[Intraosseous cavernous hemangioma of the middle turbinate. Clinical cases]

Intraosseous vascular pathology of the turbinates is extremely rare in the practice of an otorhinolaryngologist and can be presented in various histopathological variants. The article presents two clinical cases in which an intraosseous cavernous hemangioma was hidden under the mask of a hypertrophied middle turbinate. The final diagnosis was established by the results of histological examination. The analysis of these clinical cases indicates that, despite the low prevalence, atypical clinical and CT picture, intraosseous formations of the nasal cavity can be of a vascular nature and certainly require a comprehensive examination, including CT, CT with contrast and/or MRI of the nose and paranasal sinuses. These clinical observations indicate that preliminary embolization of feeding vessels before surgical treatment is not required.

[The evolution of ideas about cyst-like stretching of the paranasal sinuses. Part I]

Treatment of patients with severe chronic and recurrent forms of sinusitis, complicated by pathological stretching of the paranasal sinuses, is not a trivial task. This is especially true for those clinical cases where a pathological increase in the size of the sinus leads to widespread destruction of its walls and may be accompanied by serious complications from adjacent structures. The paper presents an analytical review of publications on the topic of pathological stretching of the paranasal sinuses. Potential factors influencing the development of this pathology, mechanisms of pathogenesis and classification options are described in detail. Modern approaches are considered in the surgical treatment of this pathology, which can be carried out in one or two stages, depending on the presence of secondary aesthetic defects.

[Atresia or severe stenosis of the external auditory canals with normal auricles in children]

In the article we present the experience of observing 27 children with bilateral stenosis or atresia of the external auditory canals with normal or slightly hypoplastic auricles. Three children had bilateral stenosis of the external auditory canals due to abnormal or premature fusion of the skull bones. The remaining 24 children had external auditory canals atresia in the bone part or throughout. 9 of them had a syndrome of deletion of the long arm of chromosome 18, 1 child had a mosaic form of Edwards syndrome. The average age at the time of diagnosis was 4 years 3 months. Atresia of external auditory canals in normal auricle is often caused by abnormalities of 18 pairs of chromosomes, and severe stenosis of external auditory canals can be observed in children with craniostenosis and other anomalies of the skull bones.

[Spontaneous otoliquorrhea, complicated by recurrent secondary meningitis, in a 6-year-old child with an abnormality of the inner ear]

Congenital anomalies in the inner ear structures development are one of the reasons for unilateral hearing loss in children. Unilateral hearing loss is predominantly congenital, thus children with this pathology are initially deprived of the ability to hear with both ears, which leads to the formation of a specific «individual hearing norm». Due to this, children do not complain of hearing loss, and unsuspecting parents can only guess why their child is poorly studying and lagging behind his peers. Unfortunately, in some situations the detection of malformations of inner ear structures occurs only after the development of complications, namely spontaneous otoliquorrea, leading to bacterial meningitis, and exactly episodes of meningitis (sometimes recurrent) become the cause for examination of patient and diagnosis of this pathology. We present one of this clinical observations.

[Partial sequestration of the labyrinth in a child with chronic suppurative otitis media with cholesteatoma]

A clinical case of a 16-year-old child with chronic suppurative otitis media with cholesteatoma complicated by partial labyrinth sequestration is presented. The case describes is a rare disorder. Computed tomography of temporal bones consistent with intraoperative data was decisive in establishing the diagnosis and the surgery extent.

[Clinical and radiological classification of otosclerosis]

The article presents various classifications of forms of otosclerosis (OS), which change with the development of diagnostic methods. At the same time, according to the literature, a unified OS classification has not yet been adopted. All existing classifications are imperfect to some extent. The classification of clinical forms of OS according to TPA data makes it possible to determine the indications for surgical treatment and to suggest its possible effect, but not the localization of OS foci. X-ray classifications of localization of OS foci indicate their diversity, distribution, and do not always correlate with the type of hearing loss. At the same time, modern diagnostics of OS should be based on audiological data, localization of foci and their density according to the results of X-ray methods of examination. Based on the examination and treatment of 1532 patients with various forms of OS, a modern clinical and radiological classification of the disease is proposed, based precisely on these provisions. This classification, in our opinion, will improve the quality of diagnosis of various forms of OS, will allow to differentiate the tactics of treating patients with this disease to stabilize hearing loss, indications for surgical treatment, suggest its effectiveness with a reduction in the risk of surgical failures and possible further rehabilitation of the patient.

[Features and results of surgical rehabilitation of hearing loss in osteogenesis imperfecta]

Osteogenesis imperfecta (OI) is a form of congenital osteoporosis. Depending on the type of OI, patients experience various types of hearing loss. Depending on the type and degree of hearing loss, various methods of hearing rehabilitation are used in this category of patients.

OBJECTIVE

To evaluate the features and results of surgical rehabilitation of hearing loss in patients with osteogenesis imperfecta.

MATERIAL AND METHODS

During the period from 2009 to 2022, 2221 primary stapedoplasty was performed in the department, of which 23 (1.04%) in 21 patients were performed in patients with OI. There were 14 women and 7 men. According to TPA, bilateral hearing loss was detected in 19 patients and unilateral in 2. Conductive hearing loss was observed in 9 cases and mixed - in 14. The average thresholds for bone conduction (BC) were 22.7±8.04 dB, and the bone-air interval (ABG) - 36.1±5.3 dB. According to CT of the temporal bones, all patients showed a bilateral and symmetrical decrease in the density of the auditory ossicles, and in 7 patients there were extensive areas of non-uniform decrease in the density of the bone labyrinth up to +500 - +1000 HU.21 patients underwent 23 operations: in 21 cases stapedoplasty with laser assistance and in 2 cases ossiculoplasty.

RESULTS

BC thresholds 6 months after surgery averaged 24.6±8.2 dB, and ABG - 12.1±2.9 dB. Closing of ABG ≤10 dB at spoken frequencies was detected in 30.5%, ABG ≤20 dB - in 95%. After 12 months or more after the operation, no change in the audiological parameters was noted.

