The histopathology of mastoidectomy cavities, with particular reference to persistent disease leading to chronic otorrhoea

The effect of fascia and free skin graft on the healing of mastoid cavity after canal wall down mastoidectomy

OBJECTIVE

Post-mastoidectomy delayed cavity healing is a challenge to manage. This study aimed to cut down healing time with a simple technique (fascia with a skin graft) and compared it with controls without this technique.

METHOD

The current study was a prospective non-randomised controlled study, conducted in a tertiary referral hospital. Thirty cases and 30 controls with squamosal type chronic otitis media were studied.

RESULTS

By the end of first month, 23.3 per cent of cases had healed compared with 3.3 per cent of controls. At the third month follow up, 83.3 per cent of cases and 53.3 per cent of controls had healed. At the sixth month follow up, 93.3 per cent of cases and 86 per cent of controls had healed.

CONCLUSION

Healing of the mastoid cavity, as evidenced by epithelialisation and formation of a dry cavity, was faster in cases that received the graft when compared with controls without the graft.

Mastoid obliteration and external auditory canal reconstruction with silicone block in canal wall down mastoidectomy

OBJECTIVE

To prevent cavity problems in canal wall down mastoidectomy, silicone block for mastoid obliteration was used.

METHODS

In this retrospective cohort study, 39 patients (21 males and 18 females) underwent canal wall down mastoidectomy and mastoid obliteration using silicone block. We evaluated the postoperative outcome, the time until epithelialization of the cavity, graft success rate, and the hearing outcome.

RESULTS

The time until complete epithelialization of the mastoid cavity was 35.5 ± 5.4 days. We had a graft success rate of 100% during the follow-ups. The postoperative evaluation revealed 36 dry ears (92.3%) patients without any cavity problems. However, one ear developed granulation tissue, and two ears had partially exposed silicone block, which required revision mastoidectomy. Regarding hearing outcomes, a complication such as deaf ear was not reported.

CONCLUSION

Silicone block is safe and suitable for mastoid obliteration and external auditory canal reconstruction in canal wall down mastoidectomy.

LEVEL OF EVIDENCE

4.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

Histopathological and Inflammatory Features of Chronically Discharging Open Mastoid Cavities: Secondary Analysis of a Randomized Clinical Trial

Importance

Many patients with an open radical mastoid cavity experience therapy-resistant otorrhea. Little is known about the underlying histopathological substrate of unstable cavities and the correlation with treatment failure.

Objective

To study the histopathological and inflammatory features of chronically discharging open radical mastoid cavities and the influence of different treatments.

Design, Setting, and Participants

This secondary analysis of a randomized clinical trial was a histopathology study of tissue samples of a cohort of 30 patients with a chronically discharging open mastoid cavity. Samples were taken from the cavities, which were treated with either honey gel or conventional eardrops in a tertiary center between 2012 and 2013. Tissue staining was performed in May 2014; final computer analysis/correlation studies were performed in June 2016.

Main Outcomes and Measures

Differences of epithelial tissue coverage, infiltration of T cells (CD3, CD4, CD8) and macrophage (CD68, isoenzyme nitric oxide synthase, arginase 1) (sub-)populations, infection status, and the correlation with clinical presentation.

Results

There were 30 patients (24 [80%] male; mean [SD] age, 59 [14] years). Cavities were covered with either stratified squamous (keratinized) epithelium (n = 10), respiratory columnar epithelium (n = 9), or granulation tissue (n = 10). The presence of respiratory epithelium was associated with lower treatment success (posttreatment VAS improvement of 3.1 [95% CI, 0.5 to 5.8] for discomfort and 3.6 [95% CI, 0.2 to 6.9] for otorrhea in the group with granulation tissue coverage vs 4.9 [95% CI, 0.2 to 9.6] and 5.8 [95% CI, -0.1 to 11.6] in the group with squamous [keratinized] epithelium coverage and 1.4 [95% CI, -1.2 to 4.1] and 2.5 [95% CI, -1.3 to 6.2] in the group with respiratory columnar epithelium coverage). In all 3 tissue types of cavity-covering tissues, T-cell infiltrates consisted of helper T cells and cytotoxic T cells, together with a lower number of macrophages. The immunopositivity for isoenzyme nitric oxide synthase and arginase 1 was high and not restricted to a macrophage subpopulation, but seen in various cell types. Inflammatory infiltrations varied strongly in all 3 tissue modalities.

Conclusions and Relevance

Discharging open mastoid cavities can be classified histologically into 3 different types, based on their coverage: squamous epithelium, respiratory epithelium, or granulation tissue. Treatment is less successful in cavities covered with respiratory epithelium, possibly explained by the status of bacterial infection and local immunological differences.

