A difficult case: sarcoidosis of the middle ear

Sarcoidosis is a common multisystemic granulomatous disorder affecting several organs and tissues. However, the respiratory tract is the region commonly involved in more than 90% of patients, and the middle ear is a direct extension of it. In spite of this, direct middle ear and/or mastoid involvement of sarcoidosis is more rarely seen. Otological involvement may mimic a number of other diseases of the ear; sarcoidosis will probably not be considered prospectively. In addition, pulmonary symptoms of the patients often go unnoticed for some time. We report a patient presenting with hearing loss and tinnitus as the primary manifestation of sarcoidosis of the ear.

Fibroma of the tympanic membrane

A primary tumor of the tympanic membrane is very rare. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. There was no evidence of recurrence 2 years after the operation, and the patient's hearing was normal. Fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane.

Tympanomastoidectomy: planned second-look tympanotomy

OBJECTIVE

To review the outcome following surgery for cholesteatoma/retraction pocket disease where second-look tympanotomy was recommended for selected patients.

DESIGN

Retrospective outcome analysis following canal wall down mastoid surgery for cholesteatoma/retraction pocket disease.

SUBJECTS

The study included 158 patients (163 ears) operated on between 1993 and 2003. Data were collected on the recommendation for second-look tympanotomy, the findings at second-look tympanotomy, and hearing threshold.

RESULTS

Second-look tympanotomy was recommended for 36 patients, 32 had surgery, and 30 were free of residual disease. The respective mean pre- and postoperative bone conduction threshold was 8.9 dB and 18 dB for single-stage surgery and 15.8 dB and 16.8 dB for second-look tympanotomy. The mean preoperative air-bone gap (0.5, 1, 2, 4 kHz) was 27.1 dB for single-stage surgery and 27.9 dB for staged surgery. The 1-year air-bone gap was 24.6 dB and 28.6 dB, respectively.

CONCLUSION

Planned second-look tympanotomy demonstrated excellent early disease control and allowed management of the middle ear pathology.

Retrospective study of the long-term results of otoplasty using a modified Mustardé (cartilage-sparing) technique

OBJECTIVE

To determine the long-term results and the complication rates of a cartilage-sparing otoplasty technique.

PATIENTS AND METHODS

In our study, patients who had undergone otoplasty from 1990 to 2002 inclusively were evaluated retrospectively. The study consisted of a chart review and a telephone survey. The minimum follow-up for patients was 5 years.

MAIN OUTCOME MEASURES

The main outcome measures were long-term satisfaction rates, early complications, late complications, and rate of revisional procedures. A detailed description of the surgical technique is included.

RESULTS

The overall long-term satisfaction rate was 95.7%. Early complications (< 1 month) included one case of bleeding (1.0%) and five cases of asymmetry (4.9%) between both ears, two of which required reoperations. One case of early unilateral recurrence was noted owing to trauma inflicted by another child (1.0%) and necessitated a revisional procedure. Late complications (> 1 month) included five cases (4.8%) of suture granulomas/extrusions, three (2.9%) keloids, and one case of hypertrophic scarring (1.0%). Seven cases of partial recurrence of the deformity (10.3%) were noted, six of which were unilateral and one of which was bilateral, none requiring reoperation. There was only one case of overcorrection of the deformity (1.4%). Three cases within the sample of 104 patients underwent reoperation, yielding a 2.9% rate of revision procedures.

CONCLUSIONS

On long-term follow-up, the otoplasty technique used in our institution yields a high satisfaction rate and a low complication rate.

Useful surgical techniques for facial nerve preservation in tumorous intra-temporal lesions

The management of the facial nerve in tumorous temporal lesions is particularly challenging due to its complex anatomic location and potential postoperative complications, including permanent facial paralysis. The most important concern regarding surgical treatment of a tumorous temporal lesion is the inevitable facial paralysis caused by nerve injury during the tumor removal, especially in patients with minimal to no preoperative facial nerve dysfunction. We describe successful four cases in which various surgical techniques were developed for the preservation of the facial nerve in treatment of intratemporal tumorous lesions.

[The study on the en bloc resection of the external auditory canal to treat external auditory canal carcinoma in the early stage]

OBJECTIVE

To introduce the en bloc resection of the external auditory canal. To improve early diagnosis and the effective surgical management of external auditory canal carcinoma.

METHOD

Twelve cases of the early stage external auditory canal carcinoma were reviewed retrospectively. All cases were undergone surgical treatment by en bloc external auditory canal resection plus lateral temporal bone resection and superficial parotidectomy. All the patients were followed up from 1 to 3 years.

RESULT

There were 7 males and 5 females, age ranged from 28 to 75 years. According to T stage, there were 4 T1, 8 T2. Eight cases complaint of otalgia or ear pain and 6 cases present with otorrhea. Among 6 otorrhea cases, 3 cases had bloody secretions. Mass with variable sizes in the external auditory canal could be identified by physical examination. Six cases were diagnosed by biopsy preoperatively, another 6 cases were diagnosed by mass resection pathologically. Postoperative pathological diagnosis revealed that 6 cases with adenoid cystic carcinomas, 5 cases of squamous cell carcinomas, 1 case of cerumenal adenocarcinoma. No lesion involved in parotid gland and lymphoid of parotid surface. Safety lateral incision margin was obtained and no lesion penetrated tympanic membrane in all cases. Five cases of squamous cell carcinomas, 1 case of cerumenal adenocarcinoma and 3 cases of adenoid cystic carcinomas received radiotherapy postoperatively. All patients were alive free of carcinoma during the follow-up. Operation side in 6 cases present with incomplete facial paralysis immediately postoperatively and graded III to IV by House-Brackmann Facial Nerve Grading System, which all fully recovered within 1-3 months. All cases showed conductive hearing loss after surgery. The preoperative average hearing threshold was 38dB (500, 1000, 2000 Hz) while postoperative average hearing threshold of all cases was 65 dB (500, 1000, 2000 Hz). One patient had parotid fistula after surgery and recovered by pressure pocketing.