CONCLUSIONS

Stapes surgery for conductive and mixed hearing loss in OI patients is functionally effective. The best results are achieved after therapy with bisphosphonates with preparations of sodium fluoride, calcium and vitamin D, performing the operation when the density of demineralization zones reaches 1000 HU and using laser assistance. Taking into account the demineralization of the bone structures of the temporal bone, it is recommended to use autocartilaginous stirrup prostheses to restore sound conduction or to cover the attachment area of other prostheses with autologous tissues to prevent necrosis of the long stalk of the incus and stabilize long-term functional results.

[Unilateral subjective tinnitus «vanishing bone» disease (Goram-Stout syndrome).]

The article presents the case history of an 11-year-old girl with Goram-Stout disease, who debuted with unilateral subjective tinnitus. A review of the literature, cases with damage of the temporal bones and modern methods of treatment of this disease is made.

[Diagnosis and surgical outcomes in the management of petrous bone cholesteatoma]

OBJECTIVE

To evaluate the effectiveness of surgical treatment of patients with petrous bone cholesteatoma (PBC) depending on the localization of the pathological process.

MATERIAL AND METHODS

The analysis of surgical treatment using various surgical approaches and its results in 32 patients with PBC, depending on the type, localization in petrous bone and intraoperative findings, is presented. Patients with supralabirint PBC underwent extended atticoantromastoidotomy with tympanoplasty and mastoidoplasty with automaterials (n=19), labyrinthectomy (n=4), subtotal petrozectomy with labyrinthectomy and suturing of the external auditory meatus (EAM) (n=2). In infralabirint and infralabirint-apical PBC, a transotic approach was used with Rambo suturing of EAM (n=9). The pre-sigmoid approach was performed in 1 patient. With an extradural subtemporal approach, PBC of apical localization was removed in 1 case.

RESULTS

After surgical treatment, hearing remained at the same level in 15 (47%) patients, 14 of them had deafness. In the early postoperative period, a temporary increase in bone conduction hearing thresholds by 10-20 dB was detected in 14 (44%) patients with their gradual recovery over 3 months. Deafness in the postoperative period developed in 3 (9%) patients after removal of supralabirint cholesteatoma. In the early postoperative period, 3 (9%) patients developed systemic dizziness, which was stopped after 3 months. In 25 (78%) patients, the function of the facial nerve in the early postoperative period remained at the same level, of which 14 (44%) were normal, and 11 (34%) had the same degree according to the House-Brackmann (HB) classification. Improvement of function by one degree of HB classification was observed in 4 (12.5%) patients on average 5 months after surgery.

CONCLUSION

An adequate personalized choice of surgical treatment methods allowed mainly to preserve the function of hearing and facial nerve. In cases of deterioration of facial nerve function in the postoperative period, gradual improvement was observed for 3-10.5 months with further positive dynamics.

[Tendoplasty and its effectiveness in the rehabilitation of hearing loss in patients with otosclerosis]

The article briefly presents the physiology of the stapes muscle tendon (SMT), and features in its defeat. Its length was studied using high-resolution multispiral computed tomography of the temporal bones. We also studied the possibility of its restoration using the author's method of tendoplasty using metallized stapes prostheses. Tendoplasty with stapedoplasty was performed in 74 patients with otosclerosis (OS), and 48 patients had stapedoplasty without tendoplasty. As a result of research, the average length of the SMT was 2.38±0.02 mm, which explains the need to use a 3 mm long venous autograft for tendoplasty. The author's method of tendoplasty for stapedoplasty allows restoring the acoustic reflex in 54.1% of OS patients using artificial stapes prostheses. The preservation of the vascular bed in the thickness of the restored tendon can improve the trophy of the long incus process and reduce the risk of its dystrophic changes in the postoperative period. In addition, this fact confirms the importance of the stapes muscle in the acoustic reflex.

[Clinical and diagnostic criteria and differential diagnosis in the first and second stages of the development of Ménière's disease - A modern view of the problem]

The results of a comprehensive examination of 82 patients with clinical signs of definite Ménière's disease, unilateral lesion and confirmed by extratympanic electrocochleography endolymphatic hydrops are presented. The results of the study showed that only 38% of patients had cochleovestibular syndrome due to Ménière's disease. In 45% of patients, Ménière's disease was combined with other diseases: benign paroxysmal positional vertigo, vestibular migraine, persistent postural-perceptual dizziness, superior semicircular canal dehiscence. In 17% of patients cochleovestibular syndrome was due to other reasons: vestibular migraine, tumor of the posterior cranial fossa, superior canal dehiscence syndrome, Cogan's syndrome, enlarged vestibular aqueduct, otosclerosis. Complaints, medical history of the disease and life, brain MRI, temporal bone CT and pure tone audiometry in dynamics are important in suspected Ménière's disease. For 1 and 2 Ménière's disease stages the most important characteristic are: progressive unilateral sensorineural hearing loss and reduced slow faze velocity values of caloric nystagmus in dynamics, mainly in warm response if attacks of vertigo is maintain; normal head impulse test between vertigo attacks and pathological result of this test in attack of vertigo with the normalization of gain during the first day.

[A case of obliteration of a round window in otosclerosis]

The article presents a brief review of the literature on the anatomy and physiology of the round window (RW) niche, the causes of occlusion, the diagnosis of this pathology, the features of auditory disorders and tactics when it is detected in patients with otosclerosis (OS). A clinical case of diagnosis and effective surgical treatment for obliteration of RW in a patient with advanced OS, which occurred in 2019 in 0.7% of cases, is described. Removal of RW niche obliteration was carried out with a curette and microcresis by smoothing the canopy over RW until partial visualization of the secondary membrane. It was this stage of the operation that made it possible to restore the normal hydrodynamics of the inner ear fluids and contributed to a functional result. Thus, the diagnosis of RW obliteration in patients with OS is difficult, but possible when using computed tomography of the temporal bones and assessing the mobility of the RW membrane or analyzing changes in hearing at the end of the operation, if it is performed under local anesthesia. The simultaneous performance of stapedoplasty and the removal of bone obliteration of RW makes it possible to safely achieve functional rehabilitation in patients with OS.

