Retrograde approach and soft wall reconstruction in surgery for congenital cholesteatoma

CONCLUSIONS

A retrograde approach and soft wall reconstruction is thought to be an effective surgical approach for patients with good eustachian tube function and good mastoid development such as in congenital cholesteatoma.

OBJECTIVE

To analyze the usefulness of a retrograde approach and soft wall reconstructive surgical treatment for congenital cholesteatoma.

METHODS

Data from 24 patients (25 ears in total) who underwent surgical intervention for congenital cholesteatoma at Kanazawa University Hospital between January 2001 and July 2011 were retrospectively reviewed. We had used a retrograde approach for congenital cholesteatomas in which bone is removed as necessary in a retrograde manner from the external auditory canal side. The extent of bone removal was determined according to the location of the cholesteatoma. The posterior walls of the external auditory canals were reconstructed with soft tissue using temporal fascia.

RESULTS

Good preoperative mastoid development was identified in 83% of the patients. Postoperative recurrence was seen in 1 of 25 ears. Analysis of pre- and postoperative hearing ability showed significant improvement in both pure tone audiogram air conduction and pure tone audiogram air-bone gaps.

Mastoid surgery under local anesthesia for medically unfit patients: techniques and outcome

OBJECTIVES

We present the surgical techniques and outcomes of mastoid surgery under local anesthesia in patients who were unfit for general anesthesia.

METHODS

Five tertiary-referred patients with multiple comorbidities and failed conservative treatment for chronic otitis media were operated on under local anesthesia. No sedation was administered. The principles of cholesteatoma surgery were observed, but the technique was adapted to keep surgical time to a minimum.

RESULTS

None of the patients had perioperative problems, and all have dry, waterproof ears with preservation of hearing after surgery. So far, none of the patients have had recurrent or residual disease.

CONCLUSIONS

Cholesteatoma surgery can be successfully performed with a local anesthetic in patients who are medically unfit for general anesthesia. Surgery requires a good coordination of the operating team in order to shorten the operating time. Otologists should develop and maintain their skills by performing ear surgery with local anesthetic on a regular basis.

Chronic suppurative otitis media atticoantral- type undergone canal wall down mastoidectomy in a peripheral government hospital of Nepal

INTRODUCTION

Chronic suppurative otitis media is a severe type of chronic ear infection which is quite common in all geographical situations of Nepal. The mainstay of treatment of this disease is surgery, preferably of canal down method. The objective of the study was to identify the common presentation(s) and the clinical and operative finding(s) in patients with chronic suppurative otitis media attico-antral type and evaluation of efficacy of canal-wall down mastoidectomy in the achievement of dry ear and change in hearing in a setting of a peripheral hospital of Nepal in terms of subjectivity. Per-operative evaluation of mastoid cavities in terms of types of pathologies and post- operative assessment of ears in terms of achieving a dryness and change in hearing ability was carried out in the ENT Department, Bharatpur Hospital, Chitwan, Nepal. Study was done from January 2005 to December 2010.

METHODS

Seventy three patients with chronic suppurative otitis media atticoantral-type were evaluated preoperatively in terms of gross pathologies. Postoperatively, patients were subjectively evaluated twice in six months in reference to persistent ear discharge and change in hearing ability.

RESULTS

By six months of surgery, 75% of the patients had no discharge. Fifty two patients did not experience any change in hearing ability. Only 16% experienced betterment in hearing while 19% had diminution in hearing.

CONCLUSIONS

Canal wall down mastoidectomies are very effective in controlling otorrhoea and complications related to chronic suppurative otitis media attico-antral type.

Use of bone anchoring device in electromagnetic computer-assisted navigation in lateral skull base surgery

CONCLUSION

The use of the bone anchoring device associated with a fiducial marker, both fixed close to the operating field, improves the reproducibility and effectiveness of the computer-assisted navigation in lateral skull base surgery.

