average history of ear drainage was 22 years, 18 patients (90%) had subjective hearing loss, and 13 patients (65%) had dizziness. The fistula test was positive in 9 patients (45%). 2 patients had anacusis in the affected ear. The preoperative pure tone average for bone conduction thresholds was less than 30 dB in 11 patients, between 31 and 50dB in 3 patients, and more than 51 dB in 4 patients. The ears with a positive fistula test had worse preoperative hearing than those with negative test (P < 0.01). The fistula was detected by CT in 2 of 9 patients. Cholesteatoma was present in 18 patients (90%) and granulation tissue was present in 2 patients (10%). The lateral semicircular canal was the site of labyrinthine fistula. The lesion at the site of fistula was completely removed in 17 patients and exteriorized in the remaining 3.

CONCLUSION

There are no reliable methods at present for preoperative diagnosis of labyrinthine fistula, ultimately, the most reliable way to identify a fistula is during surgery. The method of manipulation of labyrinthine fistula is based on the concrete conditions of fistula and patient.

Radical cavities and cochlear implantation

Profoundly deaf patients with chronic suppurative otitis media have been contraindicated for cochlear implantation in the past. Complications such as infection of the radical cavity, fat necrosis, skin flap problems, change in electrode position and cholesteatoma have occurred in subjects with radical cavities. The aim is to create a dry, self-cleansing, infection-free cavity. This is essential in patients about to receive a cochlear implant, as infection may be introduced into the cochlea at the implantation site and destroy any remaining neural elements. The aim of this paper was to show that it is possible to obliterate the radical cavity and perform cochlear implantation using a one-step surgical technique. Eight patients suffering from long-term bilateral chronic middle ear diseases with chronic sepsis leading to severe hearing impairment underwent cochlear implant surgery. No major complications were observed in these subjects.

[Post-surgical and post-infectious meningoencephalic herniation in the middle ear]

Meningoencephalic hernia of the middle ear, due to the advent of antibiotics, the surgical microscope, and the new surgical techniques for the treatment of chronic otitis media, is an infrequent pathology in the presents days. The goal of this paper is to present four cases of meningoencephalic hernia of the middle ear, three of then postsurgical and the remaining of inflammatory origin. Diagnosis, treatment and complications are discussed. Meningoencephalic hernia of the middle ear is usually asymptomatic and diagnosis is accidental. Immediate surgical treatment is indicated in order to avoid the potential complications of this disease. Transmastoid approach has been used for three cases and a middle cranial fossa approach was used in the fourth patient.

Prevalence of chronic otitis media in a randomly selected population from two communes in southern Vietnam

The prevalence of chronic otitis media was studied in an urban and a rural community in southern Vietnam in 1995. A total of 3,300 children, aged from 6 months to 10 years, were selected randomly by taking every third child on the vaccination list. In this cross-sectional study, 453 ears were found to have chronic otitis media or sequelae otitidis, giving an overall prevalence of 6.86%. A total of 140 ears had perforations. Various attic changes were found in 73 ears and other chronic tympanic membrane changes, such as atrophy, tympanosclerosis and adhesions, in 219 ears. Cholesteatoma was seen in two ears.

Mature teratoma of the middle ear

OBJECTIVE

The authors report a case of mature teratoma of the middle ear in a 3-year-old girl with a 1-year history of otitis media.

METHODS AND RESULTS

Radiologic investigation revealed a partially cystic lesion of the petrous portion of the right temporal bone. It produced opacification of the middle ear as well as destruction of septal air cells. The patient underwent a subtotal petrosectomy. Histologically, the tumor was composed of an intimate admixture of mature tissues representing all three germ layers, including brain, myelinated nerve trunks, skeletal muscle, bone, immature cartilage, seromucinous glands, and respiratory epithelium. Of note within the brain tissue was choroid plexus within an ependyma-lined rudimentary ventricle. Immunohistochemical studies were also performed. Twenty months after surgery, the patient was well, with complete recovery from symptoms.

CONCLUSION

Teratomas of the middle ear are rare neoplasms. Only a few examples have been reported. As a rule, they are cured by resection and do not require adjuvant therapy.