[Acoustic neurinomes of childhood]

The article presents a review of the literature on the vestibular schwannoma of childhood, the features of its clinical manifestations, diagnostic methods, methods of treating education and indications for their use.

[Exudative otitis media as a manifestation of spontaneous otoliquorrhea]

Spontaneous otoliquorrhea (SOL) often mimics the picture of exudative otitis media (EOM), which leads to delayed diagnosis of the underlying disease.

PURPOSE OF STUDY

Is to evaluate causes, clinical features and diagnostic algorithm for patients with SOL.

PATIENTS AND RESEARCH METHODS

From 2007 to 2018, 33 patients with SOL underwent examination and treatment in the Department of Ear Microsurgery of the Institute. At the preoperative stage, all patients underwent a complete examination, including examination of ENT organs, anthropometric, biochemical, audiological, ultrasound and radiological tests, which made it possible to make the correct diagnosis.

RESULTS

SOL was more likely to occur in women over 50 who are obese (69.7%, stage II-III). The disease onset in 51.6% of patients was preceded by conditions accompanied by a short-term or prolonged increase in intracranial pressure. SOL was manifested by the clinical picture of EOM in 72.7% of cases, only in 45.5% of cases was accompanied by release from the ear and nose, was often intermittent and complicated by meningitis in 12.1% of patients. Difficulties in diagnosing the disease are caused by clinical manifestations of exudative or acute otitis media in the absence of a causative factor, which led to the verification of SOL from 1 to 4 years in 81.9% of patients who received long-term treatment for other ENT diseases.

CONCLUSION

The master factors in the diagnosis of SOL are otomicroscopy and endoscopy of the nasopharynx, Halo test and screening determination of glucose level in the obtained discharge, as well as high-resolution CT of the temporal bone, which allows to localize the cerebrospinal fluid fistula and to determine the size of the defect.

[Artificial temporal bone]

This article presents assembly technology and the main stages of dissection on artificial temporal bone. This sample of artificial temporal bone is a domestic product. The use of this material makes it possible to develop basic dissection skills, such as anthromastoidotomy, posterior tympanotomy, and facial nerve decompression. Artificial temporal bone can be used as a teaching tool for students, residents and postgraduate students who train otosurgical skills in the form of basic stages of dissection work on complex structures of the temporal bone.

[Variants of treatment of the head direction at the festulars of the labi-rint of inflammatory genesis]

PURPOSE

To analyze the effectiveness of various methods of treating dizziness with fistulas of the labyrinth (FL) of inflammatory genesis. An analysis of the surgical treatment of 216 patients with chronic suppurative otitis media (CSOM) with cholesteatoma complicated by FL using a variety of FL treatment methods is presented. All patients underwent a debridement operation on the middle ear or revision of the postoperative cavity: in 48 patients with a matrix of cholesteatoma in situ on the fistula, in 109 patients with matrix removal followed by plastic repair or FL filling with various autotissues, in 59 patients with matrix conservation, plastic removal or filling FL and SLD labyrinth. In the last two groups, filling of a semicircular canal (SC) defect was performed in 33 patients, and mastoidoplasty - in 47.

CONCLUSION

All used FL treatment techniques are effective in the treatment of peripheral vestibular disorders. Careful treatment of SC fistula after removal of all pathological conditions in the absence of active inflammation and the appointment of hormone therapy in the postoperative period are the main factors in preserving the functions of the labyrinth in any surgical technique. Filling of the lumen of the SC and mastoidoplasty in patients with CSOM with FL can eliminate peripheral dizziness.

[Middle ear osteoma: case report and literature review]

The short literary review of frequency of occurrence, complaints, results of diagnostics and surgical treatment of patients about osteomine is presented to a drum cavity in article. Two own cases of clinical inspection and surgical treatment of patients about osteomine of a drum cavity are described.

[Diaphanoscopy palatal tonsils with use of the diode laser]

For the purpose of decrease in intraoperative blood loss during a tonsillectomy the technique of a laser diaphanoscopy (DS) of the palatal tonsil (PT) and paratonsil space is developed. In the conditions of a transillumination of tissues of throat vessels paratonsil space which are preventively coagulated by the holmium laser are visualized. In carrying out DS of structures of a throat the 'pilot' red laser of the surgical laser LUMENIS Versa Pulse Power Suite 20W system was used. In a research there were 60 patients with chronic tonsillitis. Laser DS was carried out before tonsillectomy, at the same time 120 PT were subjected to raying. As result of the conducted research established that 60% of PT (n=72) anatomic were deeply shipped in a sidewall of a throat, 44,2% of PT (n=53) - had the expressed top pole, 0,8% of PT (n=1) - an additional segment. Also it was established that laser transillumination of paratonsil space is possible in the conditions of infiltration of fabrics isotonic physiological NaCl solution of 0,9%. Carrying out preventive coagulation of vessels of paratonsil space of Ho:YAG laser in the conditions of DS allows to reduce the volume of intraoperative blood loss to 4,17±0,37 ml that is 10,1 time less in comparison with the tonsillectomy which is carried out on traditional techniques.

[The clinical definition and etiology of Pendred syndrome (a review of the literature and clinical observations)]

The aim of this work was a clinical study of the patients with mutations in the SLC26A4 gene and clinical diagnosis of the Pendred syndrome. The Pendred syndrome is a hereditary autosomal recessive disorder characterized by combined pathology of the inner ear and the thyroid gland. CT of the temporal bones demonstrates the Mondini-type structural anomaly in the inner ear and enlarged vestibular aqueduct. Examination of the thyroid gland reveals hypothyroidism and euthyroid goiter. A total of 20 unrelated children at the age from 2 to 16 years presenting with the hearing loss of different severity were available for the examination. High-resolution CT of the temporal bones demonstrated abnormal development of the inner ear including the Mondini-type structural anomaly and enlarged vestibular aqueduct. Five children with congenital hypothyroidism suffered from bilateral sensorineural impairment of hearing. The routine methods of audiological and molecular genetic examination were used throughout the study.

RESULTS

As a result of molecular genetic studies, four out of the 20 patients were found to carry six recessive mutations of the SLC26A4 gene in the compound heterozygous and one such gene in the homozygous state which confirmed the hereditary nature of the disease. The children suffered the hearing loss of varying severity diagnosed at different age. The thyroid hypofunction in one child was identified when it was 2 years of age, and in two children at the age of 8 and 9 years.

CONCLUSION

The first step in the diagnosis of the Pendred syndrome among children with congenital hearing loss was a CT scan of the temporal bones that showed incomplete separation of the curls of the cochlea and enlarged vestibular aqueduct. It is necessary to continue to study epidemiology, clinical and molecular genetics of the Pendred syndrome in the Russian population.

[The application of stapedoplasty for the treatment of hearing loss in the patients suffering from obliterative otosclerosis]

This article presents the results of analysis of the data obtained during the examination and the surgical treatment of the patients presenting with the obliterative form of otosclerosis and suffering from hearing impairment with special reference to the intraoperative findings, technical aspects of stapedoplasty, and its effectiveness. A total of 14 patients (17 ears) were recruited for the participation in the present study including 10 women at the mean age of 38.8±6.2 years and 4 men (mean age 44.8±3.9 years). The duration of the hearing loss in the period preceding the surgical treatment in 7 (50%) patients was more than 8 years. According to the results of tonal threshold audiometry (TTA), the mean bone conduction (BC) threshold for conductive hearing loss in the frequency range from 0.5 to 4.0 kHz was 24.9±8.1 dB with the mean bone air gap (BAG) equaling 38±5.1 dB. Computed tomography (CT) of the temporal bones revealed grade 1 obliterative otosclerosis in 4 patients, grade II of the same condition in 6 patients, and grade III in 7 ones. These findings were confirmed intraoperatively. In 15 cases, stapedostomy was carried out with the use of the non-contact CO2 laser-based system, in the remaining cases a microdrill was employed. Five patients underwent laser-assisted piston stapedoplasty while in 11 others the stapes prosthesis was placed on the autovein. One patient was treated by the same method with the use of the autocartilaginous prosthesis. The functionally acceptable results within 1 year after the surgical intervention were obtained in all the treated patients with the mean bone air gap equaling 13.2±3.4 dB. The best outcome (the reduction of the BC threshold and BAG by 7 dB and 25.9 db on the average respectively within 1 year after surgery was achieved in the patients with grade III obliterative otosclerosis.

[Results of molecular genetic testing in Russian patients with Pendred syndrome and allelic disorders]

Pendred syndrome is an autosomal recessive inherited disorder characterized by a combination of sensorineural hearing impairment and euthyroid goiter; its clinical manifestation in children is hardly distinguishable from nonsyndromic hearing loss. Pendred syndrome is one of the most frequent types of syndromic hearing loss. Hearing impairment is accompanied by abnormal development of the bony labyrinth—enlarged vestibular aqueduct (EVA) and occasionally combined with Mondini dysplasia. Mutations in the SLC26A4 gene, which encodes the pendrin protein, are responsible for both Pendred syndrome and for allelic disorder (nonsyndromic enlarged vestibular aqueduct). The present study for the first time conducted molecular genetic analysis in 20 Russian patients with Pendred syndrome, EVA and/or Mondini dysplasia. As a result, six pathogenic mutations in the SLC26A4 gene were revealed in four patients. The mutation c.222G>T (p.Trp74Cys) was detected for the first time. Mutations were found in patients with Pendred syndrome and nonsyndromic EVA with or without Mondini dysplasia. Mutations were not detected in patients with isolated Mondini dysplasia. One proband with clinical diagnosis Pendred syndrome was homozygous for the c.35delG mutation in the GJB2 gene. The absence of frequent mutations, including well-known ones or “hot” exons in the SLC26A4 gene, was reported. Therefore, the optimal method to search for mutations in the SLC26A4 gene in Russian patients is Sanger sequencing of all exons and exon-intron boundaries in the SLC26A4 gene.

[Apical petrositis, osteomyelitis of the base of the skull bones and of the first cervical vertebra in a 5 year-old children following chicken pox]

This publication was designed to describe a rare case of development of apicalpetrositis in a child presenting with acute otitis mediafollowing chicken pox experienced in the preceding period. We carried out the study with the use of computed tomography (CT) that demonstrated destruction of the temporal bone, bones of the base of the skull and of the first cervical vertebra. The treatment strategy chosen for the management of this condition that included antibiotic therapy and expectant observation proved justified and can be recommended as an algorithm of choice taking into consideration the difficulty of surgical approach to the apex of the petrous pyramid. However, this approach is associated with the high risk of disability arising from the potential injury to the craniocerebral nerves.

[The application of the modern radiodiagnostic methods in otorhinolaryngology]

This paper highlights the problems and difficulties associated with the introduction of the modern radiodiagnostic methods including computed and magnetic resonance tomography into the otorhinolaryngological practice in this country. The approaches to addressing these problems and overcoming difficulties are proposed. The review of the diagnostic potential of various modalities is presented. The modern algorithms for the examination of the patients presenting with various diseases of the ears, nose, and throat are described with special reference to their diagnostic value.

[DETERMINING THE DEGREE OF DISRUPTION OF THE STRUCTURE OF THE LIVER AND THE SEVERITY OF PORTAL HYPERTENSION IN CHILDREN]

AIM

To develop a system to define the degree of liver disruption and severity of portal hypertension in children based on the International Classification of Functioning, Disability and Health (ICF).

PATIENTS AND METHODS

Studied the results of laboratory and instrumental methods 382 children: 267 patients with various liver diseases, including 49 patients who underwent liver transplantation, and 115 children without liver disease.

RESULTS

Based on analysis of statistical data obtained were identified 10 indicators, a set of changes which can be used to assess the degree of disruption of the structure of the liver and the severity of portal hypertension: indicators that reflect the severity of fibrosis and cirrhosis of the liver (METAVIR score on a scale at fibroelastometrii, scores are Desmet at morphological study of the liver) and indicators that reflect the severity of portal hypertension (the diameter of the portal vein, splenic vein diameter, the length of the spleen, recanalization of the umbilical vein, esophageal varices, ascites, hydropericardium, hydrothorax). Each of the indicators was assessed on a 5-point system. Number of points reflects the sum of the changes of these parameters. Decrease the number of points on 0-4% (38-40 points) is regarded as a lack of structural failure of the liver and the severity of portal hypertension by 5-24% (30-37 points)--minor violations on 25-49% (20-29 points) -moderation disorders, 50-95% (3-12 points)--severe handicaps, 96-100% (0-2 points)--absolute violation. Studied the dynamics of children with autoimmune hepatitis, Wilson's disease and chronic hepatitis C.

CONCLUSION

The proposed scoring system for assessing the degree of disruption of the structure of the liver and the severity of portal hypertension can be used as an objective criterion of the severity of the pathological process, to estimate the dynamics of defeat against the background of the therapy, determining the prognosis of the disease and as a criterion of the indications for liver transplantation.

[Enlarged vestibular aqueduct syndrome: etiology, clinical features, diagnostics, and rehabilitation of the patients]

This publication was designed to describe the clinical manifestations of the enlarged vestibular aqueduct syndrome (EVAS), the currently employed methods for its diagnostics, and the strategy for the rehabilitation of the patients presenting with this pathological condition. In addition, the article provides information about the topographic anatomy and X-ray anatomy of the vestibular aqueduct, the specific clinical features of EVAS, the modern algorithm of its diagnostics, and the facilities for hearing rehabilitation in this group of patients.

[The new complex multimedia program for the training in otosurgery]

The objective of the present study was to develop the complex program for the training in otosurgery. The proposed complex program for teaching surgical procedures on the ear is described. The program consists of two steps, preparation and dissection. The first stage is designed to prepare the learner surgeons for dissection with the use of the teaching materials "Manipulations on the temporal bone" and the 3D model of the temporal bone. At the second stage, the learners perform successively two tasks: dissection of an artificial and cadaveric bones with the maximum possible number of surgical procedures on each bone. The aforementioned teaching materials and 3D model of the temporal bone are used at the dissection stage too.

[Clinical and roentgenological diagnostics of the severity of mucositis in the patients presenting with chronic suppurative otitis media]

The objective of the present study was to determine the prevalence of mucositis and its roentgenological manifestations in the patients presenting with chronic suppurative otitis media (CSOM). A total of 390 patients with CSOM (mesotympanitis) and 85 ones suffering CSOM with concomitant mucositis were available for the observation. The signs of mucositis were evaluated based on the patients' complaints, results of otomicroscopy, and computed tomography (CT) of the temporal bones. This randomized clinical study involving 390 patients presenting with CSOM revealed the signs of mucositis in 44.6% of the cases. Analysis of the results of temporal bone CT performed in 85 patients with CSOM and mucositis in the absence exacerbation has demonstrated the possibility of detecting mucositis and evaluating its severity from the changes in the airness of the tympanic cavity, attics, and antrum due to the presence of the pathological substrate in these regions.

[The difficulties encountered in diagnostics of malignant neoplasms of the middle ear in the children]

The objective of the present work was to estimate the potential of CT and MRI diagnostics of malignant neoplasms of the middle ear in the children. Diagnostics of these tumours encounters great difficulties. We analysed the main subjective and objective causes underlying these difficulties and accounting for the late detection of the pathology being considered. Special attention is given to the possibilities of using CT and MRI techniques for diagnostics of malignant neoplasms of the middle ear in the children. The differential radiodiagnostic criteria for malignant tumours are proposed.

[Efficiency and safety of human monoclonal antibodies to TNF-alpha in children with juvenile idiopathic arthritis in primary and secondary ineffectiveness of other biologicals]

PURPOSE

To evaluate the safety and efficiency of adalimumab in children with severe refractory JIA with primary inefficiency, partial effect or loss of the effectiveness of other biologicals.

PATIENTS AND METHODS

The article presents the results of the retrospective observational study of the efficacy and safety of adalimumab in 68 patients aged 10 (3, 17) years with various embodiments of JIA, with the primary inefficiency or partial or loss of the effectiveness of other biologicals. JIA diagnosis established on the basis of criteria ILAR (International League of Associations for Rheumatology).

RESULTS

Efficacy was assessed during 1 year in 68 and 2 years--in 56 patients . At the 24th week we observed the improvement by criteria AKR 30, 50.70 in 100, 91 and 74% of patients, respectively, and at the 52th week--in 100, 96 and 90%, respectively. Inactive disease status was recorded in 55.8, 66.1 and 98.2% of study participants after 6 months, 1 and 2 years, respectively. Remission was achieved in 55.8 and 96.4% of patients after 1 and 2 years of observation, respectively.

CONCLUSIONS

Adalimumab was effective and well tolerated by patients with primary inefficiency, partial and loss of efficiency of other biologicals. In clinical practice, patients with non-systemic JIA transition to the second TNF-alpha blocker can restore the biological effect of the first drug without increasing the frequency of infectious AEs.

[The early diagnostics of retraction pockets of the tympanic membrane in children]

The most important literature data concerning retraction pockets (RP) of the tympanic membrane and their currently accepted classification are presented. The objective of the present work was to develop criteria for the objective estimation of the dynamic state of the tympanic retraction pockets in children presenting with non-perforating forms of otitis media. A total of 138 children suffering from exudative otitis media were available for observation; retraction pockets were found in the majority of these patients. Otomicroscopic characteristics of various RP species are described. A diagnostic approach to the observation of the dynamic state of the tympanic retraction pockets is proposed. The presence of the retraction pockets of the tympanic membrane is considered to be a risk factor of the development of cholesteatoma and chronic purulent pathology of the middle ear in the children. Deep retraction pockets without a controllable bottom and attic cholesteatomas were identified in 16 (11.6%) and 6 (4.3%) of the examined children respectively. They were treated by means of sparing otosurgery.

[The diagnostics and treatment of Minor's syndrome]

This publication was designed to describe the clinical manifestations of dehiscence of the superior semicircular canal (Minor syndrome), currently employed methods for its diagnostics, and the first case of this pathology reported in this country with the good outcome of the treatment. Also described are the historical background relevant to the problem, pathomorphological changes in the superior semicircular canal, clinical manifestations of the disease, the patients' subjective complaints, and the methods for diagnostics of dehiscence of the superior semicircular canal (Minor syndrome). The successful diagnostics and treatment of a female patient presenting with the aforementioned case of Minor syndrome is considered in much detail.

[Criteria for the objective assessment of the dynamic state of the retraction pockets in the children presenting with excudative otitis media]

This publication continues the preceding paper entitled "Early diagnostics of the retraction pockets in the tympanic membrane of the children". The objective of the present work was to develop the criteria for the objective estimation of the dynamic state of the retraction pockets (RP) in the children at different stages of excudative otitis media. The secondary objective was to develop an approach to the early diagnostics of cholesteatoma of the middle ear. A group of 138 children at the age varying from 1 to 17 years was placed under dynamic observation for the purpose of drawing up the individual "photo-roentgenological passport of the retraction pockets". Special attention was given to RP-semiotics of different forms of the syndrome and its severity in accordance with the classification universally accepted by foreign researchers. The results of the dynamic observations were used to develop the indications for the early preserving surgical treatment. It was given to 16 children six of which presented with cholesteatoma. The original illustrative materials for all variants of the retraction pockets are presented.

[Comparative characteristics of computed tomography and dissection of the temporal bone in young children]

The authors undertook the comparative analysis of the data obtained during layer-by-layer dissection and computed tomography of temporal bones from young children. It is concluded that the results of the study should be taken into consideration during surgery on the middle ear in young children.

[Computed tomography of the temporal bone for the diagnosis of facial nerve neurinoma]

The present retrospective study of 6,200 subjects with temporal bone pathology allowed for the identification of a group of 12 patients aged between 12 and 59 years in whom the presence of facial nerve neurinoma diagnosed by computed tomography was confirmed during surgical intervention and by histological methods. The patients were allocated to three groups depending on the localization of neurinoma. Patients of group 1 (n=8) had neurinoma of the mastoidal segment, those of group 2 presented with neurinoma of the tympanic segment, and patients of group 3 showed combined lesions of the tympanic and labyrinthine segments. Clinical and CT characteristics of each group are presented. CT of the temporal bone is shown to provide a tool of high informative value for the diagnosis of facial nerve neurinoma. It is suggested that CT should be used to examine patients with facial nerve paresis or conductive and mixed hearing loss of unspecified etiology for the early diagnosis of facial nerve neurinoma.

[Potential of temporal bone CT in the study of external acoustic meatus in health and pathology]

Computed tomography (CT) was used to examine 50 patients (100 temporal bones) aged from 10 days to 60 years with healthy external acoustic meatus (EAM) and 53 patients (62 temporal bones) aged from 4 to 75 years with symptoms of acquired stenosis, atresia or obturation of the external acoustic meatus. Polyposition CT of the temporal bone including axial and coronary projections is the most informative method of visualization of the EAM bone part. In axial projection the assessment covers the anterior and posterior walls of the EAM, in the coronary one - the upper and the lower walls. In the presence of EAM changes, CT is able to characterize them (soft tissue, bone, size, position). In patients with EAM neoplasms CT of the temporal bone detects polyps of the acoustic meatus, glomal tumors, neurinomas of the facial nerve, inherited cholesteatomas, cancer of the temporal bone. The detected alterations in the EAM and other structures of the temporal bone determine further policy of treatment.

[Glomus tumors of the middle ear in children]

Glomus tumor (GT) is a rare tumor of the middle ear in children. In spite of cytologically benign nature of this tumor, its course can be characterized as malignant because of GT infiltrative growth, destruction of the adjacent bone tissue, possible intracranial involvement. Because of scare symptoms, early GT diagnosis is problematic. At admission to hospital principal complaints of the children are poor hearing, discharge from the ear. These often underlie misdiagnosis -- acute otitis media. GT of the middle ear are detected with application of computed tomography which is able to show changes in the soft tissue and bone destruction, and angiography. Combination of the above two methods allows assessment of location and advance of the pathological process. GT treatment planning depends on the examination data and can include radiotherapy, endovascular occlusion of the vessels carrying blood to the tumor, surgical treatment and combination of the methods. Modern approaches to GT diagnosis and treatment are described. A case of GT of the temporal bone with involvement of the middle cranial fossa in a 4-year-old child is reported.

[Possibilities of temporal bone CT in examination of patients after sanitation operation on the middle ear]

The author presents the analysis of 56 CT images of the temporal bone in 5 to 72 year old patients operated on the middle ear; characterizes CT possibilities in the study of the operated ear; shows that the operation outcomes may be different (complete epidermization of the postoperative cavity, the presence of the granulation tissue, cholesteatoma recurrence); presents CT changes in the temporal bone in various perioperative and postoperative complications: otoliquorrhea, paresis of the facial nerve, labyrinthitis, progressive hypoacusis and deafness.

[Computed tomography of the temporal bone in diagnosis of adhesive otitis media]

CT of the temporal bone was made in 64 patients (age 2 to 66 years) with adhesive otitis media (AOM), in 21 of them AOM was bilateral. A total of 85 series of temporal bone tomograms were analysed. CT confirmed AOM in 62 cases, detected otosclerosis in 7 cases, local malformation of the auditory ossicula and/or labyrinthine windows in 11 cases. In 5 cases CT picture was normal. CT symptoms of AOM in the patients were the following: soft tissue streaks and/or sites of soft tissue density fixing the auditory ossicula or blocking niches of the labyrinthine windows (31 temporal bone), sclerosis or ossification of the middle ear ligaments and tendons (7 temporal bones), foci of calcification in the tympanic cavity (9 cases), osteosclerotic changes in the epitympanium (2 cases), scarry alterations of the tympanic membrane (24 cases), destructive alterations of the auditory ossicula (19 temporal bones). Thus, there is evidence for CT ability to differentiate between adhesive otitis media, otosclerosis and congenital anomalies of middle ear structures.