OBJECTIVES

Computer-assisted navigation in lateral skull base surgery using the electromagnetic system Digipointeur(®) needs an external fiducial marker (titanium screw) close to the operating field to increase position accuracy (PA) to about 1 mm. Displacement of the emitter placed in the mouth (Buccostat(®)) induces a drift of the system, leading to at least 20% of unsuccessful procedures. The aim of this study was to evaluate the PA, stability, and reproducibility of computer-assisted navigation in lateral skull base surgery using a bone anchoring device to provide a fixed registration system near the operating field.

METHODS

Forty patients undergoing a lateral skull base procedure with the Digipointeur(®) system performed with both the titanium screw and bone anchoring device were included in this prospective study. They were divided in two groups. In the first one (n = 9), the PA was measured before and after screw registration for five intratemporal landmarks, during a translabyrinthine approach. In the second group (n = 31), all lateral skull base procedures were included and the PA was evaluated visually by the surgeon on different landmarks of the approaches as well as the stability of the system.

RESULTS

In the first group, the PA was 7.08 ± 0.59 mm and 0.77 ± 0.17 mm (mean ± SEM, p < 0.0001) before and after screw registration, respectively. In the second group, the PA was considered as accurate by the surgeon in all cases and no drift of the system was observed. Computer-assisted surgery was never abandoned due to increased stability of the bone-anchored emitter.

Transcutaneous bone-conduction hearing device: audiological and surgical aspects in a first series of patients with mixed hearing loss

CONCLUSIONS

The Bonebridge(®) (BB) transcutaneous bone conductive implant (BCI) may overcome some of the issues related to a percutaneous BCI, such as management of the external screw, delayed activation or possible skin complications. Moreover, it has been shown to enable a functional outcome similar to percutaneous BCI in both conductive and mixed types of hearing loss.

OBJECTIVES

To obtain clinical data from a preliminary series of patients implanted with a new transcutaneous BCI.

METHODS

Four subjects affected by conductive/mixed hearing loss underwent implantation of the BB by two approaches: the transmastoid, presigmoid approach and the retrosigmoid approach. Soundfield thresholds were assessed with warble tones in a soundproof audiometric booth, and word recognition scores (WRSs) as speech reception thresholds (SRTs) were used to compare the unaided versus the post-implantation condition.

RESULTS

The surgical procedure was completed in all cases, with only minor intraoperative divergence from the CT-based planning and no postoperative complications. The average improvement of the SRT in quiet with the BB in comparison to the unaided condition was 36.25 dB. All the implanted subjects reached SRT values below 65 dB, indicating a better understanding in quiet, with 100% word recognition.

[Mastoidectomy with reconstruction of the posterior canal wall and obliteration preventing postoperative morbidity]

INTRODUCTION

A cholesteatoma in the mastoid or in the middle ear presents a hazard to the well-being of patients. Commonly used surgical interventions are not an ideal solution as they bear with them postoperative morbidity such as the need for water precautions, a high rate of cholesteatoma recurrence and the inability to undergo hearing rehabilitation.

METHODS

Forty-five patients underwent an innovative surgical procedure that enables complete removal of the cholesteatoma, preservation of ear anatomy and hearing restoration. Our series was divided into two groups. The first group comprised those in whom this innovative procedure was the first one and the posterior bony canal was preserved (primary surgery). The second group comprised those in whom the bony wall had been removed previously during surgery (secondary surgery).

RESULTS

In the first group, which included 29 patients, the middle ear cavity was found to be aerated in 69% of the patients, the tympanic membrane was intact in 93% and the rate of cholesteatoma recurrence was 10.3%. In the second group, which included 16 patients, the middle ear cavity was found to be aerated in 56.2% of cases, the tympanic membrane was intact in 75% and the rate of cholesteatoma recurrence was 25%.

DISCUSSION

Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO) was found to be an effective approach for completely removing a choLesteatoma and preventing cholesteatoma recurrence. It is water-safe and provides an excellent basis for hearing restoration. The use of the original posterior bony canal for middle ear reconstruction was found to be beneficial. The authors advise an MRI study 18 months after surgery for cholesteatoma detection.

