Long-term deterioration of bone-conduction hearing level in patients with labyrinthine fistula

Clinical Study of Labyrinthine Fistula in Cholesteatomatous Chronic Otitis Media: A Tertiary Care Hospital-Based Retrospective Study in a South Indian Population

INTRODUCTION

Among the extracranial complications of cholesteatoma, the most common is labyrinthine fistula (LF). The causes are still poorly understood for cholesteatoma-induced labyrinthine fistula. Some of the possible factors described in the literature are the patient's age, duration of the disease, growth pattern of cholesteatoma, and disease aggressiveness. These affect the site of development of labyrinthine fistula. Cholesteatoma and its complications pose a great burden on the economic and health sector of developing nations.

AIM AND OBJECTIVE

 The objective is to estimate the incidence of labyrinthine fistula in cholesteatomatous chronic otitis media (COM) and analyze the clinical presentation and post-surgical improvement in hearing and vertigo in the study cohort.

MATERIALS AND METHOD

The study was conducted in the Department of Otorhinolaryngology. It involved retrospective data collection of case records between 2018 and 2022. All patients diagnosed with chronic otitis media (COM) with cholesteatoma were reviewed retrospectively in a tertiary healthcare center. Of the 324 cases reviewed, 21 had an LF.

RESULTS

The incidence rate of LF in our study was 6.48%. Sixteen (76.1%) patients were male, and five (23.9%) were female. The youngest patient was a 10-year-old male, and the oldest was a 51-year-old female. The mean ± standard deviation (SD) age was 34.09 ± 10.05 years. The left ear (76.1%) was affected more than the right ear. All cases were from rural areas, and 16 (76.1%) of them were farmers. Ear discharge (85%) was the most common symptom, followed by hearing loss (76%) and then vertigo (47%). A very peculiar risk factor of self-cleansing the ear was noticed in all patients. Out of the 21 patients who underwent surgery, it was observed that the lateral semicircular canal (LSCC) was the commonest site of the fistula. According to the Dornhoffer and Milewski classification, type II LF was the commonest type. In one patient with a type III LF, a foreign body (a piece of a twig) was found intraoperatively near the LSCC fistula site. Two patients had multiple fistulae. Six patients had associated mastocutaneous fistula, and one had facial nerve paralysis. All patients, except one, were free of vertigo following surgery. Postoperatively, the bone conduction thresholds were similar to the pre-surgical values in 12 of 16 (74%) patients.

CONCLUSION

 The incidence of LF is still higher in developing countries, predominantly in rural populations, where the habit of self-cleansing the ear is a common practice. The common symptoms of COM with LF are ear discharge, hearing impairment, and vertigo. All the cases had a habit of frequent self-cleansing of the external ear as an important risk factor. Therefore, implementing awareness programs on maintaining aural hygiene in rural health centers may reduce the incidence of cholesteatomatous LF, thereby preserving hearing and vestibular functions and improving the quality of life. However, the above statement needs further validation with large multicenter studies.

Presentation, Management, and Hearing Outcomes of Labyrinthine Fistula Secondary to Cholesteatoma: A Systematic Review and Meta-analysis

OBJECTIVE

The current study systematically reviewed the literature to compare auditory outcomes of patients treated for labyrinthine fistula (LF) based on characteristics of disease and surgical management.

DATABASES REVIEWED

PubMed, Scopus, Web of Science.

METHODS

Original series (at least five cases) published from 2000 reporting management and hearing results of LF secondary to cholesteatoma were included. Proportion and odds-ratio (OR) meta-analyses were conducted through inverse variance random-effects models based on logit transformation.

RESULTS

The prevalence of LF is estimated to be 7% (95% confidence interval [CI], 5-9%). Fistulae involving the lateral semicircular canal (90%; 95% CI, 87-93%) and larger than 2 mm (53%; 95% CI, 43-64%) were common, whereas membranous involvement was less frequent (20%; 95% CI, 12-30%). Complete removal of the cholesteatoma matrix overlying the LF was mostly applied. Bone conduction (BC) preservation was frequently achieved (81%; 95% CI, 76-85%); new-onset postoperative anacusis was rarely reported (5%; 95% CI, 4-8%). A higher chance of BC preservation was associated with sparing the perilymphatic space (OR, 4.67; 95% CI, 1.26-17.37) or membranous labyrinth (OR, 4.56; 95% CI, 2.33-8.93), exclusive lateral semicircular canal involvement (OR, 3.52; 95% CI, 1.32-9.38), smaller size (<2 mm; OR, 3.03; 95% CI, 1.24-7.40), and intravenous steroid infusion (OR, 7.87; 95% CI, 2.34-26.42).

CONCLUSION

LF occurs in a significant proportion of patients with cholesteatoma. In the past two decades, complete removal of the cholesteatoma matrix followed by immediate sealing has been favored, supported by the high proportion of BC preservation. Hearing preservation depends primarily on characteristics of the LF, and specific surgical strategies should be pursued. Intraoperative and postoperative intravenous steroid infusion is recommended.

Clinical Characteristics of Patients with Cochlear Fistulas Caused by Chronic Otitis Media with Cholesteatoma

OBJECTIVES

To analyze the clinical characteristics of cochlear fistulas (CFs) and propose a new fistula classification system with regard to the cochlea.