[Computed tomography in the evaluation of cochlear structural features in cochlear implantation]

Temporal bone computed tomographic scans were studied in 136 deaf patients of different age and sex, including 56 patients (39 children and 17 adults) rehabilitated with cochlear implantation (CI). The mean values of the cochlear parameters that are important for the results of a surgical CI stage, namely: the diameter of the cochlear base (DCB), the diameter of the basal helix, the height of the cochlea, the angle between the cochlear base and the promontorial wall, were calculated. These parameters were compared in different age groups. A correlation was determined for each of the studied parameters and for the depth of intracochlear insertion of electrodes. There was a significant correlation between DCB and the depth of insertion of the electrodes of CI22M and CI24M cochlear implants. DBC at which the active part of the electrode chain of an implant could be significantly more frequently placed in the tympanic scala of the cochlea was estimated.

[Computed tomography of the temporal bone in diagnosis of chronic exudative otitis media]

Computed tomography (CT) of the temporal bone was made in 37 patients aged 2 to 55 years with chronic exudative otitis media (CEOM). In 21 of them the pathology was bilateral. The analysis of 58 CT images has identified CT signs of chronic exudative otitis media. They include partial (17 temporary bones) or complete (38 temporal bones) block of the bone opening of the auditory tube, pneumatic defects of the tympanic cavity (58 temporal bones), pneumatic defects of the mastoid process and antrum (47 temporal bones), pathologic retraction of the tympanic membrane. The examination of the temporal bone detected both CT-signs of CEOM and other causes of hearing disorders in 14 patients (26 temporal bones) with CEOM symptoms and inadequately high hypoacusis. Among these causes were malformation of the auditory ossicula (n=5), malformation of the labynthine window (n=2), malformation of the middle and internal ear (n=4), a wide aqueduct of the vestibule, labyrinthine anomaly of Mondini's type (n=1), cochlear hypoplasia (n=4), stenosis of the internal acoustic meatuses (n=2). Sclerotic fibrous dysplasia was suggested in 2 temporal bones (by CT data). CT was repeated after surgical treatment of 10 patients (14 temporal bones) and visual assessment of tympanostomy results was made.

[Potentialities of temporal bone computed tomography in the identification of causes of hypoacusis of postinflammatory genesis]

Temporal bone computed tomography (CT) was used to examine 64 patients with impaired hearing due to inflammatory diseases of the middle year. In 21 patients, the pathological process was bilateral. A total of 85 series of temporal bone CT scans were analyzed. The patients' age ranged from 2 to 66 years. CT verified adhesive otitis media in 62 cases, otosclerosis in 7, local malformation of the auditory ossicles and/or the labyrinthine fenestrae in 11. No CT changes were revealed in 5 cases. The CT symptoms of adhesive otitis media were identified. These included soft tissue bands and/or soft tissue-density portions that fix the auditory ossicles or block the niches of the labyrinthine fenestrae (31 temporal bones); sclerosis or ossification of the ligaments and tendons of the middle ear (7 temporal bones); calcification foci in the tympanic cavity (9 cases); osteosclerotic changes in the epitympanus (2 cases); cicatricial changes in the tympanic membrane (24 cases); destructive changes in the auditory ossicles (19 temporal bones). There has been evidence that CT may be used for the differential diagnosis of adhesive otitis media from otosclerosis and congenital malformations of the structures of the middle ear.

[Computed tomography in the diagnosis of exudative otitis media]

Temporal bone computed tomography (CT) was used to examine 37 patients aged 2 to 55 years who had exudative otitis media; in 27 patients of them, a pathological process was bilateral. An analysis of 58 temporal bone CT scans identified the CT signs of chronic exudative otitis media. These included a partial or complete block of the osseous foramen of the auditory tube; impaired pneumatization of the tympanic cavity, mastoid process fenestrae, and antrum; pathological drawing-in of the tympanic membrane. The preservation of the auditory ossicles and the absence of destructive changes in the walls of the cavities of the middle ear were observed in most cases. Repeated temporal bone CT study was performed in 10 patients (14 temporal bones) in different periods (from 2 months to 3 years) after surgery. The results of tympanostomy were visually assessed. These included recovered pneumatization of middle ear cavities (7 temporal bones), a cicatricial process in the tympanic cavity (5 temporal bones), recurrence of the CT manifestations of exudative otitis media (2 temporal bones).

[CT of the temporal bone in the study of the inner ear structures in detection of the causes of neurosensory hypoacusis]

Computed tomograms of the inner ear structures (n=175) of 150 patients (age 0-75 years) with unaffected temporal bones were studied in detail. It is shown that polyposition CT of the temporal bone is a non-invasive method of visualization of the osseous labyrinth structures: cochlea, vestibule, semicircular canals, aqueducts of the labyrinth and internal acoustic meatus which are reflected on tomograms in 100% cases irrespective of the patient age. Their age-related features are analysed. CT imaging was made in 65 patients with neurosensory hypoacusis of inherited and acquired genesis. The following causes of neurosensory hypoacusis and deafness were revealed: congenital malformation of the labyrinth of Mondini type, common cavity of the labyrinth, cochlear hypoplasia, dysplasia of the vestibule and semicircular canals, a wide aqueduct of the vestibule, stenosis of the internal acoustic meatus, bulboform enlargement of the inner acoustic meatus, neurinoma (schwannoma) of the hearing nerve, Langerhans-cell histiocytosis with affection of the labyrinth capsule, atypical cholesteatoma. The detected changes in the inner ear structures determine further treatment policy.