Unique microbiology of chronically unstable canal wall down tympanomastoid cavities: considerations for surgical revision

OBJECTIVE

To review the microbiology of open tympanomastoid cavities in patients who underwent revision surgery due to chronic instability.

METHODS

This paper describes a retrospective chart review of surgical revision cases of chronically unstable open mastoid cavities. Patient records from 2000 to 2010 were reviewed for the type of organism cultured, antimicrobial resistance and the presence of cholesteatoma.

RESULTS

In total, 121 revision surgical procedures were performed on 101 patients. Seventy-nine procedures involved culture specimen processing, 37 of which were positive. The most commonly cultured organism was Staphylococcus aureus, which was more than twice as common as any other pathogen. The presence of cholesteatoma had no impact on the likelihood of a positive culture or polymicrobial culture. Antimicrobial-resistant pathogens were uncommon.

CONCLUSION

A positive culture was not an overwhelmingly common characteristic of unstable tympanomastoid cavities. Furthermore, antimicrobial resistance did not appear to play an essential role in leading patients towards revision open mastoid surgery.

Down-regulation of toll-like receptor 4 in the granulation tissues of postoperative mastoid cavities with otorrhea

CONCLUSIONS

The expression of toll-like receptor (TLR) 4 and associated downstream events, such as the activation of signal pathway proteins and inflammatory cytokine production, were down-regulated in the granulation tissues of postoperative mastoid cavity with otorrhea, possibly leading to endotoxin tolerance.

OBJECTIVE

The postoperative mastoid cavity is exposed to a high density and diversity of bacteria, but very little is known about how the immune environment is maintained in these regions with otorrhea. In this study, we investigated the changes in the TLR2 and TLR4 signaling pathways and inflammatory cytokine production in the granulation tissues of mastoid cavities with otorrhea and in normal auditory canal skin.

MATERIALS AND METHODS

We investigated the expression of TLR2 and TLR4, as well as downstream signal pathway proteins, nuclear factor-kappaB (NF-kappaB) DNA binding, and secretion of tumor necrosis factor-alpha (TNF-alpha) in 28 samples of granulation tissue obtained from the postoperative mastoid cavity with otorrhea and 10 normal external auditory canal skin samples.

RESULTS

We found that the frequency of TLR2- and TLR4-positive cells was not increased in granulation tissues relative to normal skin, but the TLR4 mRNA and protein were down-regulated. In this pathophysiological process, there was also a lack of downstream signal pathway protein activation and secretion of TNF-alpha.

Long-term Outcome of the Hong Kong Vascularized, Pedicled Temporalis Fascia Flap in Reconstruction of Mastoid Cavity

OBJECTIVES

The vascularized, pedicled temporalis fascia flap (Hong Kong flap) is an established procedure in the reconstruction of the mastoid cavity. The long-term outcome and complications have not been studied. We set out to appraise this procedure in our study.

STUDY DESIGN

The clinical records of 302 ears that had the Hong Kong flap procedure from 1987 to 2006 were retrospectively studied. The study reviewed the otologic complaints leading to Hong Kong flap, the number and findings of the second or more looks, analysis of procedures year by year, time to achieve a dry ear, and the complications.

RESULTS

The main otologic complaint leading to use of the Hong Kong flap is otorrhoea. The number of Hong Kong flap procedures has decreased in recent years. Twenty-one percent had second or more looks after the procedure. Forty percent of the mastoid cavities at the second look were found to have residual or recurrent cholesteatoma. It takes a median of 2 months to achieve a dry ear after the procedure.

CONCLUSIONS

We conclude that the Hong Kong flap procedure is simple and desirable for mastoid reconstruction to achieve a safe and dry cavity with few complications.

Canal wall down mastoidectomy: A long term commitment to the outpatients?

BACKGROUND: Canal wall down and canal wall up mastoidectomy represent two surgical approaches to middle ear cleft pathology. Very few studies have examined the effects of these procedures both on the patients' well being and on the resources needed to maintain that state. In this study the authors report the outpatient attendance pattern of canal wall down mastoidectomy patients METHODS: This is a retrospective case-note review of 101 patients who underwent a CWD mastoidectomy at Derriford Hospital, Plymouth, UK. All surgery was performed by the senior author (PCW-T) between 1985 and 1997. The main outcome measures were the frequency of outpatients' visits, clinical problems at visit and the percentage of discharged patients. RESULTS: The studied patients made a total of 1341 outpatient visits between November 1985 and December 1998 with an average of 13.3 visits per patient (median of 11 visits). Almost two thirds of the group still attend for regular follow up. The greatest number of visits occurred in the first 24 months after surgery. The commonest reasons for outpatient visits were the removal of the clinical features of chronic cavity inflammation. Residual/recurrent cholesteatoma, residual perforations and structural cavity problems were infrequent. CONCLUSION: CWD mastoidectomy carries an intrinsic morbidity resulting in a long term attendance in the outpatients.