Comparison of the incidence of cholesteatoma surgery before and after using ventilation tubes for secretory otitis media

Inserting ventilation tubes has become, probably, the most common surgical operation performed on children in the free world. In our study, we attempted to examine whether the widely used procedure of inserting ventilation tubes in children with secretory otitis media is indeed justified in the long term. For this purpose, we have studied the influence of the procedure on the formation of cholesteatoma by comparing the incidence of cholesteatoma surgery before and after using ventilation tubes in our department. The data were divided into two periods. The first period included the number of operations in the 10 years (1961-1970) before ventilation tubes were used as a routine treatment for secretory otitis media in our department. The second period included the number of operations in the last 10 years (1989-1998) following the usage of ventilation tubes over 30 years. We found that the number of cholesteatoma operations has decreased, from 413 operations in the 10 years before ventilation tubes were used to 228 operations over the last 10 years. The number of operations per 10000 of the entire population has decreased from 20 operations to 6.6 operations after using ventilation tubes (P=0.0000001). We have shown that the incidence of surgery for cholesteatoma has been declining. Having analyzed the options that might cause this decline, we believe that using ventilation tubes in secretory otitis media might help to reduce the incidence of cholesteatoma surgery in the long term.

Traumatic porencephalic cyst and cholesteatoma of the ear

Porencephalic cyst expanding into the ear is a very rare complication of temporal bone fracture. We report a case of a 20-year-old male who developed a traumatic porencephalic cyst of the temporal lobe expanding into the ear through a tegmen fracture in association with a cholesteatoma. The clinical presentation was otitic meningitis. This occurrence was not encountered in any of the cases reviewed in the literature. The diagnosis, pathogenesis, treatment and prognosis of this condition are reviewed.

Organic change of effusion in the mastoid in otitis media with effusion and its relation to attic retraction

To try to solve the pathogenesis of severe attic retraction viewed from mastoid condition, we examined the residual soft tissue density (RSTD) in the mastoid by computed tomography (CT) in 85 patients (107 ears) with otitis media with effusion (OME) 3 months after tympanostomy tube insertion or later. The incidence of RSTD in the mastoid was significantly higher in OME of adults (52.6%) than in children (24.1%). Ears with severe attic retraction had RSTD significantly more frequently (80%) than those with no or mild attic retraction, and many of the mastoids with severe attic retraction were occupied totally by RSTD. The area of the mastoid (mastoid pneumatization) was significantly smaller, and CT density of the mastoid (sclerotic tendency) was significantly higher in ears with RSTD than in those without. RSTD after tympanostomy tube insertion in the mastoid indicating organic change of effusion was considered one of the important factors relating to the pathogenesis of severe attic retraction.

Labyrinthine fistula after cholesteatomatous chronic otitis media

OBJECTIVES

To report on cases of labyrinthine fistula diagnosed in an ear, nose, and throat department and to study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of two types of cholesteatomatous labyrinthine fistulae-the extensive fistula that erodes both the bony and membranous labyrinths and the bone fistula that affects only the bony labyrinth.

STUDY DESIGN

Retrospective case review.

PATIENTS

Fifty-four patients with cholesteatomatous chronic otitis media with labyrinthine fistulae.

SETTING

Tertiary referral center.

INTERVENTIONS

Diagnosis and treatment.

MAIN OUTCOME MEASURES

Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae.

RESULTS

The incidence of labyrinthine fistulae was 7% in all patients who underwent surgery for chronic otitis media. The bone type (66%) is more common than the extensive type (33%). Compared with bone fistulae, the outcome for extensive fistulae is more severe in terms of hearing loss, vertigo, and facial palsy. In terms of preoperative diagnosis, computed tomography imaging ensured early diagnosis in 89% of extensive cases and in 28% of bone cases. For extensive fistulae, the surgical technique was more radical, requiring an open technique in 66% of cases versus 22% of the bone fistulae cases. The most common location is the lateral semicircular canal (61%).