CONCLUSION

Timely and accurate biopsy is the key point to diagnose the early stage external auditory canal carcinoma. The complete resection with safety margin of external auditory canal carcinoma can improve the effect of surgery.

Lessons learned from the surgical management of benign paroxysmal positional vertigo: the University Health Network experience with posterior semicircular canal occlusion surgery (1988-2006)

OBJECTIVE

To assess the long-term efficacy and safety of posterior semicircular canal (PSCC) occlusion for intractable and incapacitating benign paroxysmal positional vertigo (BPPV) and identify lessons that may be learned from our experience.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral centre.

METHODS

Clinical records and results of audiometric and vestibular testing were reviewed on a series of patients who underwent occlusion of the PSCC for intractable BPPV between 1988 and 2006.

OUTCOME MEASURES

Postoperative neurotologic examination, audiometry, and vestibular testing were assessed.

RESULTS

Thirty-two PSCC occlusion procedures were performed (24 females, 8 males; mean age 46 years). The average follow-up was 63 months. All patients had complete resolution of their PSCC positional vertigo, which has been maintained long term. Thirteen patients (40%) have experienced other forms of dizziness postoperatively (contralateral BPPV in four, continued Meniere disease attacks in three, ipsilateral lateral or superior canal BPPV in two, otolithic symptoms in two, continued oscillopsia in one, and subsequent cerebellar degeneration in one). Postoperative audiometry demonstrated an average reduction in pure-tone threshold of 6.1, 6.3, and 6.9 dB at 0.5 to 3, 4, and 8 kHz, respectively. Five patients had a mild to moderate reduction in caloric activity in the operated ear postoperatively. Two patients with Meniere disease had a significant postoperative caloric reduction. No patient had postoperative facial weakness.

CONCLUSIONS

PSCC occlusion is a safe and highly effective treatment for intractable BPPV. However, other forms of vertigo may persist or arise subsequently in approximately 40% of cases. Patients with Meniere disease may be susceptible to increased caloric reduction postoperatively.

Unilateral secondary (acquired) postmastoidectomy low-set ear: postoperative complication with potential functional and cosmetic implications

OBJECTIVE

This article reports the development of low-set ear following tympanomastoidectomy via endaural and/or postaural approaches.

DESIGN

Description of 10 cases who had developed low-set ear following mastoid surgery undertaken to clear chronic suppurative otitis media. The surgical approach was via endaural or postaural incisions.

SETTING

Tertiary care referral hospital.

METHOD

The operative history and development of low-set ear complication are described. Potential factors responsible for the development of postoperative low-set ear and a possible way to avoid such a complication are discussed.

MAIN OUTCOME MEASURES

The development of postoperative low-set ear following endaural or postaural incisions.

RESULTS

The described 10 cases had tympanomastoidectomy. A postaural approach was employed in six cases and an endaural approach in four. Canal wall down mastoidectomy was done in seven cases, whereas canal wall up mastoidectomy was done in three. Seven patients were aware of postoperative auricular changes, and two of them were unhappy with this. Potential predisposing factors include dissection of the auricle and ear canal and lowering of the posterior bony canal wall. This could result in weakening of the supportive elements that keep the auricle in the normal position.

CONCLUSION

Low-set ear should be recognized as a potential complication following mastoid surgery. It can have cosmetic and functional implications for the patient. Possible ways to avoid its development are suggested. This is the first report of such a postmastoidectomy complication in the English literature.

Hearing preservation in 2.7 cm vestibular schwannoma

Hearing preservation is exceedingly difficult in vestibular schwannoma surgery, especially with increasing tumor size. We herein report a case of hearing preservation in a 2.7 cm vestibular schwannoma, where the patient maintained her pre-operative hearing threshold of 55 dB till a year after surgery. Hence, it appears that an attempt at hearing preservation is worth pursuing.

[An update on the treatment of vestibular schwannoma]

The increase in the diagnosis of ever smaller vestibular schwannomas (VS), the fact that many tumours can be observed with serial MRI, and the development of radiosurgery as an alternative to microsurgery have led the neurotologic surgeon to a new global approach to patients with VS. On the other hand, the spread of internet-based information sources, often with biased or incomplete information, makes counselling patients with VS a challenging task. This study provides an overview of the natural history of these tumours and the main therapeutic options: observation, surgery and radiosurgery, with comments on their indications, advantages and disadvantages. Due to the completely different approach and peculiar features of bilateral VS in patients with type II neurofibromatosis, these are excluded.

Cutaneous squamous cell carcinoma of the external auditory canal

Cutaneous squamous cell carcinoma (SCC) along with basal cell carcinoma (BCC), collectively known as Nonmelanoma skin cancer (NMSC), are the most common cancers in the United States. Squamous cell carcinoma of the skin is less common than BCC, but is known to be more aggressive with a higher mortality rate. Squamous cell carcinoma of the external auditory canal (EAC) is rare when compared to SCC on other cutaneous sites. Due to the rarity of SCC originating in the EAC, there is currently no universal staging system, making it difficult to analyze data and form a treatment strategy. This is a case of a 76-year-old man who initially presented with actinic keratosis of the EAC that died in just over a year from metastatic cutaneous SCC.

