The Nobelpharma auditory system bone-anchored hearing aid: the Edmonton experience

The unique ability of titanium to osseointegrate has been utilized in clinical practice for bone-anchored hearing aids in Sweden since 1977. The percutaneous design by Nobelpharma has been shown to be useful not only for pure conductive hearing loss but also mixed losses with a bone pure tone average of 45 dB (60 dB with the HC220). We examine our experience, since May 1991, with 15 patients aged 8 to 73 years, including indications, complications, and both objective and subjective results. In addition, we have found the second stage can be successfully completed during the initial anesthetic without the usual delay of 3 months for many patients. We believe the technique for osseointegration is a suitable addition to the armamentarium for the otolaryngologist against hearing loss.

Case reports: heterotopic brain tissue of middle ear associated with cholesteatoma

Heterotopic brain tissue reportedly occurs occasionally in various sites, including rare occurrences in the middle ear. Association with cholesteatoma in middle ear cases, however, has not been reported yet. In this article, the authors describe three cases of heterotopic brain tissue in the middle ear associated with cholesteatoma: a 3-year-old boy with recurrent meningitis resulting in right acute otitis media and bony dehiscence of the right attic; a 36-year-old man with chronic right ear infections, right radical mastoidectomy 2 years previously, and brain herniation through the tegmen tympani; and a 65-year-old man with chronic otitis for many years, right ear surgery 25 years previously, and extensive involvement of right middle ear ossicles and mastoid antrum by cholesteatoma. The heterotopic brain tissue in each of these cases was diagnosed by histologic examination, and its glial component was confirmed by immunohistochemical staining for glial fibrillary acidic protein. After a microscopic review of 40 additional surgical pathology cases of cholesteatoma, no evidence of heterotopic brain tissue was found. With these findings, it is suggested that the unusual occurrence of heterotopic brain tissue in the middle ear associated with cholesteatoma may result from local destruction of bone secondary to the cholesteatoma, otitis media, meningitis, or previous surgery.

[Mondini's dysplasia: a rare cause of recurrent meningitis in childhood]

Recurrent meningitis in children may be due to immune deficiency or abnormal communication of CSF spaces with mucosal spaces (basal skull fractures, encephalocele, etc.). We report a 6-year-old boy, suffering from recurrent meningitis and sensorineural hearing loss. CT scans of the temporal bones demonstrated a bilateral Mondini dysplasia. In patients with this congenital inner ear anomaly, recurrent meningitis may be due to a CSF-middle ear fistula. We think that it is necessary to investigate all patients with recurrent meningitis and sensorineural hearing loss with CT scans of the temporal bones.

Laboratory diagnosis of immune inner ear disease

Immune inner ear disease is a relatively new and distinct clinical entity that produces unexplained, rapidly progressive, bilateral sensorineural hearing loss. The diagnosis is based on clinical manifestations, positive immune laboratory testing, and beneficial response to a trial of corticosteroids. Immune laboratory tests are used to confirm a presumptive clinical diagnosis. The two tests most commonly used are the lymphocyte transformation test and Western blot immune assay. The rationale behind these tests is presented, and the role they play in laboratory diagnosis of immune inner ear disease is discussed.

[An analysis of reoperations on the middle ear in childhood]

According to the data provided by the Moscow ENT hospitals, the number of resurgery on the middle ear in children rose 3-fold. This is due to frequent failure of antrodrain surgery, higher prevalence of mycotic infection and recurrent inflammation in the middle ear. When planning otic surgery in children it is necessary to take into consideration both the involvement of the middle ear and medical personnel ability to provide proper postoperative care. Resurgery is justified in complicated disease course after primary intervention.

[Vertigo and middle ear pathology]

The association of vertigo and diseases of the middle ear is not uncommon. It occurs especially during the course of chronic or acute otitis but can also occur as a sequela. Vestibular involvement is due to several pathophysiological mechanisms that influence the choice of treatment. The same is true for expansive processes of the tympanic cavity. When associated to otospongiosis, vertigo occurring during Ménière's disease can transiently contraindicate an operation on the tapes. On the contrary, vertigo resulting from traumatic lesion of the middle ear can suggest surgical intervention. Surgery of the middle ear can itself cause severe vertigo which sometimes requires a new operation. Lastly, the fortuitous association of disease of the middle ear with labyrinth disease, especially retrolabyrinthic such as eighth cranial nerve neurinome, is not uncommon, but can be long overlooked if it is not routinely suggested in the presence of labyrinth type symptoms.

Oculomotor and nystagmus tests in subjects with strabismus

Smooth pursuit (SP) and saccades (SC) as well as nystagmus were recorded with electro-oculography in 21 healthy subjects with manifest non-paralytic strabismus. A normal SP function under binocular conditions could be recorded in 67% of the subjects and complementary monocular recordings increased the figure to 81%. The corresponding figure for the SC test was 38 and 67%, respectively. However, a minority of the subjects presented a normal test result under both binocular and monocular conditions. Spontaneous nystagmus and/or nystagmus after headshaking was present in 67%. These findings may indicate that subjects with strabismus have a combination of a 'subclinical' vestibular and oculomotor dysfunction.