[Why does a mastoidectomy cavity become suppurative? Our experience and revision of the literature]

The main goal for performing surgery for chronic otitis media is to eliminate the disease and improve hearing whenever possible. Persistent drainage of a mastoid cavity means failure of surgery and of achieving the goal. In this study, we present our department's attitude for suppurative mastoid cavities as well as the reasons that do not allow adequate control of them.

A technique of mastoidectomy and meatoplasty that minimizes factors associated with a discharging mastoid cavity

OBJECTIVES

To present and assess a surgical technique designed to minimize the known causes of a discharging mastoid cavity.

STUDY DESIGN

A temporal bone dissection to establish the anatomical relationships on which the surgical technique is based. A presentation of the proposed surgical technique and a prospective assessment of the technique in twenty consecutive mastoidectomies.

METHODS

Five temporal bone dissections were performed to establish the relationship between the chorda tympani and the facial nerve when these structures are approached from above. The surgical technique is presented and the mastoid cavities of twenty consecutive patients assessed. The assessment included measurement of the facial ridge height, "kidney-shape" of the cavity, size of the cavity, size of the meatus, and state of the tympanic membrane.

RESULTS

In the temporal bone dissections the vertical height between the chorda tympani and the facial nerve at 3/9 o'clock was a mean of 2.01 mm. Nineteen of the 20 consecutive mastoid cavities (95%) performed with the presented technique remained well healed and dry. The mean facial ridge height was 2.7 mm at 3/9 o'clock and 4.8 mm at 6 o'clock. The kidney-shaped measurement was 1.45 mm. The mean size of the cavities was 2.6 mm and 18 of the 20 patients (90%) had an intact tympanic membrane. The mean largest diameter of the meatus was 10.1 mm.

CONCLUSIONS

The surgical technique presented produces a mastoid cavity with a low facial ridge and oval shape. These two factors have been previously identified as important in the outcome of mastoid surgery.

Treatment of chronic postoperative otorrhea with cultured keratinocyte sheets

Cultured allogeneic ear keratinocyte sheets were used to treat 26 ears presenting with long-standing (average 37 months) chronic otorrhea, resistant to regular treatment, long after surgery for atresia (n = 8), cholesteatoma (n = 10), and chronic otitis media (n = 8). Complete epithelial healing and cessation of otorrhea were obtained in 18 cases (69%), following an average of 2.2 weekly applications. Temporary epithelial healing lasting at least 3 months was observed in 3 patients (12%) subsequently needing repeated applications. Lack of complete epithelialization was documented in 5 cases (19%). In 3 of those 5 cases, a reason could be determined. The authors speculate that the allocultured keratinocytes are able to promote migration and proliferation of resident cells at the wound edges, despite their short survival time, by release of keratinocyte-stimulating factors.

The role of the Davis graft technique in the treatment of chronic post-mastoidectomy otorrhoea

The effect of grafting mastoid cavities with small Davis cutaneous pinch grafts was assessed in 15 patients. Following revision of the cavity and Davis pinch grafting the resultant cavity was completely dry in 13 patients (87%) over a period ranging from 1 to 30 months with a mean of 7.3 months, with five becoming dry within 1 month. Patient satisfaction with respect to reduction in discharge and smell was excellent (87%). We believe that the Davis graft technique has a beneficial role in persistent post-mastoidectomy otorrhoea especially when previous standard revision techniques have failed.

Epithelial migration in open mastoidectomy cavities

Twenty patients who had undergone open cavity mastoidectomy for chronic middle ear disease were selected for study. Following initial microscopic aural toilet, each cavity was painted in its medial aspect with a marker solution of Bonney's Blue dye. Each patient was assessed at weekly intervals for a minimum of three months following application of dye, and a photographic record made of the cavity. Information was also sought regarding the clinical behaviour of the mastoid cavities, with particular regard to degree of otorrhoea, and accumulation of debris. Migration of epithelium inferred by visible movement of dye occurred in 17 of the 20 mastoid cavities. In all these cases migration occurred in a medial to lateral direction, towards the exterior. In two cases there was no visible migration throughout the period of observation, and inspection after six months revealed the dye to be still present in the original position. Both these cases were of dry trouble-free cavities in which accumulation of debris did not appear to be a problem. This finding calls into question the assumption that clean trouble-free cavities are maintained by a satisfactorily functioning epithelial migration. In the four cavities which suffered from intermittent otorrhoea, epithelial migration occurred at a similar rate to that in dry cavities.