Electromyographic monitoring of facial nerve under different levels of neuromuscular blockade during middle ear microsurgery

BACKGROUND

The evoked electromyography (EMG) is frequently used to identify facial nerve in order to prevent its damage during surgeries. Partial neuromuscular blockade (NMB) has been suggested to favor EMG activity and insure patients' safety. The aim of this study was to determine an adequate level of NMB correspondent to sensible facial nerve identification by evaluating the relationship between facial EMG responses and peripheral NMB levels during the middle ear surgeries.

METHODS

Facial nerve evoked EMG and NMB monitoring were performed simultaneously in 40 patients who underwent tympanoplasty. Facial electromyographic responses were recorded by insertion of needle electrodes into the orbicularis oris and orbicularis oculi muscles after electrical stimulation on facial nerve. The NMB was observed objectively with the hypothenar muscle's twitching after electrical stimulation of ulnar nerve, and the intensity of blockade was adjusted at levels of 0, 25%, 50%, 75%, 90%, and 100% respectively with increased intravenous infusion of Rocuronium (muscle relaxant).

RESULTS

All of the patients had detectable EMG responses at the levels of NMB <or= 50%. Four out of forty patients had no EMG response at the levels of NMB >or= 75%. A significant linear positive correlation was present between stimulation thresholds and NMB levels while a linear negative correlation was present between EMG amplitudes and NMB levels.

CONCLUSIONS

The facial nerve monitoring via facial electromyographic responses can be obtained when an intraoperative partial neuromuscular blockade is induced to provide an adequate immobilization of the patient. The 50% NMB should be considered as the choice of anesthetic management for facial nerve monitoring in otologic microsurgery based on the relationship of correlation.

Vibrant Soundbridge for hearing restoration after chronic ear surgery

INTRODUCTION

Middle ear surgery is primarily concerned with resolving the discharging pathology, in the case of chronic otitis media (COM), or with complete eradication, in case of cholesteatoma. Either of these procedures may require repeated surgeries, often resulting in severe mixed hearing impairment. A middle ear implant may be indicated in these cases instead of a hearing aid because the anatomical conditions in such cases often impede an adequate acoustic coupling. The objective of this study was to evaluate MED-EL Vibrant Soundbridge (VSB) implantation in patients with severe conductive and mixed hearing loss occurring after middle ear surgery for cholesteatoma or chronic otitis media (COM).

MATERIALS AND METHODS

Over a 2-years period, the VSB system was implanted in 40 patients between 35 and 81 year old (mean: 59.5). Surgery was performed with comparable technique in 3 regional hospitals in Italy: Rovereto (n=16), Meran (n=12) and Tortona (n=12). The 40 candidates for implantation had a history of 1-5 previous surgeries. Of those, 20 patients suffered from COM and 20 from, cholesteatomas. The floating mass transducer (FMT) of the VSB was placed and stabilized on the round window niche in 32 cases; alternative positioning was necessary in 8 cases. Bone conduction (BC) was tested 1 day post-operatively. At 1 month post-surgery and between 6-9 months, open-field warble tones threshold in VSB-off and VSB-on conditions and open-field speech audiometry for words in quiet were conducted.

RESULTS

Results of BC audiometry one day post-operatively showed no significant changes in hearing. Unaided mean pure tone average (PTA4) was 82.38 dB SPL with a mean speech recognition threshold (SRT) of 94.28 dB SPL. Results obtained after a minimum of three months post-operatively were evaluated in terms of aided thresholds and functional gain. At VSB activation, the mean PTA4 was 50.63 dB SPL with a mean SRT of 61.68 dB. After 6-9 months, the group had a mean PTA4 of 47.89 dB SPL and a mean SRT of 53.33 dB SPL.

CONCLUSIONS

Implantation of the VSB with its direct driver of the inner ear fluids appears promising for auditory rehabilitation of severe mixed hearing loss associated with sequelae of cholesteatoma surgery. Patients' results improved over time, allowing us to assume a positive effect of consolidation of the coupling related to fibrosis. Results reported here refer to 6-9 months of observation and do not provide evidence of long term stability.

[The role of computed tomography in the diagnosis of exudative otitis media and in the evaluation of the efficacy of its treatment]

Management of exudative otitis media is a challenging problem in view of its high prevalence and frequent complications in the form of stable hearing loss. The highest morbidity rate is documented among 25 and 50-year old subjects which accounts for the substantially reduced level of social activity associated with this disease. Clinical examination and audiologic techniques are frequently insufficient to diagnose exudative otitis media. Computed tomography provides a reliable tool for the exact diagnosis, optimal choice of treatment strategy, and evaluation of its efficacy during dynamic observations.

[Peculiarities of sanitizing middle ear reoperations]

This paper is devoted to the problem of surgical rehabilitation of patients with the so-called <<operated ear disease>>. Twenty such patients underwent second operation following sanitization ear surgery for the treatment of recurrent (more than once a year) otorrhoea in the previous period. The operation was performed in two (sanitizing and reconstructive) steps. All the patients were allocated to 3 groups based on the results of preoperative examination and the cause of purulent discharge. Group 1 comprised patients with the <<open>> Eustachian tube, group 2 included patients with the carious-granulation process in the mastoidal part of the cavity, group 3 was composed of patients with the both conditions. Reconstructive surgery in patients of groups 1 and 2 included tympanoplasty (n=7). Four patients of group 2 underwent mastoidoplasty with the use of osteotropic material Stimul-oss, and 9 patients were treated by simultaneous tympano- and mastoidoplasty using Stimul-oss blocks. The outcome of surgical treatment in all reoperated patients was regarded as positive taking into account the absence of purulent discharge from the treated ear and the formation of a small self-purifying cavity. Improved hearing was documented in 15 cases. These results give reason to recommend two-step (sanitizing and reconstructive) reoperation to patients with <<operated ear disease>> using a surgical procedure chosen individually depending on the cause of purulent discharge.