Three-dimensional magnetic resonance imaging of the inner ear in idiopathic sudden sensorineural hearing loss

Five patients with idiopathic sudden sensorineural hearing loss (ISSHL) were examined by a combination of high-resolution computed tomography and special magnetic resonance imaging techniques. By three-dimensional constructive interference in steady state magnetic resonance imaging excellent visualization of the membranous labyrinth was obtained. No fibrous or osseous obliteration of the intralabyrinthine fluid spaces was observed in all investigated temporal bones. The results provide further evidence for a viral pathogenesis of ISSHL.

Additional conductive hearing loss in children from a school for the deaf in Malaysia

A total of 165 children from a school for the deaf in Malaysia were screened to find out the prevalence of additional conductive hearing loss. Otological examination, tympanometry and pure tone audiometry were performed in all these children. Fifty-one children (30.9%) had additional conductive hearing loss. Middle ear disorders were present in 15 children (9.09%). The deaf children seldom complain about the change in their hearing sensitivity, so there is a need for regular otological examination in deaf children to detect the additional conductive hearing loss.

Horizontal semicircular canal variant of benign positional vertigo

We report the clinical features and results of quantitative eye-movement testing in 13 patients with episodic positional vertigo and nonfatiguing direction-changing horizontal positional nystagmus (beating to the right with the head turned to the right and beating to the left with the head turned to the left). The benign history and lack of associated neurologic findings support a peripheral localization of the lesion. This syndrome probably represents a horizontal semicircular canal variant of benign positional vertigo. Free-floating debris in one horizontal canal may explain many of the clinical and oculographic findings.

Eustachian tube dysfunction and its sequelae in patients with cleft palate

The incidence of middle ear disorders in patients with cleft palate deformities was determined in a retrospective review of 110 children with palate or palate and lip involvement. Ages ranged from 2 months to 18 years and included patients with associated abnormalities such as Pierre Robin syndrome and Treacher Collins syndrome. Clinical manifestations of eustachian tube dysfunction were found in 79% in the form of effusions, retraction pockets, adhesions, and ossicular erosion. Only two patients had confirmed cholesteatoma formation. Despite the low incidence of acquired cholesteatoma in these patients, the frequent occurrence of other disorders that affect hearing warrants early and aggressive otologic management to prevent long-term sequelae.

Recurrent meningitis due to a congenital fistula of the stapedial footplate

A rare case of a congenital fistula of the stapes footplate, in a 10-year-old girl, resulting in recurrent meningitis, is reported. A full ENT examination and a high index of suspicion, is essential if the diagnosis is to be made. Exploratory tympanotomy should be considered on clinical grounds, even if a high resolution CT scan of the temporal bones does not show any anomalies, in order to ascertain the definite diagnosis of a fistula and to seal it permanently.

[Surgical treatment possibilities of middle ear hearing loss]

Otological surgery is performed under the operating microscope with special microinstruments. The introduction of new technical means such as the argon laser, equipped with a fiberoptic handpiece, and the sceeter microdrill have improved the results according to the statistic of Berne. An important aspect is the approach to the structures in the temporal bone. The classical retroauricular and endaural incisions are replaced whenever possible by the less traumatic transmeatal approach directly through the external ear canal without external skin lesion. Ear drum perforations and cholesteatomas with and without ossicular lesions are repaired by different types of tympano-ossiculoplasty. Destroyed ossicles are replaced by allogenic prostheses or homologous ossicles. Otosclerosis is treated by a 'small-fenestra' stapedotomy with insertion of a teflon-platinum wire piston. Bone conduction hearing aids with conventional mastoid vibrators can be replaced by more efficient bone-anchored hearing aids directly fixed in the skull. The teamwork between ear surgeon, audiologist and electronical engineer has turned out to be important for the implantation of hearing aids.

Pathogenesis of tympanosclerosis

In spite of the wealth of information on the clinical, histologic, and pathologic aspects of tympanosclerosis, the pathogenesis of tympanosclerosis is still unclear. In an attempt to understand the pathogenesis, 319 human temporal bones from 196 individuals with otitis media were studied. The extent and nature of tympanosclerosis and the characteristics of the otitis media associated with it were studied. Forty-five temporal bones from 35 individuals with otitis media were found to have tympanosclerosis, giving an incidence of 14.1%. It was seen most commonly in individuals over 40 years of age (86.7%). The male-to-female ratio was 1.6:1. The most common site of occurrence was the tympanic membrane (88.9%). Tympanosclerosis was seen more often in the anterior and posterior inferior quadrants of the tympanic membrane and that, too, in a central position. Tympanosclerosis was seen more commonly in temporal bones with irreversible inflammatory changes, and in this group, late plaques were more commonly seen than early or intermediate plaques. Audiometric charts failed to show any direct relationship between extent of tympanosclerosis and the severity of hearing loss. The only audiometric finding of any consequence was a mixed hearing loss in the presence of middle ear tympanosclerosis.