MATERIALS AND METHODS

A retrospective chart review was conducted between January 2008 and December 2015 to identify patients who had undergone surgery for cholesteatoma with an associated CF. The following data were collected: preoperative symptoms, findings of temporal bone computed tomography (TBCT), fistula stage, cholesteatoma classification, surgical technique, and pre- and postoperative pure-tone audiometry.

RESULTS

We analyzed a total of 159 patients, out of which 9 (5.7%) were diagnosed with a CF. The average duration of the chronic otitis media was 19.8 years. Cholesteatomas that induced CF rarely existed in the nonaggressive state; recurrent otorrhea was observed in all but one of our subjects. All the patients with CF had a distinct origin of cholesteatoma that developed from the retraction of posterior pars tensa; further, 88.9% cholesteatomas extended to and filled the sinus tympani. Preoperative audiometry revealed total hearing loss in 4 (44.4%) patients. Further, five patients with residual hearing before surgery had stage I fistulas, and the bone conduction thresholds remained stable after surgery.

CONCLUSION

Cochlear fistulas were often detected in patients with (1) a history of chronic otitis media (exceeding 10 years), (2) frequently recurring otorrhea, and (3) pars tensa cholesteatomas that extended to the posterior mesotympanum and filled the sinus tympani. Such patients can suffer from potentially severe and irreparable sensorineural hearing loss.

Treatment using diffuse laser energy of cochlear and vestibular fistulas caused by cholesteatoma

OBJECTIVE

To measure the outcomes of laser treatment of cholesteatoma covering cochlear and vestibular fistulas.

METHODS

Cholesteatoma matrix over the fistula was denatured; the power density was sufficient only to gradually heat, but not vaporise, the keratin-forming matrix. The denaturing speed was controlled so that the integrity of the fistula cover was maintained. The change in bone conduction threshold and the residual rate of cholesteatoma at the fistula were measured.

RESULTS

Thirty-six fistulas were assessed. There were seven cochlear fistulas. All were 5 mm or less in maximum length. For the entire group, the average change in bone conduction threshold was -0.3 dB. For cochlear fistulas, the average change in bone conduction was + 0.2 dB. The distribution of hearing results for the entire group was Gaussian; the apparent changes in hearing could be attributed to errors associated with testing. All patients underwent second-stage surgery. In all cases, the cholesteatoma was completely cleared from the fistula site. There were no facial palsies.

CONCLUSION

Laser denaturing of cholesteatoma matrix over fistulas measuring 5 mm or less of vestibular apparatus and the cochlea is effective at eliminating cholesteatoma, and is not associated with cochlear hearing loss or facial palsy.

Imaging of labyrinthine fistula after repair with bone pate

OBJECTIVES/HYPOTHESIS

To demonstrate imaging of labyrinthine fistula due to cholesteatoma and illustrate outcome following repair with bone pate.

STUDY DESIGN

Retrospective review.

METHODS

Patients with labyrinthine fistula due to cholesteatoma were identified, and pre- and postoperative imaging was assessed. Method of repair was recorded. The fistula site was examined for patency and bone density after repair.

RESULTS

Twenty-nine fistulae were seen in a cohort of 375 cholesteatoma cases (8%). Preoperative computed tomography (CT) imaging for fistula detection showed sensitivity of 96% and specificity of 90%. The lateral semicircular canal was the most common site of dehiscence occurring in all cases. Facial nerve dehiscence is observed in 91% of fistula cases and stapes erosion in 69%. Severe hearing loss was present preoperatively in four (14%) cases. Bone pate was used to repair the fistula with CT-documented restoration of the otic capsule in 11/13 cases with postoperative imaging. When bone pate was not used, the otic capsule defect persisted.

CONCLUSIONS

Spontaneous repair of the otic capsule following treatment of cholesteatoma is expected to be an uncommon occurrence. Repair of the fistula with bone can result in long-lasting restoration of the otic capsule.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1643-1648, 2018.

Surgery for Cholesteatomatous Labyrinthine Fistula

OBJECTIVE

There is uncertainty regarding the ideal surgical management of cholesteatomatous labyrinthine fistulae. The objective was to review the published evidence to determine whether a difference exists in hearing outcome for cholesteatoma matrix removal or matrix exteriorization.

DATA SOURCES

Systematic MEDLINE and Web of Science searches identified publications describing hearing results after cholesteatoma matrix removal or matrix exteriorization.

REVIEW METHODS

Three reviewers appraised the studies for quality, level of evidence, and extracted data. Fistula characteristics such as single-site, multisite, size, grade, and follow-up time were extracted for subanalyses, and when appropriate, data were pooled for statistical analysis.

RESULTS

Twenty-eight articles met inclusion criteria, and the level of evidence was judged no better than level 3b. There was no difference in hearing preservation detected between matrix removal and exteriorization (87% for matrix removal, 95% CI, 0.82-0.90; 95% for exteriorization, 95% CI, 0.85-0.98). An analysis of the individual cohort studies that compared these groups directly did not show a difference in calculated odds ratio (OR), 0.96 (95% CI, 0.66-1.40).

CONCLUSION

The level of evidence on which to base surgical decision making related to cholesteatomatous labyrinthine fistula is poor, and the data do not demonstrate significant differences in hearing outcomes based on surgical technique.