Vibrant Soundbridge middle ear implant in mixed hearing loss. Indications, techniques, results

OBJECTIVES

The aim of this article is to illustrate the aetiologies of mixed hearing loss that can benefit from a Vibrant Soundbridge (VSB) middle ear implant, the techniques performed and the first results.

MATERIALS AND METHOD

The authors report their experience of 13 implantations in mixed hearing loss due to otosclerosis, sequelae of chronic otitis media and congenital aural atresia. The VSB implant was implanted alone or in association with another middle ear surgical procedure, on the ossicular chain or on the round window membrane.

RESULTS

The average auditory gain for all patients is 32 dB for pure tone thresholds, and 25 dB for speech recognition. It results from the addition of a gain on the conductive hearing loss by direct stimulation of the inner ear, to a gain on the sensorineural hearing loss by amplification.

CONCLUSION

Middle ear implants are the only hearing aids affording a gain in both the conductive and sensorineural components of mixed hearing losses.

[Multispiral computed tomography for the assessment of the extent of surgical intervention in patients with chronic suppurative otitis media]

The utility of the data obtained by multispiral computed tomography (MSCT) for the choice of surgical techniques is discussed with special reference to chronic suppurative otitis media. Specific features of bone tissue destruction are described in patients with cholesteatoma and without it. Results of MSCT were used to estimate the optimal extent of surgical intervention. Intraoperative findings were in excellent agreement with MSCT data.

Bone-anchored hearing aids (BAHA): skin healing process for skin flap technique versus linear incision technique in the first three months after the implantation

BACKGROUND

Since the introduction of the BAHA (bone-anchored hearing aid), two main different surgical procedures have been used to insert the implant: the skin flap technique and the linear incision technique.

AIM OF THE STUDY

The aim of this retrospective study is to compare the short terms results (3 months after the implantation, the usual period of skin healing) of the skin healing process in the surgical field and around the BAHA implant of these two different techniques.

MATERIAL AND METHODS

113 implantations were done from January 2004 to mid May 2008. Between January 2004 to December 2006, 62 were inserted with the skin flap technique and between January 2007 to mid May 2008, followed by 51 with the linear incision technique. All cases were done by the same surgeon.

RESULTS

Four implanted BAHA with the skin flap technique necessitated a revision of the operating field because skin necrosis around the implant and only 1 with the linear incision technique. For the other cases and outside the normal range of fixed controls, the cases with the skin flap technique necessitated 25 unforeseen visits by 21 patients for cleaning and removal of crusts, in contrast to 2 visits by 2 patients for the cases with the linear incision technique.

CONCLUSION

This study clearly demonstrates that the linear incision technique has statistically lower risks of skin problems than the skin flap technique in the first three months post-implantation.

Psychosocial effects of otoplasty in children with prominent ears

This study aimed to investigate changes experienced by children during the pre- and postoperative periods of prominent ear corrective surgery. A total of 30 patients with prominent ears, sometimes called "lop ears" or "cup ears," ranging in age from 6 to 14 years were consecutively enrolled in this study. Half of the patients (n = 15, 50%) were male. The inclusion criteria specified children with prominent ears and reports of evident anatomic deformity. Clinical evaluations, routine laboratory tests, and interviews were performed in the pre- and postoperative periods. To assess the dissatisfaction or social maladjustment caused by the prominent ears, questionnaires, which are used routinely in psychological and psychiatric practices, were applied in the pre- and postoperative periods. The tests used were the Child Behavior Check List, the State-Trait Anxiety Inventory for Children, and the Children's Depression Inventory. The patients themselves and their parents or guardians reported improvements in terms of anatomic aspect. For the psychological tests, improvements in almost all the assessed items were observed. In conclusion, psychological problems caused by anatomic deformities, such as prominent ears, can be improved by adequate corrective surgery. Psychological support is necessary for the patients.

The results of surgical treatment of middle ear cholesteatoma by using open and closed techniques

Middle ear cholesteatoma caused by repeated ear infections over time, destroys the delicate middle ear bones and causes permanent hearing loss or dizziness. It may grow to involve the facial nerve causing facial paralysis. In some instances, cholesteatomas can expand up into the brain, causing meningitis, sinus thrombosis, facial nerve palsy, vestibulitis and differently localized abscess. Nearly all patients with cholesteatoma require surgery to cure the disease. Therapeutic and rehabilitative surgical procedures were done, using either a closed technique (TCT) or an open technique: tympanoplasty in open technique (TOT). The aim of the work was to compare the advantages of TCT and TOT surgical technique for the treatment of cholesteatoma disease. The research was conducted in Tbilisi State Medical University Otorhino-laryngological Clinic on 65 patients with middle ear cholesteatoma: 21 women and 44 men in 2006-2008. Their average age was 29. The youngest was 7 years old, and the oldest one - 67. The investigation revealed that after TCT recidivations were noted in 16% of patients; after TOT in 42.3% of patients. It is concluded that CT technique is the most appropriate and optimal surgical interference for the treatment of chronic middle ear diseases.

