The MO-meatocanalplasty: a modification of the M-meatoplasty to address the superior quadrants and the bony canal

Radiological Follow-up After the Bony Obliteration Tympanoplasty in Detecting Residual Cholesteatoma: Towards an Optimal Postoperative MR Imaging Protocol

INTRODUCTION AND AIM

There is no consensus in literature on the most optimal follow-up imaging protocol for non-echoplanar diffusion-weighted magnetic resonance imaging (non-EP DW MRI) after the canal wall-up bony obliteration tympanoplasty. Clearly, no residual cholesteatoma should be missed but on the other hand, unnecessary MR controls should be avoided. The aim of this study is to evaluate the postoperative results of non-EP DW MRI after canal wall-up bony obliteration tympanoplasty surgery at our Institute and to propose an optimal postoperative MR imaging scheme based on our data.

MATERIAL AND METHODS

Retrospective cohort study; all 271 patients who underwent the bony obliteration tympanoplasty between January 2010 and January 2016 with follow-up at our Institute were included. A postoperative MR imaging was systematically performed at 1 year after surgery and repeated at either 5 or both 3 and 5 years after surgery, based on the preferences of the surgeon. Variables of interest were retrieved from electronic patient records.

RESULTS

The median follow-up time was 60 months (inter-quartile range 56-62 mo). Two hundred seventy-one patients (100%) received a 1-year MRI, 107 (39%) a 3-year MRI, and 216 (79.7%%) a 5-year MRI. Residual cholesteatoma was found in nine cases (3.3%), corresponding with an estimated residual rate at 5 years follow-up of 3.7% when using Kaplan-Meier analysis. Of these nine cases, six cases of residual cholesteatoma (66.7%) were detected at the 1-year MRI (12-14 mo postsurgery), two cases (22.2%) at the 3-year MRI (35-39 mo postsurgery), and one case (11.1%) at the 5-year MRI (51 mo postsurgery, in this patient no 3-year MRI was performed). An uncertain MRI result was found in 15 cases, presenting as relatively hyperintense lesions. However, subsequent follow-up scans did not show persistent evidence for residual disease in 14 of these 15 cases.

CONCLUSIONS

A postoperative MRI scan after 1 and 5 years is essential to detect early and late residual cholesteatoma. In our cohort, 22.2% of residual cases were detected at the 3-year MRI. However, this percentage could potentially have been higher when all patients would have received a 3-year MRI. Therefore, in order to detect residual disease as soon as possible, we propose to perform an MRI scan at 1, 3, and 5 years after the bony obliteration tympanoplasty. In cases with an unclear MR result, we suggest a repeat MRI after 12 months.

The MO-meatocanalplasty: long-term results in the narrow external auditory canal with recurrent otitis externa or the inability to wear a hearing aid

OBJECTIVE

The MO-meatocanalplasty is the oblique modification of the M-meatoplasty. The MO-meatocanalplasty was designed to address the superior quadrants of the meatus and the bony canal without the need for a retro-auricular incision. This retrospective analysis was performed to evaluate the long-term results of the MO-meatocanalplasty in patients with a narrow external auditory canal (EAC) with recurrent otitis externa or in patients unable to wear a hearing aid.

METHODS

Twenty-two ears in twenty consecutive patients who received a MO-meatocanalplasty for a narrow EAC with recurrent otitis externa or the inability to wear a hearing aid were analysed retrospectively. There were no patients included with any type of previous or planned second stage tympanoplasty procedures. A follow-up period of 3 years was analysed for postoperative recurrent narrowing, the self-cleaning capacity of the EAC, the recurrence of otitis externa, the inability to wear a hearing aid, change in hearing level and for all types of aesthetical complaints.

RESULTS

The MO-meatocanalplasty procedure was effective in 82% (n = 18). Postoperative recurrent narrowing was detected in 9% (n = 2). Insufficient self-cleaning capacity of the EAC was 9.1% (n = 2). The ability to wear a hearing aid was restored in all patients with the need for a hearing aid. No aesthetical complaints were reported.

CONCLUSION

The MO-meatocanalplasty is an effective, safe and aesthetical accepted procedure to address the narrow meatus and external auditory canal. With this procedure, there is no need for a retro-auricular incision in order to create a well aerated, dry and self-cleaning EAC in patients with a narrow EAC with recurrent otitis externa or in patient with the inability to wear a hearing aid.