[Computed tomography of the temporal bone in diagnosis of otitis media chronica purulenta]

Computed tomography (CT) of the temporal bone has been used to study thirty-eight 5-72-year-old patients with otitis media chronica purulenta (OMCP), in 14 of them the process was bilateral. A scheme of CT assessment of the temporal bone is proposed. The analysis of 52 CTs of the temporal bone with consideration of otoscopic and operative findings helped to distinguish CT signs of non-cholesteatomic OMCP. These signs include sclerotic alterations of the bone tissue of the mastoid process (82.7%), defective pneumaticity of the middle ear cavities (tympanic cavity - 80.7%) due to pathological substrate, destructive changes of the auditory bones (50%), carious alterations of the walls of the middle ear cavities (21%). The study of the temporal bone by the proposed scheme detected such anomalies and structural features as presentation of the sigmoid sinus (36.5%), elevation of the bulb of the jugular vein (3.8%), diverticulum of the jugular vein (3.8%), low fundus of the middle cranial fossa (7.7%).

[Computed tomography (CT) of the temporal bone in diagnosis of acquired cholesteatoma of the middle ear]

The analysis of 51 CTs of the temporal bone in patients aged from 2 to 74 years with otitis media purulenta chronica, cholesteatoma has established that cholesteatoma of different location and severity has specific CT-symptoms. A reliable diagnostic key to CT-diagnosis of cholesteatoma is attic deformation due to destruction of the lateral wall by a soft tissue lesion, extension of the aditus to the antrum, the presence of the cavity with sclerotic walls in the antromastoid area, carious changes in the auditory ossicles, medial or lateral shift of the ossicles. CT registers carious alterations in the middle ear cavity walls including the roof and labyrinthine wall of the tympanic cavity. This allows diagnosis of a labyrinthine fistula and intracranial complications of cholesteatoma. CT well visualizes spread of cholesteatoma on the top of the pyramid. Age-related features of cholesteatoma are studied.

[Temporal bone CT in the diagnosis of acquired diseases of the external auditory canal]

CT was used to examine 50 patients (100 temporal bones) aged 10 days to 60 years who had no signs of lesion of the external auditory canal (EAC) and 23 patients (27 temporal bones) aged 13 to 65 years who had clinical manifestations of acquired stenosis or obturation of the EAC. Polypositional CT of the temporal bone is the most informative technique of visualization of the osseous part of the EAC, at the same time the anterior and posterior EAC walls were evaluated in the axial projection and the upper and lower EAC walls were assessed in the coronary projection. According to CT data, formation of the osseous part of the EAC occurs within the first 7 years of a child's life. In the presence of EAC changes, CT may assess their pattern (a soft tissue or osseous one), their magnitude and location along the walls of the canal, the tympanic membrane, and other structures of the temporal bone. CT reveals the causes of acquired EAC obturation, stenosis, and atresia: osteocartilaginous exostoses, osteomas, polyps of the EAC, tumors of the temporal bone, as well as obturative keratosis and posttraumatic stenosis of the EAC. The detected EAC changes determine further management policy in a patient.

[Potentialities of temporal bone CT in the diagnosis of chronic purulent otitis media and its complications]

Temporal bone CT was used to examine a group of 87 patients with chronic purulent otitis media (103 temporal bones). The patients' age ranged from 2 to 74 years. A scheme was developed and proposed to evaluate the temporal bone by CT. The CT signs of chronic purulent otitis media uncomplicated by cholesteatoma and those of cholesteatomic purulent otitis were identified. The CT symptomatology of chronic purulent otitis includes: sclerotic changes in the bone tissue of the mastoid process, impaired pneumatization of the cavities of the middle ear, including the tympanic cavity, destructive changes in auditory ossicles, carious changes in the walls of the cavities of the middle ear. The CT semiotics of cholesteatoma depends on its site and spread into the temporal bone and includes as follows: deformation of the epitympanum due to soft tissue mass-induced destruction of the lateral wall; the dilated entrance into the antrum; the presence of a cavity with the sclerosed walls in the antromastoid area; carious changes in the auditory ossicles; the displacement of a chain of ossicles medially or laterally in relation to the initial site of cholesteatoma. CT reflects carious changes in the walls of the cavities of the middle ear, including the roof and labyrinthine wall of the tympanum, which allows labyrinthine fistula and intracranial cholesteatomic complications. The study of the temporal bone by the proposed scheme may reveal anomalies and the specific features of its structure: the presentation of the sigmoid sinus, the high elevation of the bulb of the jugular vein, diverticulum of the latter, the low standing of the bottom of the ACH.

[Potentialities of temporal bone computed tomography in the study of the facial nerve and in the diagnosis of peripheral pareses of thr 7th pair of cranial nerves]

Computed tomography (CT) was used to examine 200 patients (400 temporal bones) aged 3 to 74 years who had no signs of facial nerve lesion and 28 patients who had clinical manifestations of peripheral paresis of the facial nerve of varying genesis. Multipositional CT of the temporal bone is the most informative mode of visualization of the fallopian canal which is embodied on tomographic scans in 100% of cases irrespective of the age of a patient. CT data indicate that the formation of the facial nerve canal brings to completion by the age of 6 years. The following causes of n. facialis paresis were identified: facial neuroma; sarcoma of the temporal bone sarcoma; dehiscence of the canal wall in otitis media acuta; destruction of the tympanic wall of the canal in otitis nedia chronica, fractures of the temporal bone, anomalies of the fallopian canal in temporal bone malformations; stenosis of the canal in fibrous dysplasia. The detected alterations of the n. facialis canal permits further policy of management of a patient to be defined.

[Oval window canal and CT-diagnosis of peripheral pareses of the facial nerve]

Computed tomography (CT) has examined 200 patients (400 temporal bones) at the age of 0-74 with unaffected facial nerve and 28 patients with symptoms of peripheral paresis or paralysis of the facial nerve of different genesis. Polyposition CT of the temporal bone is an intravital noninvasive method of the Fallopius' canal visualization. The canal is visualized on the tomograms in 100% cases irrespective of the patients' age. The following causes of n. facialis paresis were revealed: neurinoma of the facial nerve, sarcoma of the temporal bone, destruction of the tympanic canal wall in chronic otitis media, fractures of the temporal bone, malformations of the Fallopius' canal in malformations of the temporal bone, stenosis of the canal in fibrous dysplasia. The above alterations of n. facialis canal determine further therapeutic policy.