CONCLUSIONS

The breach in the membranous labyrinth is consistent with a more aggressive pathology, causing more severe pre- and postoperative symptoms. Preoperative computed tomography is more sensitive for diagnosing extensive fistulae, which also require a more radical treatment.

The buffering effect of middle ear negative pressure by retraction of the pars tensa

OBJECTIVE

To measure the middle ear (ME) volume displaced when the pars tensa (PT) retracts during conditions of atelectasis (AT).

STUDY DESIGN

Measurements were carried out on AT tympanic membrane (TM).

SETTING

Measurements were carried out on ambulatory patients in a private clinic.

PATIENTS

Thirty-nine patients treated for otologic disorders who came for a routine follow-up.

INTERVENTIONS

Quantitative assessment of ME volume displaced by retraction of the PT was achieved by measuring the amount of fluid needed to fill up the retracted part of a TM. The fluid-3% aqueous boric acid solution was colored with gentian violet.

MAIN OUTCOME MEASURES

Retraction of the PT may prevent formation of high ME negative pressure by reducing the ME volume. Retraction of the PT acts as a pressure buffer according to Boyls law, in which volume x pressure = constant.

RESULTS

Direct correlation was found between the degree of AT and the ME volume displaced by the AT. Measurements of 12 AT ears grade I showed them to have a volume of 5 microL to 31 microL (average, 19.5 microL) and ten AT ears grade II had a volume of 15 microL to 87 microL (average, 39.5 microL). Eight AT ears grade III had a volume of 26 microL to 67 microL (average, 54.3 microL), and nine AT ears grade IV had 80 microL to 200 microL (average, 130.6 microL).

CONCLUSIONS

Retraction of the PT may counteract an important potential negative ME pressure (up to several hundred millimeters of water) depending on the degree of retraction and the extent of mastoid pneumatization.

Surgical complications of cochlear implantation: a report of three cases and their clinical features

The most common complications of cochlear implantation are flap necrosis, compressed or improperly placed electrodes, and facial nerve injury, paresis, or stimulation. We report on three recent complications experienced at our institution: 1) a flap ischemia and partial-thickness necrosis without infection or device exposure, 2) facial nerve stimulation, which was managed with a new programming technique, and 3) a postimplant cholesteatoma in a patient with chronic eustachian tube dysfunction that required reoperation and explanation. We discuss the pathophysiology, likely etiology, and recommendations for management of these complications.

Uncommon and unusual complications of otitis media with effusion

Some complications of otitis media with effusion (OME) are not obvious and not always associated with otitis media by physicians and patients; the authors propose to call them 'unusual complications', although they may be quite frequent. Complications such as dizziness, clumsiness and behavioural disorders are classified in this group. Other complications are rare and uncommon such as sensorineural hearing loss and cholesteatoma. Some of these sequelae are structural, others more functional. The impact of OME on complex functions such as language, learning or behaviour is still controversial but seems to have been underestimated until now. Not only withholding treatment in children with OME may cause complications but also the treatment of OME may lead to sequelae, although serious side effects caused by the treatment of OME are rare. In this literature review, the epidemiology, importance and diagnosis of the uncommon and unusual complications of OME will be discussed.

Epidemiology and aetiology of middle ear cholesteatoma

A total of 500 patients with cholesteatoma diagnosed and operated during 1982-91 in the region of Tampere University Hospital and Mikkeli Central Hospital in Finland were analysed retrospectively. The mean annual incidence was 9.2 per 100,000 inhabitants (range 3.7-13.9) and during the study period the annual incidence decreased significantly. The incidence was higher among males under the age of 50 years. There was no accumulation of cholesteatoma diseases in lower social groups. The majority (72.4%) of cholesteatoma patients had suffered from otitis media episodes. Tympanostomy was carried out in 10.2% and adenoidectomy or adenotonsillectomy in 15.9% of all cholesteatoma ears prior to cholesteatoma surgery. Cholesteatoma behind an intact tympanic membrane with no history of otitis media was verified in 0.6% of patients and in cleft palate patients in 8%. In this study, 13.2% of patients had ear trauma or ear operation in anamnes.