HEAR MAPS a classification for congenital microtia/atresia based on the evaluation of 742 patients

OBJECTIVE

Describe anatomical and radiological findings in 742 patients evaluated for congenital aural atresia and microtia by a multidisciplinary team. Develop a new classification method to enhance multidisciplinary communication regarding patients with congenital aural atresia and microtia.

METHODS

Retrospective chart review with descriptive analysis of findings arising from the evaluation of patients with congenital atresia and microtia between January 2008 and January 2012 at a multidisciplinary tertiary referral center.

RESULTS

We developed a classification method based on the acronym HEAR MAPS (Hearing, Ear [microtia], Atresia grade, Remnant earlobe, Mandible development, Asymmetry of soft tissue, Paralysis of the facial nerve and Syndromes). We used this method to evaluate 742 consecutive congenital atresia and microtia patients between 2008 and January of 2012. Grade 3 microtia was the most common external ear malformation (76%). Pre-operative Jahrsdoerfer scale was 9 (19%), 8 (39%), 7 (19%), and 6 or less (22%). Twenty three percent of patients had varying degrees of hypoplasia of the mandible. Less than 10% of patients had an identified associated syndrome.

CONCLUSION

Patients with congenital aural atresia and microtia often require the intervention of audiology, otology, plastic surgery, craniofacial surgery and speech and language professionals to achieve optimal functional and esthetic reconstruction. Good communication between these disciplines is essential for coordination of care. We describe our use of a new classification method that efficiently describes the physical and radiologic findings in microtia/atresia patients to improve communication amongst care providers.

Surgical outcomes of 43 cases with adenoid cystic carcinoma of the external auditory canal

PURPOSE

To evaluate surgical outcomes for adenoid cystic carcinoma (ACC) of the external auditory canal (EAC).

METHODS

Forty-three patients with ACC of the EAC in Eye and ENT Hospital of Fudan University were analyzed retrospectively for survival. The patients were staged according to the modified Pittsburgh staging system. Thirteen patients with T1 stage underwent local resection (LR), 6 patients with T1 stage underwent lateral temporal bone resection (LTBR), and 8 patients with T1 stage underwent LTBR including superficial parotidectomy (SP). Two patients with T2 stage underwent LTBR, and 1 patient with T2 stage underwent LTBR+SP. Three patients with T3 stage underwent LTBR. One patient with T4 stage underwent LTBR, two patients with T4 stage underwent subtotal temporal bone resection (STBR), and 7 patients with T4 stage underwent LTBR+SP.

RESULTS

Of all patients that underwent surgery, 13 died of their primary cancers during the follow-up time. The 5-year survival rates of patients with T stages 1 through 4 were 85%, 67%, 67%, and 30%, respectively. There was statistically significant difference in 5-year survival rate between T1 and other stages (T2, T3, T4) using the log-rank test (p<0.05). There was significant difference in 5-year survival rate between T4 and other stages using the log-rank test (p<0.05). The 5-year survival rates after LR, LTBR or LTBR plus SP for T1 were 77%, 87% and 100%, respectively. The 5-year survival rates after LTBR, STBR or LTBR plus SP for T4 were 0%, 50% and 29%, respectively. The 5-year survival rates for 19 patients with clear surgical margins and 24 patients with positive margins were 89% and 54%, respectively. The 5-year survival rates of patients with radiotherapy and without radiotherapy were 62% and 86%, respectively.

CONCLUSION

An en bloc resection including superficial parotidectomy is favored in an effort to produce negative surgical margins for ACC of the EAC. Adjunctive radiotherapy is used for patients with positive margins and in advanced lesions.