Sleep disturbance associated with chronic tinnitus

Sleep disturbance is a common and frequent complaint reported by tinnitus sufferers. Recent studies have shown that when insomnia and depression are associated with tinnitus there is decreased tolerance and increased discomfort with the tinnitus. The purpose of this study was to assess the reported prevalence and severity of sleep disturbance in chronic tinnitus patients. Patients (n = 80) were military personnel without major psychiatric disturbance and their tinnitus was associated with noise-induced permanent hearing loss (NIHL). Mini Sleep Questionnaire (MSQ) scores for sleep disturbance were found to be higher than those of normal controls in 77% of the patients. Highest MSQ scores in tinnitus patients with a sleep complaint were for delayed sleep, morning awakenings, mid-sleep awakenings, morning fatigue, and chronic fatigue. In contrast, a complaint of excessive daytime sleep (EDS) was not common. The self-rated severity of the tinnitus was greater in subjects with higher sleep disturbance scores. Self-rated depressive symptomatology was also highly correlated with sleep disturbance. Retrospective examination of sleep records and polysomnographic data for 10 patients with a complaint of chronic tinnitus revealed a combined effect for the tinnitus condition when associated with another conventional sleep disorder. In spite of the common complaint of sleep disturbance in tinnitus, only a minority seek a sleep examination.

[Traumatic auricular hematoma in athletes: histopathological findings and clinical considerations on the experimental animal model]

Surgical procedures used for treating hematomas of the auricle are often defective in obtaining complete cosmetic and functional results when hematoma is of traumatic origin, as often thickening and deformity may outcome. Up to date, some pathological aspects of the healing process of auricular hematomas due to blunt trauma are still unclear as only lesions similar to spontaneous hematoma were experimentally produced and studied. Traumatic auricular hematoma, a lesion caused by rough contacts in sports like rugby, judo, karate, wrestling, etc., was never experimentally induced and studied. The Authors have induced both traumatic and non-traumatic hematomas in a group of 5 rabbits, injecting blood clots under the perichondral layer of one auricle while in the contralateral the hematoma was induced by compressive friction as it is caused during the above referred sports activities. Lesions of both sides were examined after 15 and 60 days and it was found that histopathological picture and clinical course of traumatic hematoma deeply differ from those of non-traumatic one. Non-traumatic lesion appears like a circumscribed hematoma without any evident sign of surrounding reaction, while traumatic lesion shows clear signs of polymorphic and marked reaction. In traumatic hematoma reactive and reparative processes are observed which alter the cartilage and perichondrium associated with many which alter the microhematomas in the subcutaneous connective tissue, close to the main hematoma. Histological findings found 2 months after injury show cartilaginous auricolar skeleton to be thickened by chondrocytes grouped in islands or fingered from perichondrium.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate electronystagmography in the diagnosis of the dizzy patient

STUDY OBJECTIVES

To determine whether the results of electronystagmography (ENG) testing improve an emergency physician's diagnosis of dizziness.

DESIGN

Prospective, one-year.

SETTING

University and three community hospital emergency departments.

TYPE OF PARTICIPANTS

Ninety-three consecutive patients presenting with dizziness.

INTERVENTIONS

ED impression was recorded after complete ED evaluation. An ENG was performed within one hour by an audiologist, who gave a reading of "central," "peripheral," or "normal." The result was given to the emergency physician, who was invited to revise his or her impression (the "ED impression after ENG result"). Final diagnosis was based on the ED impression and by contact with the patient's physician(s) as well as the patient by telephone after one and four weeks. Accuracy of ENG was assessed by comparing ENG reading with the final diagnosis using the chi(2) test. In addition, the contribution of ENG to ED diagnosis was assessed by comparing the accuracy of the ED impression after ENG reading with the ED impression alone using McNemar's test (hit versus no-hit).

MEASUREMENTS AND MAIN RESULTS

Both ED impression and the ENG significantly correlated with the final diagnostic category (chi(2) = 104.9, P < .001; chi(2) = 70.79, P < .001, respectively). ENG correctly diagnosed nine of 11 patients with central dizziness. Of 23 patients with undetermined cause after ED evaluation, ENG correctly identified seven patients with peripheral dizziness and three with central dizziness. ED impression after ENG reading was more accurate than ED impression alone (chi(2) = 6.13, P < .05).

CONCLUSION

Emergency physicians correctly categorized most dizzy patients, but audiologist performance and interpretation of an ENG significantly improved this categorization. ENG may have the potential to identify clinically unsuspected central dizziness and to categorize dizziness of "unknown" cause. Further study is needed to determine whether ENG could be performed by modifying certain types of heart monitors available in the ED.