The bony obliteration tympanoplasty in cholesteatoma: safety, hygiene and hearing outcome: allograft versus autograft tympanic membrane reconstruction

OBJECTIVE

To evaluate early results on hygiene, safety and functional outcome in a population undergoing a canal wall up technique with bony obliteration of the mastoid and epitympanic space (CWU-BOT) for extensive cholesteatoma, performed by a single surgeon. This study compares different techniques of tympanic membrane reconstruction, viz. allografts and autografts.

PATIENTS

A consecutive series of 61 ears with acquired cholesteatoma treated with primary or revision CWU-BOT surgery from 2009 to 2014.

INTERVENTION

Obliteration was performed by the use of cortical bone-chips and bone pâté. Patients were followed up with micro-otoscopy and MRI with diffusion-weighted imaging. Ossicular reconstruction was performed using a remodelled autologous or allogenic incus or malleus.

MAIN OUTCOME MEASURES

Residual and recurrence rate and short- and mid-term hearing outcome prior to any revision tympanoplasty were analysed, the effect of type of tympanic membrane reconstruction was considered.

RESULTS

44 Ears were primary cholesteatoma cases, 17 cases were referred for revision surgery. Mean postoperative follow up was 45 months (SD 18.08) and mean follow-up until the last non-EP DW MRI 42 months (SD 17.72). Recurrent disease was present in 3%, no residual disease was present. An AC gain was seen in 75% of all ears undergoing ossicular reconstruction.

CONCLUSION

Reproducible safety, hygiene and hearing results with limited recurrence and residual disease can be obtained by younger otologic surgeons performing the BOT-CWU for extensive cholesteatoma while using a variety of grafts for tympano-ossicular reconstruction. The tympano-ossicular allograft nevertheless shows superior hearing results when a mobile intact stapes is present.

LEVEL OF EVIDENCE

Level 4.

Augmented reality for inner ear procedures: visualization of the cochlear central axis in microscopic videos

PURPOSE

Visualization of the cochlea is impossible due to the delicate and intricate ear anatomy. Augmented reality may be used to perform auditory nerve implantation by transmodiolar approach in patients with profound hearing loss.

METHODS

We present an augmented reality system for the visualization of the cochlear axis in surgical videos. The system starts with an automatic anatomical landmark detection in preoperative computed tomography images based on deep reinforcement learning. These landmarks are used to register the preoperative geometry with the real-time microscopic video captured inside the auditory canal. Three-dimensional pose of the cochlear axis is determined using the registration projection matrices. In addition, the patient microscope movements are tracked using an image feature-based tracking process.

RESULTS

The landmark detection stage yielded an average localization error of [Formula: see text] mm ([Formula: see text]). The target registration error was [Formula: see text] mm for the cochlear apex and [Formula: see text] for the cochlear axis.

CONCLUSION

We developed an augmented reality system to visualize the cochlear axis in intraoperative videos. The system yielded millimetric accuracy and remained stable throughout the experimental study despite camera movements throughout the procedure in experimental conditions.

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Hearing Results

OBJECTIVE

To present the hearing results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up (CWU) approach with bony obliteration of the mastoid and epitympanic space, with a standard residual rate of 5.8%, a recurrence rate of 2.9%, and all ears waterproof, free of otorrhea and all external ear canals patent and self-cleaning.

STUDY DESIGN

Retrospective consecutive study.

PATIENTS

Thirty-three children (≤18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009.

INTERVENTIONS

Therapeutic.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASURES

Hearing and gain in hearing at 1- and 5-year postsurgery: (1) pure-tone average (PTA), (2) pure-tone average high frequency, (3) pure-tone average including 3 kHz, (4) bone conduction at corresponding frequency averages, (5) gain at corresponding air conduction and bone conduction (gain at corresponding air conduction) frequency averages. (6) The Amsterdam Hearing Evaluation Plots were used to study the individual cases.

RESULTS

The Amsterdam Hearing Evaluation Plots at 5-year showed in 58.8% of patients a positive gain air conduction. In 23.5% a successful functional result was achieved, defined as an air-bone gap closure to 20 dBHL or less. In 6 patients (17.6%) a limited bone conduction deterioration was shown all limited to maximum 20 dBHL.

CONCLUSION

The CWU bony obliteration tympanoplasty in a consecutive series of pediatric extensive cholesteatoma shows a similar to slightly improved hearing outcome as compared with CWU surgery without BOT. Although the series shows a clearly reduced reoperation rate and a significantly improved safety and hygienic outcome as compared with CWU without BOT, better hearing outcomes remain desirable in this group of children.