Carcinoid tumor of the middle ear: report of a case

Carcinoid tumor of the middle ear is an extremely rare lesion of the middle ear, and thus its diagnosis is frequently delayed. Some authors found it hard to differentiate middle ear carcinoid from the middle ear adenoma. However, the balance of opinion is currently on the side of considering it as a separate clinical entity. Definitive diagnosis is made by identifying neurosecretory tumor cells using immunohistochemistry and electron microscopy. It usually follows a nonaggressive clinical course, rarely metastases, and infrequently recurs after radical excisions. We present a patient with middle ear carcinoid, who is free of disease 2 years after the resection of the tumor mass with canal wall-down procedure. The relevant literature is also herewith reviewed.

[Endoscope-assisted surgical resection of acoustic neuroma]

OBJECTIVE

To explore the therapeutic efficacy and complications of endoscope-assisted surgical resection of acoustic neuroma.

METHOD

Assisted by hard-tube ear endoscope, 11 patients with acoustic neuroma were operated via labyrinthine approach and retrosigmoid approach.

RESULT

Total removal was achieved in 9 (81.8%) cases, while subtotal removal was achieved in 2 (18.2%) cases. Facial nerves and cochlear nerves were preserved completely during operation in all cases. After operation 9 (81.8%) cases had no facial paralysis, while the other 2 cases (18.2%) had mild peripheral facial paralysis. The same hearing level as that of preoperation in 2 patients (18.2%), hearing impairment in different degrees in 9 patients (81.8%), among which moderate sensorineural hearing loss in 1 patient, moderate to severe in 2 patients, severe in 3 patients, profound in 3 patients.

CONCLUSION

The application of ear endoscope in acoustic neuroma surgery can improve the total removal rate of tumors and the salvage rate of vessels and nerves. However, its disadvantages make it an assistant method for microsurgery.

Ionomer cement for reconstruction of the long process of the incus: the Pécs experience

Experience gained with the repair of the defects of the long process of the incus with ionomer cement in 35 patients is reported. The integrity of the reconstructed tympanic membrane and the four-frequency average of the air-bone gaps of the postoperative audiograms (best, most recent and at around 1 year) were evaluated. This 'physiological' reconstruction of the ossicular chain fulfilled our expectations in 40% of the patients (air-bone gap </= 10 dB). The background of the unsuccessful cases was investigated.

Association between surgical steps and intraoperative auditory brainstem response and electrocochleography waveforms during hearing preservation vestibular schwannoma surgery

Intraoperative monitoring of the auditory pathway by means of either electrocochleography or auditory brainstem response audiometry is valuable during hearing preservation vestibular schwannoma (VS) surgery. A more than 75% intraoperative reduction of the amplitude of these evoked auditory potentials was thought to be related with clear hearing compromise of hearing. We identified 22 patients who satisfied this intraoperative criterion in a cohort of 86 consecutive patients who had attempted hearing preservation VS surgery. The surgical step that temporally coincided with the above event was considered to be the most critical step for hearing monitoring during this kind of surgery. Most frequently, drilling of the internal auditory canal and direct tumor resection were associated with the aforementioned changes, but also drilling of the cortical temporal bone at the very beginning of surgery or the opening of the dura could be implicated. This profound intraoperative amplitude decrease was associated with a profound postoperative hearing impairment in 84% of the cases.

Mastoiditis in children: a prospective, observational study comparing clinical presentation, microbiology, computed tomography, surgical findings and histology

The aim of this study was to obtain comprehensive data on clinical presentation, microbiology, computed tomography, surgical findings and histology in acute, sub-acute and chronic mastoiditis. We performed a prospective, observational study in children under 16 years of age presenting to our institution during the 2-year period beginning in April 2000. The children were examined and their condition treated in accordance with a standardized protocol elaborated by the paediatric, otolaryngology (ORL) and radiology departments. Thirty-eight patients were hospitalized (22 with acute mastoiditis, seven with sub-acute mastoiditis, nine with chronic mastoiditis). There were 30 complications present in 21 patients (55%). Streptococcus pyogenes was the most common pathogen (7/24 cases), followed by Streptococcus pneumoniae (4/24 cases). Mastoid surgery was performed in 29 patients. Histology of mastoid tissue revealed predominantly acute inflammation in two cases, mixed acute/chronic inflammation in 19 cases and predominantly chronic inflammation in seven cases. Radiologic data were evaluated retrospectively. Spiral, volume-based high-resolution (HR) computed tomography (CT) of the temporal bone had a sensitivity of 100%, specificity of 38%, positive predictive value (PPV) of 50% and negative predictive value (NPV) of 100% in detecting coalescence of mastoid trabeculae. Cranial CT with contrast had a sensitivity of 80%, specificity of 94%, PPV of 80% and NPV of 94% in identifying intra-cranial extension.

CONCLUSION

histological evidence suggests that sub-acute/chronic infection underlies not only sub-acute and chronic mastoiditis, but most cases of acute mastoiditis as well. HR-CT of the temporal bone is effective in ruling out coalescence. Cranial CT is valuable in identifying intra-cranial extension. Cranial and HR-CT are recommended in the examination of children with mastoiditis.

Surgery of the semicircular canals

INTRODUCTION

Surgery of the semicircular canals is seeing a revival as recently we have witnessed the development of specialized surgeries for each canal.

OBJECTIVES

The aim of this work is through a review of the literature to describe these different surgeries while stressing on certain surgical aspects, their respective indications, results and their risks.

DISCUSSION

1: The surgery of the posterior canal relates to the benign paroxysmal positional vertigo resistant to the medical treatments. The results are very good but the indications have become rarer since the introduction of the repositioning maneuvers. 2: The surgery of the lateral canal is the most frequent and the oldest because of chronic otitis and especially cholesteatomas. It is now well codified and is subject to various factors. Plugging of the lateral canal in Menière's disease has just been described and interesting results on vertiginous crises have been reported. Its interest and its place in the treatment of this disease are still to determine. It can be an alternative to surgical management but also to the gentamycin injection. 3: The dehiscence of the superior semicircular canal must be systematically sought after when confronted with a Menière-like disease, a suspicion of perilymphatic fistula or a conductive deafness evoking an otosclerosis with preserved stapedial reflexes. Very often these dehiscences of the superior canal are asymptomatic. High density scans of the petrous bones provide the diagnosis but it is necessary to obtain a 3D view to ascertain the dehiscence. A radiological classification of the dehiscence in 3 types has been proposed. It appears to be of help during surgery. Videonystagmography with and without vibrator and vestibular myogenic evoked potentials allow the determination of the side responsible for the symptoms in case of bilateral dehiscence. The surgery usually through a middle fossa approach will be proposed only to the symptomatic and incapacitated patients. The results are promising. 4: Finally the authors discuss the cochlear risk of this surgery and the types of material used to occlude or cover the canal.

CONCLUSION

The otologists must generally know these indications as this type of surgery entails very good results with a relatively moderate risk on hearing.

Verrucous carcinoma of the temporal bone

Verrucous carcinoma is a highly differentiated variant of squamous cell carcinoma. In the literature, 11 cases of primary verrucous carcinoma of the temporal bone have been reported. We present a 48-year-old woman who had undergone radical mastoidectomy because of chronic otitis media 20 years ago; consequently, verrucous carcinoma occurred in the mastoid cavity. We discuss verrucous carcinoma of the temporal bone with the review of literature.

Post-traumatic otosclerosis: coincidence or trigger factor?

OBJECTIVE

The etiology of otosclerosis is poorly understood and environmental as well as genetic factors have been implicated. In this paper we will present 3 cases of otosclerosis with a clinical history of trauma and we will discuss with a literature review the place of trauma in otosclerosis etiology.

CLINICAL CASES

3 patients with clinically diagnosed otosclerosis, operated, and with a clinical history of previous head trauma.

DISCUSSION AND CONCLUSION

It is probable that environmental factors could be involved in the development of the disease and we think that trauma could be one of them. The mechanisms by which it could results in otosclerosis remain unknown. However these cases appear to be rare and under studied.

[Dehiscence of the superior semicircular canal: approach and CT scan classifications]

The syndrome of dehiscence of the superior semicircular canal (DCSS) is primarily associated with vertigo and/or hearing loss. The dehiscence may be completely asymptomatic and represent an incidental finding on radiological investigation.

OBJECTIVES

To demonstrate the advantages of a volume rendered CT study of the petrous temporal bone of patients with hearing loss, and to demonstrate the effectiveness of its systematic application in the protocols of examination. To propose a radiological classification of DCSS with a therapeutic application.

MATERIAL AND METHOD

The examination technique which was performed in incremental mode (axial and frontal sections) and in "volume rendered" mode, on a high resolution apparatus is described. The authors studied 154 scans of the petrous temporal bone obtained by this technique. They correlated the cases of DCSS with the indications for the radiological examination. Each 3d CT scan was studied and the type of fistula described. The authors propose a classification of fistulae into three types, depending on 3d CT scan appearance.

RESULTS

Out of 154 CT scans of the petrous temporal bone (77 patients), 13 cases of DCSS were discovered. DCSS was bilateral in 4 cases. The primary indication for investigation was the assessment of conductive or mixed hearing loss. The "volumetric" technique was compared with standard imaging techniques and/or reconstructed images in the superior canal plane. The correlation was perfect in all the cases. The description of the fistulae allowed a classification into 3 types: Type I (symmetrical fistula, 8 cases); Type II (asymmetrical fistula, 3 cases) corresponding to the canal dome; Type III (2 cases) involving the foot of the canal.

CONCLUSION

The increased frequency of DCSS in this series (prevalence of 17% against 0.5% in post mortem studies) is probably explained by the selection bias of the patients and also by the systematic application of this novel radiological technique. We propose to include this protocol in all CT scans of the temporal bone, particularly when investigating symptoms consistent with a syndrome of Minor or the Tullio phenomenom. This system of classification makes it possible to describe the fistula and to specify its location. This should prove to be a valuable aid for pre-operative planning and intra-operative localisation of the fistula.

[Combined treatment of auricular vascular neoplasms]

Two cases of combined treatment of auricular vascular neoplasms (arteriovenous malformation and hemangioma) are presented. Their two-step management included endovascular microembolization of the posterior auricular artery with polyvinyl alcohol (PVA 300, 500 mcm) and surgical resection of the tumour. The results confirm the feasibility of combination of traditional and endovascular surgery for the treatment of this pathology. Preoperative endovascular microembilization not only arrests hemorrhage from angiodysplasia but also decreases its size and isolates it from healthy tissues. Embolization of the posterior auricular artery can be performed only after the comprehensive angiographic evaluation of the blood flow in angiodysplasia and the adjacent vessels using superselective catheterization and officinal emboli.

Intraoperative findings in revision canal wall down mastoidectomy

Effective canal wall down mastoid surgery requires attention to certain key principles. We reviewed all cases requiring revision surgery at the Royal Victoria Eye and Ear Hospital over a 6 year period 1999-2004. Intraoperative findings which contributed to the need for revision surgery were identified. During this 6 year period 291 canal wall down mastoidectomies were performed. Thirty-seven were revision procedures. Nineteen (51%) cases were found to have recurrent or residual cholesteatoma. Sixteen (43%) cases had a high facial ridge, thirteen (35%) cases had an open middle ear. Nine (24%) cases had an inadequate meatus, 2 (5%) cases had a cavity sump. This study illustrated that a high facial ridge, an open middle ear segment, an inadequate meatoplasty and recurrent cholesteatoma were common intraoperative findings in this revision group. Eighty-nine percent of revision cases had dry, healed and safe cavities on follow up. Poor performance of the open technique is the most important factor in failure.

Lateral semicircular canal plugging: a simple and effective surgical treatment against incapacitating Menière's disease

OBJECTIVES

To present lateral semicircular canal plugging (LCP) technique and late results dedicated to patients with incapacitating Menière's disease.

METHOD

In a prospective case-controlled baseline study, patients with unilateral incapacitating Menière's disease were treated either by LCP (n = 11) or by vestibular neurotomy (VN) (n = 11). LCP was performed by retro auricular approach, vestibular neurotomy by retro sigmoid approach. According to Menière's disease therapeutic evaluation guidelines, disability and hearing loss were assessed before and after both surgical treatments, with a 2 years followup at least. After LCP, a CT and MRI scan analyse was performed on the inner ear

RESULTS

LCP was effective (A or B class) in 82% of cases (n = 9/11), 91% after VN (n = 10/11). When treatment was effective, 100% of patients regained a normal life after LCP (postoperative functional level I or 2, n = 9/9), versus 50% after VN (n = 5/10). After LCP, postoperative hearing level was unchanged in 82% of cases, n = 9/11 (73% after VN, n = 8/11), and decreased of about 30 dB in 18% (n = 2/11). There was no surgical complication. The endolymph interruption area was well visualized on MRI, allowing determining the optimal plugging area to be as far as possible from the ampulla.

CONCLUSION

LCP is a simple and safe new treatment that could be very useful to control vertigo in Menière's disease. Early and late tolerance are excellent. This prospective study will go on to evaluate the potential of this innovating treatment: LCP could be recommended as an alternative to VN or chemical labyrinthectomy, except in case of drop attacks.

[Evolution of facial nerve prognosis in vestibular schwannoma surgery by translabyrinthine approach]

OBJECTIVES OF THE STUDY

To evaluate our results on the postoperative facial function, its pre and preoperative predictive factors, and the application of the surgical technique to lesions of decreasing size.

PATIENTS AND METHODS

A series of 248 patients operated of an unilateral vestibular schwannoma has been reviewed. We have compared the results gathered over two periods corresponding to the evolution of our surgical technique since 1998.

RESULTS

Immediate and 1 year postoperative facial function is significantly better among patients operated after 1998 (satisfactory in 75 and 88% respectively). This trend marked by the improvement of the results since 1998 has to be discussed according to other predictive factors. One of predictive factor is the decrease of the size of the lesion during the same period. The other factors are the hearing level, deafness duration, trigeminal nerve involved, vestibular status and ABR desynchronization.

CONCLUSION

The positive predictive factors are usually correlated with the size of the tumour This implies the necessity of an early diagnosis of the schwannomas. The second predictive factor of the facial function is the use of a soft surgical technique.

Otologic surgery in HIV-infected patients

As the lifespan of patients with HIV continues to increase secondary to improvements in antiretroviral medications, patients can keep the virus in a latent state for a longer period of time than ever before. As a result, patients live longer with infection and demand a higher quality of life during the course of the disease. The most important decision in the management of otologic manifestations of AIDS is whether the patient should be operated. The surgery of HIV-infected patients includes two important issues: Risk of transmission of HIV to health care workers and delay of wound healing. In this paper we describe the three otologic procedures of two HIV-infected patients managed successfully without complication. We, like many others, believe that otolaryngologists should apply strict surgical criteria to HIV-infected patients for otologic procedures and should not withhold rational therapy because of the patient's HIV status.

[Techniques end results of surgical treatment cholesteatoma of middle ear]

INTRODUCTION

Basic surgical techniques in the treatment of middle ear cholesteatoma include the intact-canal-wall and canal-wall-down tympanoplasty and combined method, i.e. the "mobile-bridge" tympanoplasty. The techniques including reconstruction of the posterior bone wall of the external auditory canal are combination of formerly mentioned methods. These tympanoplasty procedures involve a partial or complete removal of the posterior bone wall of the meatus. Subsequently, after the elimination of pathological process, the reconstruction of the middle ear is performed.

MATERIAL AND METHODS

200 patients with middle ear cholesteatoma, who had undergone various microsurgical procedures, were monitored and evaluated in the period 1998-2006. The aim of this study was to present the main principles of tympanoplasty and outcomes of middle ear cholesteatoma surgery through a comparative analysis of the applied tympanoplasty techniques. The closed ICW and open CWD tympanoplasty were compared with the combined mobile-bridge technique with the reconstruction of the posterior bone wall of the external auditory canal.

RESULTS

The incidence values for the recurrent cholesteatoma in closed tympanoplasty and in cases of open techniques with radical trepanation of the temporal bone were 6% and 10%, respectively. In cases of combined mobile-bridge tympanoplasty with the reconstruction of the posterior bone wall of the auditory canal the incidence of residual cholesteatoma was 2%. The postoperative rejection of the replanted bone was observed in 2% of. the patients.