Hearing results with clothespin ossiculoplasty: preliminary report on the Kraus Modified Schuring Ossicle-Cup Prosthesis (Clothespin Prosthesis)

The clothespin partial ossicular replacement prosthesis (PORP) is designed to increase joint stability during incus replacement ossiculoplasty. Fundamental modifications have been made in the Schuring ossicle-cup, which include a forked well, increased well wall thickness and length, and a flexible tip disk added to the shaft. The forked well functions like a straight clothespin rather than an inverted cup. The forked well enables the clothespin prothesis to slide down over the stapes superstructure, between the facial nerve canal and the promontory, to form a stable, mortise-and-tenon prosthesis-stapedial joint. Joint stability is enhanced because the inferior tine of the forked well is able to lever against the inferior surface of the stapes superstructure, creating a counterforce to gravity. This is in contrast to the more unstable ball-and-socket joint created by most partial ossicular replacement prostheses when they articulate with the stapes capitulum. The addition of a flexible disk to the shaft tip produces a tight, stable union between the prosthesis and the ossicular cap by increasing resistance at the shaft-ossicle interface. Fluoroplastic composition maximizes intraoperative versatility and reliability while the ossicle cap minimizes extrusions. One-year hearing results for twelve chronic ear patients with mobile stapes undergoing clothespin ossiculoplasty during intact canal wall tympanomastoidectomy revealed postoperative air-bone gaps within 20 dB in 92% of cases. The mean postoperative air-bone gap was 8.9 dB, and the mean improvement in air-bone gap was 14.4 dB.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term efficacy of tympanostomy tubes for secretory otitis media in children with Down syndrome

Twenty-four children with Down syndrome, aged six to 14 years, were tested with audiometry six to nine weeks after insertion of tympanostomy tubes for bilateral secretory otitis media (SOM). There was no improvement in hearing in 40 per cent of ears, compared with only 9 per cent of ears in 21 age-matched controls with bilateral SOM. Tympanostomy tubes for SOM in children with Down syndrome have a high short-term failure rate, which should be explained to the parents before insertion, and the children should have audiometry tests shortly after the operation. Persistent hearing-loss may require the fitting of hearing aids. Management should involve ensuring that the children are in a situation in which they can hear as well as possible, and making allowances for the hearing impairment.

Hearing impairment and ear pathology in Nepal

A stratified random cluster sample of 15,845 subjects was performed in two regions of Nepal to determine the prevalence and main causes of hearing impairment (the most common disability) and the prevalence of ear disease. Subjects reporting current ear pain, or ear discharge, or hearing impairment on direct questioning by a Nepali health worker (primary screening failed), had otoscopy and audiometry (using the Liverpool Field Audiometer) performed, and a questionnaire administered relating to past history. In every fifth house subjects who passed the primary screening (1,716 subjects) were examined to assess the false negative rate of screening. An estimated 16.6 per cent of the study population have hearing impairment (either ear worse than 30 dB hearing threshold level (HTL) 1.0-4.0 kHz, or 50 dB HTL 0.5 kHz), and 7.4 per cent ear drum pathology, equivalent to respectively 2.71 and 1.48 million people extrapolated to the whole of Nepal. Most hearing impairment in the school age group (55.2 per cent) is associated with otitis media or its sequelae. Probably at least 14 per cent of sensorineural deafness is preventable (7 per cent infectious disease, 3.9 per cent trauma, 0.8 per cent noise exposure, 1 per cent cretinism, and 1 per cent abnormal pregnancy or labour). Most individuals reporting current ear pathology (61 per cent) had never attended a health post, and of those receiving ear drop treatment, 84 per cent still had serious pathology. Of subjects who reported ear drop treatment at any time, 31 per cent still had serious pathology. The use of traditional remedies was prevalent.(ABSTRACT TRUNCATED AT 250 WORDS)

Medial meatal fibrosis: the University of Western Ontario experience

Medial meatal fibrosis is an uncommon but surgically treatable cause of conductive hearing loss. A review of 10 years experience with this entity at The University of Western Ontario revealed a total of 15 cases involving nine patients. Each of them was treated by one of four otologists. This disease may arise from either recurring or chronic infection or from chronic dermatitis, and it frequently presents with bilateral involvement. It may occur at virtually any age, and to our knowledge, this series includes the first cases of this disease to be described in children. The medical and surgical management of this condition is described in detail and the results are summarized.