Conchomeatoplasty: a new technique

Stenosis of the cartilaginous auditory canal is still difficult to resolve and many techniques of plastic surgery have been proposed. Our experience was first built up in treatment of stenosis of the tracheostomy in patients who had undergone laryngectomy. Since it is simple and effective, we have transferred and modified the technique to the treatment of stenosis of the external auditory canal and of the concha. Fourteen patients with stenosis of the cartilaginous auditory canal (diameters of the stenosis prior to surgery varied from 19 to 78.5 mm(2)) underwent day-surgery conchomeatoplasty under local anaesthesia. Eight months after the operation, the results are good. Following surgery, the surface of the auditory canal, measured at the narrowest point of the external auditory meatus, varied from a minimum of 113 mm(2) to a maximum of 254 mm(2). The technique we propose to correct the stenosis of the external auditory canal is easy to carry out, short, and may be performed under local anaesthesia. Lastly, the auditory canal and the ear auricle have a good blood supply, thus ensuring the flaps will survive.

Predictive factors influencing facial nerve outcomes in surgery for small-sized vestibular schwannoma

CONCLUSION

The most important predictive factor of facial nerve outcome in surgery for small-sized vestibular schwannoma (VS) is the adhesion between the tumor and the facial nerve.

OBJECTIVES

To compare the facial nerve outcomes between middle cranial fossa (MCF) and translabyrinthine (TL) approaches, and to analyze the preoperative and intraoperative factors influencing facial nerve outcome after small VS surgery in our neurotologic department.

METHODS

A total of 29 patients were retrospectively analyzed, with 16 in the MCF group and 13 in the TL group. Facial function was serially evaluated according to the House-Brackmann classification at 7 days, 1 month, 3 months, 6 months, and 1 year postoperatively. The effects of variables such as the surgical approach, tumor size, nerve origin, extrameatal extension, intraoperative tumor adhesion to the facial nerve, and facial nerve displacement were determined.

RESULTS

Early and late facial nerve outcomes showed no significant correlation with surgical approach, tumor origin, tumor size, extrameatal extension, or facial nerve displacement pattern. However, a significant correlation was observed with tumor adhesion to the facial nerve and facial nerve outcomes.

A novel technique for reconstruction of the posterior wall of the external auditory canal and tympanum using pedicled temporalis myofascia

CONCLUSIONS

The procedure cleared the lesion completely and preserved the physiological function of the external auditory canal.

OBJECTIVE

To develop a novel surgical procedure to treat chronic suppurative otitis media (CSOM). To explore the merit of using pedicled temporalis myofascia (PTM) and reconstruction of the posterior wall of the external auditory canal with pedicled postauricular periosteal flap and intact skin of the external auditory canal.

METHODS

Forty-seven patients with CSOM were chosen. Open radical mastoidectomy was used to complete clean-up lesions; the fascia of PTM was used to repair the tympanic membrane. The PTM, pedicled postauricular periosteal flap, and intact skin of the external auditory canal were used in the reconstruction of the posterior wall of the external auditory canal. All subjects were followed up for over 2 years. Hearing thresholds, including air conduction (AC), bone conduction (BC), and air-bone gap (ABG) before and after surgery, and after follow-up, were compared.

RESULTS

The healing rate of postoperated tympanic membrane was 95.74% and the 2-year healing rate of tympanic membrane perforation was 95.65%. The 46 ears included in the 2-year follow-up showed significant improvement between preoperative and postoperative AC and ABG values.

[The effect of hyalinized chorda tympani nerve canal in protection of mastoid segment of facial nerve in middle ear surgery]

OBJECTIVE

To investigate the effect of hyalinized chorda tympani nerve canal in mastoid segment to landmark facial nerve in middle ear surgery by means of observing the location relationship between hyalinized chorda tympani nerve canal and facial nerve.

METHOD

118 cases of cholesteatoma otitis media in our hospital undergoing tympanoplasty from 2008 to 2011 were retrospectively analyzed. In all the cases, the position of horizontal semicircular and fossa incus as well as the hyalinized chorda tympani nerve canal were used for landmark the height of facial ridge and vertical segment of facial nerve.