CONCLUSION

The selection of the appropriate surgical procedure is determined by the type and extent of pathological process, anatomic features of the pneumatic space of the middle ear, available microsurgical equipment and otosurgical skills of the surgeon.

[Effect of multi-technique of intact canal and scute rebuilding in treatment of middle ear cholesteatoma]

OBJECTIVE

To assess the results of multi-technique with intact canal and scute rebuild operation for middle ear cholesteatoma.

METHODS

Analysis of 113 cases (males 60, females 53, with mean 42.7 years old), of which with double ears of 11 cases, and totally 124 ears (11 ears for one review, an ear for third time review, and totally 137 operations) was retrospectively performed. Ten cases less than 19 years old were operated from September 2001 to January 2006 for middle ear cholesteatoma as well as ossiculoplasty with intact canal and scute rebuild etc multi-technique. All cases were followed up for a mean (36.58 +/- 20.47) months.

RESULTS

There were 118 ears (95.2%) without cholesteatoma recurrence. Six ears were found cholesteatoma recurrence. Other 6 post-operation ears with drum re-perforation and hearing drop were re-operated. The pre-operation air-bone gap (ABG, average of 0.5, 1, 2 kHz) of 124 ears, with in initial 112 ears, was (33. 61 +/- 12.35) dB, while that of post-operation ABG was (13.58 +/- 9. 27) dB, by partnership t test, t = 18.35, P < 0.01. The pre-operation ABG in reviewed 12 ears at the first pre-operation was (38.83 +/- 12.43) dB, but post-operation ABG (10.38 +/- 8.99) dB, by partnership t test, t = 5.38, P = 0.00022. The ABG closure to within 20 dB was tested in 100 ears while ABG over 20 dB but air conduct (AC) in 40 dB was in 6 ears, and then as succeed was in 106 ears (85.5%). ABG closure within 10 dB was in 50 ears and though ABG over 10 dB but ABG reduced over 30 dB was in 9 ears (59/124, 47.6%) as which as best result. Bone conduct (BC) threshold was tested of 21 ears (16.93%) with raise 1-9 dB, of 42 ears (33.9%) with no change and of 61 ears (49.2%) with descend 1-28 dB. Of 10 cases less than 19 years old post-operation ABG was (8.80 +/- 5.27) dB, which indicated that all cases was as succeed.

CONCLUSIONS

Using intact canal and scute rebuild etc multi-technique a normal canal, hearing improvement and very low recurrent could be gained for middle ear cholesteatoma, especially in juvenile and children. The multi-technique should be almost no damage for hearing bone conduct.

Microvascular decompression of cochlear nerve for tinnitus incapacity: pre-surgical data, surgical analyses and long-term follow-up of 15 patients

The level of success of neurovascular decompression in ponto-cerebellar angle for hemifacial spasm and trigeminal neuralgia has already established the reality of the pathology to explain such symptoms. However, cochlear nerve compression syndrome by vascular loop is still a controversial topic. We have performed a retrospective cases review with long-term follow-up (5-7 years) concerning the results of microvascular decompression surgery of the cochlear nerve via an endoscopy assisted retrosigmoid approach on 15 patients suffering from unilateral incapacitating tinnitus with abnormal auditory brainstem response and an offending vessel on magnetic resonance imaging. During the surgery, a vascular compression was found on every patient. In a long-term follow-up, 53.3% (8 cases) of our tinnitus cases improved and 20% (3 cases) of them were completely cured. The ABR returned to normal in all patients who had good clinical results (diminished or disappeared tinnitus). When a vertebral artery loop (5 cases) was concerned we obtained 80% of good clinical results. No one showed amelioration or sudden aggravation of their hearing. Three cases required surgical correction of cerebrospinal fluid leak and one case developed spontaneously regressive swallowing problems. Such microvascular decompression surgery of the cochlear nerve appears to be successful in treating incapaciting tinnitus in particular when a vertebral artery loop is observed. Therefore, in such a case, one might recommend neurovascular decompression surgery, keeping in mind that the complications of this surgery should be minimized by a careful closure of the retrosigmoid approach. In order to ensure a better selection of patient more accurate cochlear nerve monitoring and functional MRI should be a promising assessment.

Management of acoustic neuromas in patients 65 years or older

OBJECTIVE

To analyze an optimal management protocol for patients 65 years or older at the time of acoustic neuroma diagnosis.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care hospital.

PATIENTS

Two hundred sixteen patients with acoustic neuroma 65 years or older at time of diagnosis.

INTERVENTION

Patients with smaller tumors (<2.5 cm) were followed with serial magnetic resonance imaging. If significant growth occurred, they were treated with surgery. Surgery was performed at initial diagnosis on patients with larger tumors or in selected patients for hearing preservation. Stereotactic radiotherapy was performed for poor surgical candidates and for patient choice.

OUTCOME MEASURES

Measurement of acoustic neuroma growth and tabulation of complications.

RESULTS

One hundred fourteen patients were initially managed by observation, 80 with surgery, and 3 with radiation therapy, with an average follow-up of 35.4 months. For patients in the observation group, average tumor growth was 1.2 mm/yr. Thirty-two patients required crossover to surgery or radiotherapy due to tumor growth (average growth, 4.1 versus 0.3 mm/yr for those remaining in the observation group). One of the patients in the observation group had a complication (0.9%).

CONCLUSION

Management of acoustic neuromas in elderly patients can be based on size and "biological age" criteria. Surgical treatment can safely be reserved for the few patients who have significant tumor growth.