Tinnitus characteristics in tinnitus complainers and noncomplainers

The aim of this study was to describe the characteristics of tinnitus in 87 patients (mean age = 53.7 years); 43 patients seeking professional help (complainers) and 44 patients who do not seek help for their tinnitus (noncomplainers). 'Left-sided or mostly left-sided' tinnitus was reported by 42% of complainers and 30% of noncomplainers, whereas 'right-sided or mostly right-sided' tinnitus was equally prevalent in the two groups (26 v. 25%); the differences between groups were not significant. Tinnitus 'in the head' was reported by 14% of the complainers and 6% of the noncomplainers, a nonsignificant difference, whereas noncomplainers perceived tinnitus in 'both ears equally' significantly more frequently than complainers. Complainers had significantly more often 'combined' (tonal plus buzzing) tinnitus sounds (51 v. 30%) and 'non-fluctuating tinnitus' (49 v. 25%) than had noncomplainers, whereas 'tonal' tinnitus was significantly more frequent in noncomplainers than in complainers (43 v. 16%). Further, noncomplainers had worse hearing than complainers: pure-tone averages over vocal as well as high frequencies were significantly higher. Complainers scored significantly higher than noncomplainers on the psychological variables concentration difficulties, irritability and sleep disturbance. Patients with 'combined' tinnitus sounds scored significantly higher on irritability and sleep disturbance than subjects with 'tonal' tinnitus. Patients with 'non-fluctuating tinnitus' scored significantly higher on the three psychological variables than patients with 'fluctuating tinnitus'. A conclusion to be drawn is that 'combined' tinnitus sounds and 'non-fluctuating tinnitus' might be determinants of psychological problems.

Hearing impairment in children after bacterial meningitis: incidence and resource implications

A retrospective review over ten years of childhood cases of bacterial meningitis treated in two hospitals in Nottingham revealed 301 cases: 88.4% of these children survived. The audiological and clinical hospital records of the survivors were examined to see if the children had been assessed for hearing impairment following the illness. Results indicate that 202/261 (77.4%) of the survivors remaining in the local area had had a formal hearing assessment. Fifteen of these children (7.4% of those assessed) suffered some degree of sensorineural or mixed hearing loss as a direct consequence of meningitis. The impairments ranged from mild unilateral to profound bilateral and the affected children were aged between 0 (i.e. infection at birth) to 15 years. The data indicate that bacterial meningitis of any type can result in sensorineural hearing impairment of any degree in a child of any age. A significantly increased risk of hearing impairment was found for children aged less than one month or over 5 years, for children with associated hydrocephalus, for children admitted between October and March, for those in hospital longer than 16 days and for those with a cerebro-spinal fluid glucose concentration of < or = 2.2 mmol/l. No differential increased risk was noted for different causative pathogens. Abnormal tympanograms indicative of conductive hearing impairment were measured at the first visit in 45% of children attending for hearing assessment. These conductive losses resolved in 75% of cases. These data suggest that an English health district, with a total population of 250,000, would need to provide annual resources for about 30-40 appointments for children after meningitis. Over a period of 5 years it might provide hearing aids for three children and a cochlear implant for one child. Bacterial meningitis is the single most important cause of acquired sensorineural hearing impairment in children and every attempt should be made to assess the child's hearing as soon after recovery as possible.

The role of CT imaging in the management of chronic suppurative otitis media

CT imaging of the temporal bone is highly predictive of the presence of cholesteatoma but its value in the routine management of cholesteatoma has not been assessed. We aimed to establish the indications for CT imaging in CSOM by a prospective study of patients suspected of having cholesteatoma. The patients were assessed clinically and a management plan chosen; this was later adjusted, if indicated, on the basis of radiological findings. Surgical findings were recorded and correlation with CT appearances evaluated. Twenty patients completed the study. CT altered the management plan in 10 and was considered helpful in a further 6. We recommend its routine use in children, medically unfit patients, only or better hearing ears, patients in whom the tympanic membrane cannot be adequately visualized, patients who have had previous mastoid surgery whose operative records are available and patients with intratemporal or intracranial complications of disease.

[Necrotizing osteitis of tympanal bone. Report of 2 cases]

A large variety of process can cause necrosis of the bony external ear canal, found by means otoscopic examination. Two cases with a final diagnosis or external ear canal cholesteatoma are reported. A revision of the main characteristics of this uncommon entity is performed, with a special emphasis to avoid that the scarcity of clinic symptoms favour its growing in depth.

Fate of patients with bilateral cholesteatoma

INTRODUCTION

This study was designed to assess the clinical and surgical findings and long-term results of therapy in patients treated for bilateral chronic cholesteatomatous otitis media.

PATIENTS AND METHODS

A series of 54 patients who underwent mastoid surgery for bilateral acquired cholesteatoma were followed regularly for a mean of 7.9 years (range 2 to 21 years). Results of treatment were compared with the results obtained in 349 patients treated for unilateral acquired cholesteatoma with a mean follow-up of 6.7 years. Hearing level was defined as the mean air conduction threshold at frequencies of 0.5, 1, and 2 kHz. Audiograms obtained the day before operation and at last follow-up examination were used for comparison. Results were analyzed using the t test and chi 2 test.

RESULTS

Patients with bilateral cholesteatoma were more likely to be men (60% v 61%) and young (28 years v 38 years). A majority of patients underwent canal wall down mastoidectomy. Seventy-three percent of patients had ossicular erosion. During follow-up, residual recurrent cholesteatoma was found in 8 ears (7.4%). This compared with a recurrence rate of 8.3% in patients with unilateral cholesteatoma. The mean postoperative air conduction threshold (46.1 dB) was similar to patients with unilateral cholesteatoma (46.6 dB). At last follow-up, 43% of patients with bilateral cholesteatoma had a hearing level of 30 dB or better in their best ear. No patient had bilateral anacusis.

DISCUSSION

Cholesteatoma is a burdensome disease. Our 54 patients with bilateral cholesteatoma underwent a total of 125 surgical procedures. Acquired cholesteatoma has a great tendency to recur. Fortunately, this study shows that recurrence is not higher in a group of patients with bilateral cholesteatoma when compared with the unilateral group. Unfortunately, the fate of hearing in patients with bilateral cholesteatoma is not so favorable. Only 19% had hearing levels of 30 dB or better in both ears. Hearing levels of less than 40 dB in one ear was present in 34% of patients. Fortunately, there was no case with severe sensorineural hearing loss as a complication of surgery in the present series. This reflects great efforts directed at reduction of infection preoperatively, avoidance of ossicular manipulation, and preservation of cholesteatoma matrix over fistula when encountered.

Cholesteatoma in children. An Egyptian overview

There is a long-lasting debate concerning cholesteatoma in children. This retrospective epidemiological study includes 81 ears harboring cholesteatoma and treated surgically. All patients were Egyptian and were treated at Alazhar University Hospital, Cairo. Among this group 37 ears belonged to patients younger than 18 years old. To clarify comparison with adult patients, a system of classification based on certain anatomical criteria is proposed. Statistical analysis proved that cholesteatoma in children treated at Alazhar University Hospital differs significantly in two main aspects: it is associated with more pathological changes and is associated with higher morbidity. Additionally, patients younger than 12 years are at high risk for complications. A subgroup of adolescents with cholesteatoma is marginal and has disease representing the characteristics of both adults and younger children.

Spontaneous temporal bone cerebrospinal fluid leak

Eight patients with spontaneous cerebrospinal fluid leak of temporal bone origin are presented. Pertinent history and surgical findings are reviewed and contrasted with 33 previously reported patients. Unilateral ear fullness and mild hearing loss are the most common presenting symptoms. Profuse clear otorrhea following myringotomy is virtually pathognomonic. Diagnostic methods including high-resolution computed tomography, magnetic resonance imaging, and contrast cisternography are discussed. The indications for transmastoid and combined transmastoid/middle fossa surgical repairs are compared. Both surgical approaches were found to be equally effective. We favor the transmastoid as the initial approach because of simplicity, safety, and the ability to visualize both the middle fossa and posterior fossa plates as well as the middle ear.

Verruciform xanthoma of the ear with coexisting epidermal dysplasia

We report a case of verruciform xanthoma of the ear in a 79-year-old man. The case is unique in that it contained an area of solar keratosis. In situ hybridization using biotin-labeled probe cocktails for human papillomavirus types 6/11, 16/18, and 31/33/35 yielded negative results.

Surgery of the 'only hearing ear' with chronic ear disease

The management of chronic ear disease affecting the only hearing ear is a controversial subject. The relative scarcity of literature on the subject prompted us to prepare a questionnaire which was sent to European and American otologists and to review 19 cases operated at the ENT Clinic of the University of Parma, Italy, and 16 cases operated at The Baptist Memorial Hospital, Memphis, U.S.A. Surgery of cholesteatoma involving the only hearing ear is advised by all the interviewed otologists without exception, even in the presence of a labyrinthine fistula. The cases from the University of Parma were managed as follows: a classic modified radical mastoidectomy was performed in 10 cases, a staged intact canal wall tympanoplasty was done in four cases, an open tympanoplasty in three and a radical mastoidectomy in the remaining two cases. The cases from The Baptist Memorial Hospital were managed with an intact canal wall tympanoplasty (ICWT) in nine and with an open procedure in seven cases. All the otologists interviewed agreed that surgery of the only hearing ear requires particular attention and experience, and should be performed with extreme care by a very experienced surgeon.

Experimental otitis media with effusion induced by middle ear effusion

Experimental otitis media with effusion was induced in chinchillas by middle ear effusion, which was induced by an injection of immune complex into the tympanic cavity. To elucidate the pathogenesis of otitis media with effusion, cytologic and biochemical findings of the effusion and histopathology of the middle ear mucosa of effusion-induced chinchillas were compared with those of experimental otitis media with effusion induced by different procedures; eustachian tube obstruction, intratympanic inoculation of endotoxin, and immune reaction. No significant differences were seen in cytology, biochemistry, and histopathology among OMEs induced by these procedures. However, middle ear effusions, when compared with the corresponding sera, were proven to contain higher amounts of histamine and prostaglandin E2. These findings seem to demonstrate that middle ear effusion containing a large number of inflammatory mediators is essential for induction and prolongation of inflammatory reaction in the middle ear.

Bacterial meningitis in children. Selected aspects

Accumulating clinical experience has gradually outlined the epidemiology of acute bacterial meningitis, including the epidemic and the sporadic forms, the customary clinical signs related to different age groups and causative organisms, and methods of rapid diagnosis by laboratory examinations. Effective treatment, which continues to evolve, emerged in the 1940s with the development of antibacterial antimicrobials, first with the sulfonamides and then with the penicillins. The literature relative to these aspects of the disease has been abundant in the past few years. This article is directed to a variety of topics that have direct bearing on the disorder but are less often addressed to those who deal with infants and children.

Otitis media and CNS complications

Intracranial complications from otitis media can be quite devastating to the patient if an early diagnosis is not made. Patients may develop meningitis, venous sinus thrombosis or cranial nerve palsies, as well as intracranial abscess. The presenting features in such cases may be subtle and include headache, nausea, vomiting, personality changes and signs of increased intracranial pressure as well as focal neurological deficits. A case of intracranial brain abscess is presented in a patient with a history of chronic otitis media with cholesteatoma. Delay in the diagnosis of intracranial complications of otitis media can lead to improper treatment with increased morbidity and mortality. The etiology and treatment of complications affecting the CNS is discussed.

Results of surgery for chronic otitis media in patients with a cleft palate

The long-term results of surgical treatment of 19 chronic ears in 16 patients with a cleft palate were analysed. The mean follow-up period was 6.5 years. The patients were found to be significantly younger than other patients with chronic otitis media. Granulating otitis media was the indication for surgery in 11 ears and cholesteatoma in 7 ears. A successful outcome after the primary operation was found in 68% of the patients. Four patients required a revision operation which was successful in all of them. Hearing results of patients with cleft palate did not differ significantly from those obtained in other patients. It is concluded that middle ear surgery should be offered to patients with a cleft palate with the same indications as in other patients with chronic otitis media.

Tinnitus: imaging algorithms

The causes of tinnitus can be grouped according to whether the noise is continuous or pulsatile, whether it is subjective or objective and whether there is a retrotympanic mass. Imaging algorithms can be based on these symptoms and signs. For patients with nonpulsatile tinnitus and a normal drum, magnetic resonance imaging is preferred if a retrocochlear lesion is suspected, whereas high-resolution computed tomography (HRCT) is recommended if a cochlear abnormality is likely. If a chronic inflammation in the middle ear is suspected, HRCT is the study of choice to differentiate cholesteatoma from chronic otitis media. If the bruit is objective and the tympanic membrane normal, selective cerebral angiography should be the initial investigation, because most such patients have an acquired vascular abnormality, usually a dural arteriovenous fistula. If there is pulsatile tinnitus and a retrotympanic mass, HRCT should be the first examination because this technique allows differentiation of a vascular variation, such as an aberrant carotid artery or jugular dehiscence, from a paraganglioma.

Myths in neurotology

For many diseases the etiology of disordered function is unknown and therapy is either symptomatic or empirical. The empirical approach to therapy is acceptable to many physicians, particularly if a treatment can be based on some attractive, although unproven, concept of pathogenesis. A hypothetical explanation of disordered function can become widely popular in spite of a serious lack of scientific support. When evidence emerges that refutes the logic of a concept of pathogenesis, then that concept becomes a myth. Human temporal bone studies have identified several myths in neurotology that deserve our attention. Among these myths are the following: (1) cochlear otosclerosis is a common cause for sensorineural hearing loss, (2) idiopathic sudden sensorineural hearing loss is a vascular disorder that should be treated as a medical emergency, (3) the conductive component of hearing loss in Paget's disease is caused by ossicular fixation and therefore should be surgically correctable, (4) vascular loops should be considered as a possible cause for otherwise unexplained otologic symptoms, (5) surgical manipulations on the endolymphatic sac are scientifically sound therapies for selected cases of Meniere's disease, and (6) perilymph fistulas are a common cause for audiovestibular symptoms that are not related to a stressful incident.

Wrestler's ear: pathophysiology and treatment

Management of auricular hematomas has always been a challenge for physicians. This injury is very common among wrestlers since early olympic competition times. Initial treatment usually involves simple aspiration and a compression bandage. Most of these hematomas recur; then it must be decided how to manage this recurrent problem and the eventual "cauliflower ear." A treatment is proposed that directs attention to the pathophysiology of the injury and involves total excision of the newly formed fibroneocartilaginous layer. Unless this layer is successfully removed the hematoma will persist and a thickened ear will result. This treatment can be performed on an outpatient basis under local anesthesia and allows immediate resumption of wrestling competition.

Surgery for recurrent and residual cholesteatoma

One hundred twelve patients (116 ears) were treated for recurrent and residual cholesteatoma. A retrospective review revealed that 66% had undergone canal wall down mastoidectomy at the previous surgery. The surgical procedure at revision was selected on the basis of an intraoperative assessment of the extent of disease, and clinical prediction of eustachian tube function. The average period of follow-up was 3.4 years. Revision surgery was successful in providing the patient with a safe, dry ear in 105 (91%) of 116 cases. Surgical principles and hearing results are presented.

Grading system for the selection of patients with congenital aural atresia

It is generally recognized that surgery for congenital aural atresia is difficult. In an effort to select those patients who have the greatest chance of success, we have developed a grading scheme based on the preoperative temporal bone CT scan and the appearance of the external ear. Patients are graded on a possible best score of 10. The stapes is assigned the highest rating (2 points), while all other entrees on the scale are 1 point. The grade assigned preoperatively has been shown to correlate well with the patient's chance of success, herein defined as a postoperative speech reception threshold of 15 to 25 dB. A patient with a preoperative grade of 8/10 would, therefore, have a 80 percent chance of achieving this threshold. Patients with scores of 5/10, or less, are not considered surgical candidates, because the risk of the operation would outweigh the potential benefits. We have found that the grading system allows us to avoid impossible surgical cases while allowing for a reasonable prediction of the hearing outcome.

[Congenital cholesteatoma of the middle ear and mastoid. Apropos of 5 cases]

Five cases of congenital cholesteatoma of the middle ear and mastoid as defined by Derlacki's criteria were encountered over a 14 month period. They make up 5% of all cases of cholesteatoma managed over the same period of time. Three were young children and all presented with unilateral hearing loss. One had associated multiple congenital abnormalities of the external and middle ear. Only in one patient was the diagnosis made on initial otoscopic examination and the remainder diagnosed on CTscan, myringotomy and tympanotomy. All were operated on; three by the intact canal wall technique, one by the canal down technique with mastoid cavity obliteration and one by atticotomy with lateral attic wall reconstruction. One patient required a second stage operation for excision of an extension of disease deep to the superior semicircular canal via the middle cranial fossa approach in order to preserve cochlear function. These five cases illustrate the diagnostic pitfalls of this condition in which silent danger lurks behind an intact tympanic membrane.

Congenital cholesteatoma

We present a British series of eleven patients with primary cholesteatoma, including one patient with bilateral disease. Eight children presented with a history of hearing loss, while one child had had recurrent otitis media and another had had earache. Operative findings were: in five ears, cholesteatoma confined to the antero-superior segment with intact ossicles, in a further four, cholesteatomas extending throughout the mesotympanum with ossicular erosion in one, and in two ears posterior disease throughout the middle ear and mastoid, which had eroded the ossicles in both cases. The five cases of antero-superior cholesteatoma lend most support to Michaels' concept of epidermoid formation as a possible source of congenital cholesteatoma. With a greater awareness of the problem and careful examination of the antero-superior quadrant of the tympanic membrane, earlier diagnosis may be possible enabling removal of small intact cholesteatoma sacs and preserving the structures of the middle ear and therefore the hearing. A screening programme for infants included as part of their routine examination which would be undertaken by examiners who are trained to be more aware of the problem and skilled at otoscopy, would help in the earlier detection of such cases as is shown by reports from the U.S.A.

Bone destruction mechanisms in chronic otitis media with cholesteatoma: specific production by cholesteatoma tissue in culture of bone-resorbing activity attributable to interleukin-1 alpha

To clarify specific mechanisms underlying cholesteatoma-induced bone destruction, surgical specimens of middle ear inflammatory granulation tissue with or without cholesteatoma were maintained in vitro and the bone-resorbing activity in their culture supernatants was analyzed by means of calcium release from mouse calvaria. Almost the same levels of bone-resorbing activity and prostaglandin (PG) E2 were found in the supernatants of both types of tissue. By contrast, aural polyp tissue yielded hardly any such activity or PGE2. Under the influence of indomethacin, however, only tissue with cholesteatoma produced considerable bone resorption activity, whereas PGE2 production was suppressed completely. Such activity in the cholesteatoma culture supernatant was not due to contamination of endotoxin and proved to be blocked by the introduction of anti-interleukin (IL)-1 alpha antibody into the calvarial assay system. Anti-IL-1 beta antibody had no effect on such activity. Interleukin-1 alpha was detected only in cholesteatoma tissue culture supernatants by means of enzyme-linked immunosorbent assay and by bioassay. These data suggest that the bone destruction in otitis media with cholesteatoma may be attributed to IL-1 alpha in addition to PGE2.