RESULT

The chorda tympani nerve of 99 patients were higher than the vertical segment of the facial nerve which were not exposed, and the vertical segment of the facial nerve in 9 patients, which were exposed, were 1-2 mm lower and 2-3 mm ahead or backward than the chorda tympani nerve. The horizontal semicircular and fossa incus were broken in 9 patients, of whom the vertical segments of the facial nerve were 1-2 mm lower and 2-3 mm ahead or backward than the chorda tympani nerve. The chorda tympani nerve of 1 patient were lower than the exposed vertical segment of facial nerve.

CONCLUSION

The hyalinized chorda tympani nerve canal in mastoid segment can landmark the positon of facial ridge, and it would be the complement to the traditional method of landmarking vertical segment of facial nerve, especially for those whose horizontal semicircular canal and fossa incus had been broken.

Aetiology, pathogenesis, and specific management of Stahl's ear: role of the transverse muscle insertion

Stahl's ear is an anomaly of the external ear that is characterised by a third crux in the antihelix. Its aetiology is unknown. We report 5 patients with Stahl's ear, and describe the anatomy, particularly the musculature. We identified the position of the transverse muscle of the ear as being abnormal, and this can take 2 forms: an abnormal insertion of the entire muscle, or an abnormal insertion of the superior head of the muscle.

The diagnosis and surgical treatment of occult otogenic CSF leakage

CONCLUSIONS

The diagnosis of occult otogenic cerebrospinal fluid (CSF) leakage is challenging and it can easily be misdiagnosed. Some characteristics of clinical presentation can supply important clues and confirmed diagnosis should be obtained according to these clues and suitable imaging studies before meningitis develops. Different surgical techniques should be adopted to treat the CSF leakage according to different leakage etiologies, and good results can be obtained.

OBJECTIVE

The aim of the study was to evaluate the diagnosis and surgical treatment of occult otogenic CSF leakage, including the characteristics of clinical presentation, imaging studies, and operation methods in order to decrease the rate of misdiagnosis and obtain a good curative effect.

METHODS

We performed a retrospective review of 11 cases of CSF leakage that were all misdiagnosed and accompanied by meningitis, operated in our department from 2007 to 2012 after a mean follow-up of 3 years. In this context, the characteristics of clinical presentation, imaging studies, and management of CSF leakage were studied.

RESULTS

The CSF leakage had arisen traumatically (n = 9) or congenitally (n = 2). The medical history and special clinical presentation such as repeated otorrhea or rhinorrhea, fever, headache, and unilateral deafness can supply important diagnostic clues. Imaging studies including high-resolution noncontrast CT (HRCT), CT cisternography, and magnetic resonance imaging (MRI) are very important diagnostic methods. The surgical repairs were performed via a transmastoid approach (n = 8), packing the vestibule (n = 1) or a translabyrithine approach (n = 2). Recurrent leakage did not occur.

The use of bone cement for ossicular chain defects

Bone cement is a good and cheap option for some ossicular chain problems such as incudostapedial re-bridging. The purpose of this retrospective study is to evaluate the audiologic results after reconstruction of three different types of ossicular chain defects, using bone cement. Group 1 consists of 42 patients who underwent an ossiculoplasty using bone cement between the damaged long process of the incus and an intact stapes superstructure. Group 2 consists of 46 patients in which incus interposition between malleus and stapes superstructure was performed, using bone cement to fix the interposed incus. For group 3, consisting of 32 patients who had a present malleus, a defective long process of the incus and a missing stapes superstructure, a re-shaped incus was placed between the stapes footplate and the malleus and bone cement was again used as a fixator. Preoperative and postoperative pure-tone audiometric findings were obtained and hearing differences were assessed. The mean preoperative and postoperative air-bone gaps were 34.8 and 15.6, 35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3, respectively. There was a significant improvement in hearing outcomes in all the groups when comparing preoperative and postoperative mean air-bone gaps (p < 0.001). The postoperative air-bone gap was ≤20 dB in 76 % of patients in group 1, 64 % of patients in group 2, and 46 % of patients in group 3. Bone cement is an effective and cheap option for some ossicular chain problems such as incudostapedial re-bridging. It may also be used to fix the interposed incus to the stapes superstructure and/or malleus to avert displacement.

