Risk stratification in endoscopic type I. tympanoplasty

PURPOSE

Several risk factors were studied in endoscopic type I. tympanoplasty, however, an easy-to-use risk stratification model is still missing.

METHODS

Retrospective chart review, focusing on individual risk factors and middle ear risk index (MERI). Patients who underwent endoscopic type I. tympanoplasty were included.

RESULTS

Closed tympanic cavity was succesfully created in 88.1% of the 42 cases, the overall 21,5 dB air-bone gap (ABG) was reduced by 9,8 dB. The average MERI score of the patients was 2.1 ± 1.5. 78.6% of the patients were categorised into the mild, while 21.4% into the moderate risk group. The perforation was considered small in 81.0% of the cases, while large in 19.0%. The size of the perforation and the preoperative ABG, but not the MERI status were the only single predictors of success. Using a risk stratification model that is based on the size of the perforation, the preoperative ABG and MERI status, patients could be referred into two distinct groups of risk: the majority expecting excellent outcomes with maximum one risk factor present, and patients with deteriorated rate of success when having two or three risk factors.

CONCLUSIONS

Endoscopic type I. tympanoplasty with underlay perichondrium graft can be performed with good chance of success. However, if more than one risk factors are present, the chance of residual perforation becomes great. In addition to the established risk factors, our results point out that despite its strong correlation with perforation size, ABG may have a predictive role.

Limitations of non-echo planar diffusion weighted magnetic resonance imaging (non-EPI MRI) in cholesteatoma surveillance after ossicular chain reconstruction. A prospective study

OBJECTIVE

Non-echo planar diffusion weighted magnetic resonance imaging is a reliable surveillance tool of residual cholesteatoma nowadays. It is not known whether the material of the ossicular chain prosthesis modifies the sensitivity and specificity of MRI in these cases. The aim of the study was to compare the sensitivity, specificity and a localization-specific accuracy of non-EPI DW MRI sequences for residual cholesteatoma in the following 3 subgroups: patients with titanium ossicular prosthesis (group T), with autologous cortical bone columella (group A) or without any reconstruction (group WR) of hearing bones.

METHODS

This prospective study covered 28 cases with cholesteatoma of the middle ear undergone second-look surgery, who had preoperative PROPELLER DW-MRI. Surgical findings were compared to the results of the DWI-MRI.

RESULTS

The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were: 0.76-0.8-0.76-0.8. Group T, group A and group WR sensitivity was 0.83-0.6-1, specificity: 0.75-0.75-0.85, PPV: 0.83-0.75-0.66, NPV: 0.75-0.6-1. Overall accuracy was 0.78. Size of missed cholesteatoma was 2-4 mm (mean: 2.66±1.15).

CONCLUSIONS

Various materials are suitable for ossicular chain reconstruction. The poor detectability of residual or recurrent cholesteatoma in the middle ears reconstructed with autologous bony prosthesis may still claim second-look surgery instead of the usage of non- EPI DWI sequences independently in these patients.

Mal de débarquement syndrome – “sickness of disembarkment”

Mal de débarquement syndrome is an uncommon vestibular disorder characterized by a constant sensation of swaying or motion after one disembarks from a vehicle such as a ship or plane, however, spontaneous onset also appears. These symptoms temporarily subside when the patient is subjected again to passive motion like driving a car. Chronic fatigue, anxiety, and depression are frequently associated with primary symptoms. The diagnosis is challenging, and often made by the patients themselves. The underlying pathophysiology and definitive therapy are unknown. Exposure to optokinetic stimulations and transcranial magnetic stimulations open therapeutic perspectives. We report a case series of 5 patients who presented with constant rocking, bobbing sensation that had been ongoing for several months. We found normal inner-ear function, non-related abnormalities and normal brain imaging. By presenting our patients' histories, we discuss the different diagnostic issues that help to diagnose this condition. We aimed to report the most recent findings on aetiology and treatment methods and to share our experiences with different therapeutic attempts. Mal de débarquement syndrome is a diagnosis of exclusion and often unrecognized. A thorough clinical history, negative or non-specific clinical findings with a high degree of suspicion are needed for recognizing this disorder. Increasing awareness can lead to early diagnosis and prevent multiple physician visits and unnecessary diagnostic testing. Frequent diagnostic failure has a negative impact on the quality of life, associated with anxiety and depression. Orv Hetil. 2020; 161(20): 846-851.

A unique manifestation of Langerhans cell histiocytosis: Diagnostic and therapeutic considerations of atypical cases

Langerhans cell histiocytosis (LCH) is regarded as a clonal disease, usually carrying the activating BRAF mutation V600E. Although LCH theoretically may affect all types of human tissue and typically appears during childhood, temporal bone involvement in adult patients is exceedingly rare. We report an atypical case of a 56-year-old man as one of the oldest patients diagnosed with temporal bone involvement of a BRAF-negative LCH, which caused painless otorrhea and hearing loss. Cutaneous manifestation (multifocal multisystem LCH, also known as Letterer-Siwe disease) was later recognized incidentally. Administration of ifosfamide plus doxorubicin and mesna with supplementary irradiation resulted in a temporary remission followed by slow but constant tumor progression, which after 2.5 years became resistant to treatment with cytarabine and dasatinib. Attempts at therapy (cladribine) to achieve cure are ongoing.

Severe neck infections that require wide external drainage: clinical analysis of 17 consecutive cases

Infections in the neck layers and spaces are potentially life-threatening diseases causing further complications, like mediastinitis, airway obstruction, or sepsis. Despite of the need for a conservative approach, they still regularly require surgical intervention. Records of 17 patients with severe neck infections that were treated by wide external incision and open wound management were retrospectively analyzed. The aim of the study was to clinically characterize these most serious neck infections. The most common presenting symptoms were neck pain and tense neck mass (94-94%) regularly with fever (65%), always accompanied by a marked elevation of C reactive protein level (average 192 uG/l). These findings were constant and very similar among both the deep neck infection and necrotizing fasciitis cases. More than half of the patients (53%) had at least one systemic co-morbidity. The parapharyngeal space was most commonly affected (83%), but extended disease involving more than two major neck regions was found in 13 cases (76%). Dental (29%) was the most common primary infection, followed by peritonsillar abscess (23%), Microbiological results showed a wide variety of corresponding bacteria. Mediastinitis was developed in three cases (18%), and airway obstruction requiring tracheostomy in two cases (12%). All the patients survived. Severe neck infections are a heterogenous group of diseases regarding to the primary site of infection, microbiology, localisation and host reaction. However, rapidly developed, painful, tense neck mass with a highly elevated CRP level should always alert for an extended or phlegmonous process in the layers or spaces of the neck.

Expression of bone morphogenetic protein 2, 4, 5, and 7 correlates with histological activity of otosclerotic foci

CONCLUSION

This study is the first to establish that bone morphogenetic protein 5 (BMP5) plays a role in the pathogenesis of otosclerosis. These results confirm that elevated expression levels of BMPs, members of the transforming growth factor (TGF)-β superfamily, contribute to the pathologically increased bone turnover in early, active stages of otosclerosis.

OBJECTIVES

Otosclerosis is a complex bone remodeling disorder of the otic capsule, which might be characterized by increased expression of different types of BMPs. TGF-β and BMP are both members of the TGF-β superfamily and play a critical role in bone resorption and new bone formation. It has been suggested that BMP and its receptors may be involved in the pathologically increased bone turnover observed in otosclerosis.

METHODS

Fifty-one otosclerotic and 16 non-otosclerotic ankylotic stapes footplates were histologically analyzed: conventional hematoxylin-eosin staining and BMP2, 4, 5, and 7specific immunofluorescent assays were performed. Cortical bone fragments (n = 35) and incus specimens (n = 6) were used as negative controls.

RESULTS

Active otosclerosis (n = 39) was characterized by increased expression of BMP2, 4, 5, and 7. Inactive cases of otosclerosis (n = 12) were characterized by negative immunoreaction for BMPs. Non-otosclerotic stapes specimens (n = 16) and negative controls (n = 41) showed negligible BMP expression. The BMP expression pattern showed a strong correlation with the histological activity of otosclerosis.

Effect of KTP laser on implants used in middle-ear surgery

The present study is intended to explore the effects of the KTP laser on various types of implant, used in middle-ear surgery. A laboratory study was undertaken to evaluate the interaction between the KTP laser (KTP-532 Orion Laser, Laserscope, UK) and individual middle-ear implants. A variety of middle-ear implants were used: a silicone sheet, Teflon, hydroxylapatite, ionomeric cement, gold and titanium prostheses as well as gelfoam. Following exposure to the laser, these implants were studied by direct inspection using an operating microscope. The KTP laser induced no detectable alteration in any of the implants when they were clean and dry. However, in the presence of fresh blood, under the influence of the energy of the absorbed laser, the silicone burnt and melted and the Teflon piston was vaporized. Likewise, a few tiny holes appeared on the surface of the ionomeric implant and then the prosthesis deformed. The hydroxylapatite implant broke into two pieces. However, no detectable alteration could be observed on gold or titanium pistons, even in the presence of blood. The authors conclude, that in the presence of blood, interaction between the KTP laser and both silicone and hydroxylapatite implants needs to be avoided. Teflon prostheses can be cautiously vaporized. Gold and titanium prostheses were unaffected by laser even in the presence of blood.