Superglue ear: our experience and a review of the literature

Cyanoacrylate glue (Superglue) has the ability to bond a variety of surfaces firmly within seconds of use. Its application into the external ear canal (EAC) is a challenging problem for clinicians. We present 3 case reports of patients who presented at our hospital with superglue in their EACs: 1 was accidental, 1 was iatrogenic, and 1 was intentional. To our knowledge, iatrogenic application of cyanoacrylate glue to the EAC has not been reported previously. We describe our management of these cases and review similar cases reported in the literature. These cases highlight the pressing need for changes in the size, shape and colour of the containers to make them more easily recognizable and distinctive.

Introducing endoscopic ear surgery into practice

The otolaryngologist will find in this article a direct and frank discussion and useful advice for how to get started performing solely endoscopic ear surgery for abnormalities of the middle ear. The author provides discussion and photos based on his experience with this procedure. Presented herein are selection of the endoscope, how to approach the first fully endoscopic procedure, patient selection, preoperative planning, setting up the operating room, pitfalls typically encountered, and how to gain skills to perform this procedure successfully.

[Surgical treatment results of acquired external auditory canal atresia]

Acquired post inflammatory external auditory canal atresia is a rear complication of external ear disease. It is presented as a connective tissue scar in bony part of external auditory canal. The aim of this study is clinical and epidemiological analysis and presentation of diagnostics and treatment results of patients with atresia treated in the Otolaryngology Department of Medical University of Gdansk.

MATERIAL AND METHODS

In the period of 3 years (2008-11) 10 patients (8 women and 2 men) aged 30 to 70-years-old (medium 53 years) were treated for acquired atresia. All of these patients had medial closure of EAC with thick connective tissue scar and tympanic membrane involvement. Intrameatal access was performed in 5 patients, intraural access in 3 patients and retroaurical access in 2 patients. In all cases canaloplasty with meato-tympanic angle enlargement was performed, skin defect was replaced with free epidermal flap, silicon foil with fibrinous sponge was used for coverage.

RESULTS

In all of our patients external auditory canal widening and hearing improvement was achieved. Due to increasing EAC narrowing four patients underwent second surgery with another free epidermal flap grafting.

CONCLUSION

The selection of surgical access in patients with acquired atresia should comply with the etiology of the disease and the shape of EAC. During surgery we aim at maximal broadening of the bony part of EAC. The success of the treatment depends on meato-tympanic angle enlargement and free epidermal flap grafting.

[Ear reconstruction for microtia with craniofacial deformities]

OBJECTIVE

To investigate the methods and effectiveness of ear reconstruction for the microtia patients with craniofacial deformities.

METHODS

Between July 2000 and July 2010, ear reconstruction was performed with tissue expander and autogenous costal cartilages in 1 300 microtia patients with degree II+ hemifacial microsoma, and the clinical data were reviewed and analyzed. There were 722 males and 578 females, aged 5 years and 8 months to 33 years and 5 months (median, 12 years and 2 months). The expander was implanted into the retroauricular region in stage I; ear reconstruction was performed after 3-4 weeks of expansion in stage II; and reconstructed ear reshaping was carried out at 6 months to 1 year after stage II in 1 198 patients.

RESULTS

Of 1 300 patients, delayed healing occurred in 28 cases after stage II, healing by first intention was obtained in the other 1 272 cases, whose new ears had good position and appearance at 1 month after stage II. After operation, 200 cases were followed up 1-9 years (mean, 3 years). One case had helix loss because of trauma, and 1 case had the new ear loss because of fistula infection. At last follow-up, the effectiveness were excellent in 110 cases, good in 65 cases, and fair in 23 cases with an excellent and good rate of 88.4%.

CONCLUSION

It is difficulty in ear reconstruction that the reconstructed ear is symmetrical to the contralateral one in the microtia patients with degree II+ hemifacial microsoma. The key includes the location of new ear, the fabrication of framework, and the utilization of remnant ear.

Endoscopic management of attic cholesteatoma: a single-institution experience

At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma.