Endoscopic classification system of pars tensa retractions

BACKGROUND

Previous classification systems of pars tensa retractions have not consistently incorporated ossicular erosion or the presence of cholesteatoma.

OBJECTIVE

This study aimed to illustrate our classification of pars tensa retractions, which is more precise than previous systems, with aided use of the endoscope.

METHODS

A retrospective study was carried out on 200 ears of 170 patients whose pars tensa retractions had been documented at a tertiary otological referral centre.

RESULTS

A classification system was developed. Pars tensa retractions were divided into the following subcategories: grade 0, grade 1, grade 2a, grade 2b, grade 3a, grade 3b, grade 3c, grade 4a, grade 4b, grade 4c, grade 5a, grade 5b and grade 5c.

CONCLUSION

This classification system was able to accommodate all pars tensa retractions. The distribution of grades of pars tensa retractions was based on ossicular status and the presence or absence of cholesteatoma. It is therefore a more applicable, and functionally based system than previous alternatives.

Management of attic retraction pockets

OBJECTIVE

Attic retraction pockets, classified by degree of invasion and erosion, are reconstructed here as outlined by attic retraction pocket grade.

METHOD

Attic retraction pocket grade, surgical management, subsequent conditions of tympanic membrane and middle ear, and improvement of air-bone gap pure tone average were recorded.

RESULTS

Our management strategy, based on attic retraction pocket grade, was applied to 200 ears: 44 grade I ears had non-surgical management and 156 grade II-V ears had surgical management. All 200 ears were followed up for 36-240 months, showing only 1 attic retraction pocket reformation and 1 adhesive otitis media (complication rate of 1 per cent), and improved air-bone gaps (p < 0.05). An earlier series of 50 grade IV attic retraction pockets used atticotomy with epitympanic reconstruction. These showed attic retraction pocket recurrence or cholesteatoma onset in 34 ears (68 per cent). When these ears were revised per protocol, there was no evidence of cholesteatoma thereafter.

CONCLUSION

Reconstruction of the ossicles and scutal defect according to attic retraction pocket grade shows long-term stability of the tympanic membrane, middle ear and hearing.

A Unified Classification of Middle Ear and Petrous Bone Congenital Cholesteatomas

Background:

The aim of this study was to classify congenital cholesteatoma along an entire spectrum of involvement ranging from the middle ear to petrous apex.

Methods:

A total of 131 patients (85 adults and 46 children) underwent operations for congenital cholesteatoma over the duration of 27 years.

Results:

For most cases, middle ear mucosa was normal, the first ossicle eroded by the mass was the stapes, and the mastoid air cell system was well-pneumatized on intraoperative and radiographic views. Totally 34% of patients presented with facial nerve weakness and 45% of these cholesteatomas arose from the supralabyrinthine area (32.8%) and from the petrous apex (12.2%).

Conclusion:

In this unified classification system, the otologist sees congenital cholesteatoma as a continuum, with facial nerve involvement and anacusis as part of the picture. This system of congenital cholesteatoma accommodates the supralabyrinthine and petrous bone locations of the disease.

Unmitigated negative nasopharyngeal pressure is associated with attic retraction pocket formation: LaPlace's law in action

BACKGROUND

Decades of clinical observation have led our subspecialty team to suspect that negative nasopharyngeal pressure is associated with attic retraction pocket formation. Furthermore, LaPlace's law, which states that the pressure within a sphere varies with the inverse of the radius, provides the dynamic explanation for why the attic area of the tympanic membrane tends to retract more frequently than the pars tensa.

METHODS

The attic retraction pockets of 154 patients were classified into grades of severity (grades I-V). Impedance audiometry of middle-ear pressure was measured in the resting state, and after sniffing, swallowing and the Valsalva manoeuvre.

RESULTS

Negative nasopharyngeal pressure (sniffing) caused a diminution of middle-ear pressure of -5 daPa on average in normal ears, and of -24 daPa to -45 daPa for tympanic membranes with attic retraction pockets of grade I to grade V.

CONCLUSION

Attic retraction pockets are associated with greater collapse of middle-ear volume when negative pressure is created in the nasopharynx. LaPlace's law, and the composition of the pars flaccida, suggests an explanation for why the attic region retracts more than the pars tensa.

The Thickness of the facial Nerve Sheath Consistently Varies by Region in Its Intra-Tympanic Course on Cadaveric Study

OBJECTIVES

Iatrogenic removal of intra-temporal disease processes, such as cholesteatoma and keratosis obturans, can be challenging when the facial nerve (FN) is involved. Despite this concern about possible FN injury during these procedures, our clinical observation has been that the diseased growth can be cleaned quite easily from the vertical FN epineurium. Therefore, we designed a cadaveric protocol to measure thickness of the FN sheath (epineurium) in horizontal, second genu and vertical FN segments and to correlate these measurements with surgical management of FN disorders.

METHODS

Fifty non-fixated (wet) cadaveric temporal bones were dissected over 1 year's time. The intra-temporal FN sheath epineurium was harvested from the mid-horizontal, second genu, and mid-vertical segments. Using a digital micrometric technique, the thickness of each sample was measured. Data analysis was performed using student's two-tailed, dependent t-test.

RESULTS

Epineurial nerve sheath thickness was the least in the horizontal segment (mean 0.9 mm, range 0.040-0.140 mm), greater at the second genu (mean 0.19 mm, range 0.010-0.280 mm), and greatest in the vertical segment (mean 0.29 mm, range 0.170-0.570 mm). These differences were statistically significant.

CONCLUSION

In cases of cholesteatoma and keratosis obturans involving the vertical FN, the disease process can be separated from the FN sheath because of the sheath thickness in this region. Disease in the horizontal segment involves a thinner sheath and separating the disease process from the nerve is more difficult in this area.

Prevalence of Hearing Loss, and Middle Ear Disease in 1351 School Age Children in Mekelle, Ethiopia

OBJECTIVES

The objective of this study was to begin to measure the prevalence of elevated hearing thresholds in Ethiopia, with audiometric equipment, including bone oscillators and tympanometers. To that end Ethiopian nationals were trained in audiometric techniques to obtain sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) rates in school age children.

METHODS

Five mainstreamed public grade schools in northern Ethiopia were the sites for audiometry campaigns examining 1351 children and testing them with behavioral audiometry.

RESULTS

Seven percent of students had SNHL > 20 dB in at least 1 frequency in at least 1 ear, and 0.6% of ears had SNHL > 50 dB. Eighteen percent8% of students had CHL > 20 dB in 1 or both ears. The frequency with the highest incidence of elevated pure tone thresholds was at 8000 Hz. Seven percent of students had an air bone gap at 2000 and/or 4000 Hz of at least 15 dB. Air bone gap is not obtained at 8000 Hz. There were 22 perforated tympanic membranes in 17 children (0.8% of tympanic membranes, 1% of students).

CONCLUSION

This study gives a baseline for the prevalence of hearing loss in school age children in mainstreamed northern Ethiopian schools. It is the first of its kind and perhaps can help in estimated hearing health needs there.

LEVEL OF EVIDENCE

2.

Assessing the Impact of a Training Initiative for Nasopharyngeal and Oropharyngeal Swabbing for COVID-19 Testing

Objective

The accuracy and reliability of COVID-19 testing are critical to limit transmission. After observing variability in testing techniques, we otolaryngologists at a tertiary medical center initiated and evaluated the impact of nasopharyngeal and oropharyngeal swabbing training, including video instruction, to standardize sampling techniques and ensure high-quality specimens.

Methods

Participants in the training were employees (N = 40). Training consisted of an instructional video on how to perform nasopharyngeal and oropharyngeal swabs and a live demonstration. Participants completed pre- and posttraining surveys assessing their knowledge and confidence in performing nasopharyngeal and oropharyngeal swabs. They then performed swabbing on partners, which was graded per a standardized checklist.

Results

Mean scores for knowledge-based questions and confidence in swabbing were significantly higher after the training session (both P < .001). All participants scored ≥6 of 8 on the posttraining checklist. Ninety-five percent rated the video as very or extremely useful.

Discussion

Specialized instruction for nasopharyngeal swabbing improved participants’ knowledge—specifically, the appropriate head position and minimum swab time in nasopharynx—and their confidence. After the training, their swabbing execution scores were high.

Implications for Practice

Video-assisted hands-on instruction for nasopharyngeal swab sampling can be used to standardize teaching. When prompt and accurate testing is paramount, this instruction can optimize procedural technique and should be used early and often. In addition, there may be a professional responsibility of otolaryngologists to participate in such initiatives.

Facial Nerve Decompression After Temporal Bone Fracture-The Bangalore Protocol

Background: Our tertiary otology center treats facial weakness and paralysis after motor vehicle crashes. We evaluate these patients with physical exam, audiogram, Schirmer's test, and CT scan. Our protocol for management of the facial weakness provides good results for our patients.

Methods: Our protocol begins with oral steroids, and serial evaluations. Indications for decompression and our unique transcanal approach to identify the sites for decompression are described. A retrospective review of the medical record presents our patients treated between 1998 and 2017.

Results: One hundred and forty one patients with grade 4 or more weakness underwent decompression. Mean pre-operative and post-operative House-Brackmann (HB) scores were HB5 and HB2, respectively. Fourteen of 104 patients (13%) presenting with HB5 and 6 still had HB5 or HB6 after decompression. Eighty-three of thee 104 patients (80%) achieved HB1 or HB2 at 6 months. Post-operative bone levels were unchanged. Post-operative air levels were improved in cases of perigeniculate fractures (84%).

Conclusion: This Bangalore protocol facilitates advantageous improvement in facial function and conductive hearing loss after traumatic facial nerve crush injuries. The surgical technique, albeit challenging, helps identify the fracture lines, facilitates reconstruction of disrupted ossicles, and avoids craniotomy.

The effect of surgeon experience on tympanic membrane closure

Objective

Review of the English language literature finds little documentation of the relation of otology or otolaryngology outcomes to a surgeon's age, years in practice, or numbers of cases previously performed. Because of one surgeon's adoption of a new tympanoplasty technique for uncomplicated tympanic membrane perforations, our institution was situated to report an example of a surgical learning curve with its outcome. Experience versus outcome is worth establishing objectively because these relationships reflect on training and certification.

Design

This retrospective review of the medical records tallied preoperative risk factors and perforation sizes for four consecutive 100-blocks of double-layer tympanoplasties.

Setting

An otology specialty care facility in Addis Ababa, Ethiopia.

Participants

Participants were 359 patients with tympanic membrane perforations without ossicular discontinuity or erosion who underwent 400 primary simple tympanoplasties.

Intervention

A double-layer tympanoplasty was performed in each operation using an endaural approach.

Outcome Measures

The outcomes were closure of the perforation and change in hearing.

Results

There were no statistically significant differences between the four 100-block case cohorts in preoperative risk factors and perforation sizes. Preoperative, postoperative, and change of hearing were also the same between the four groups; and statistically there was no significant difference between the four 100-block cohorts. Perforation closure for each successive 100-block increased from 74% to 98%. The closure rates of the second, third, and fourth 100-block were each statistically significantly different from the first 100-block, but not from each other.

Conclusion

This simple study demonstrates the surgical learning curve with increased surgeon experience, and is one of very few such documentations. With each additional 100 cases, the outcomes improved, and sheds light on the numbers of cases necessary for competency.

Level of Evidence

3.

Stapedectomy Is Rewarding: But How to Prove It?

OBJECTIVE

To demonstrate that neurotologists enjoy performing stapedectomies.

SUBJECTS

A group of survey recipients consisting of 174 neurotologists who perform stapedectomy, a nonoverlapping control group of 145 head/neck oncologists who perform parotidectomy, and a second nonoverlapping control group of 365 pediatric otolaryngologists who perform tonsillectomy.

OUTCOME MEASURES

Responses to surveys distributed by electronic mail to the 3 nonoverlapping recipient groups during nonoverlapping 4-week periods.

RESULTS

During the 4-week survey periods, 84 of 174 neurotologists (48%) responded, while 33 of 145 oncologists (23%) and 87 of 365 pediatric otolaryngologists (24%) responded. Most neurotologists performed stapedectomy (80/84; 95% of survey responders), while 33 of 33 (100% of survey responders) oncologists performed parotidectomy and 87 of 87 (100% of survey responders) pediatric otolaryngologists performed tonsillectomy. Seventy-six of the 80 neurotologists who performed stapedectomies (95%) enjoyed performing it, slightly more than the 30 of the 33 oncologists who performed parotidectomies (91%) and appreciably more than the 67 of 87 pediatric otolaryngologists who performed tonsillectomies (77%). Twenty-three neurotologists (30%) would sacrifice vacation time to perform additional stapedectomies, slightly more than 8 oncologists (27%) for additional parotidectomies and more than the 7 pediatric otolaryngologists (10%) for additional tonsillectomies. Ten (13%) of the neurotologists, 3 (9%) of the oncologists, and 1 (2%) of the pediatric otolaryngologists would sacrifice 5 or more vacation days to perform more of the procedures.

CONCLUSIONS

Our data suggest that neurotologists enjoy performing stapedectomy.

Langerhans' cell histiocytosis of the temporal bone in an adult with central diabetes insipidus

We present a case of Langerhans’ cell histiocytosis in a 40-year-old woman presenting with central diabetes insipidus and right ear pain. As this disease process is often clinically challenging, the presence of certain imaging findings should raise the possibility of this diagnosis. We review the pertinent imaging and correlate with histology and immunohistochemistry leading to the diagnosis.

Effective Inexpensive Management of Necrotizing Otitis Externa Is Possible in Resource-Poor Settings

Introduction:

Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well.

Materials and Methods:

Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention.

Results:

Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression.

Conclusion:

Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.

Double-Layer Tympanic Membrane Graft in Type I Tympanoplasty

Background:

Some discussion remains among otologists regarding the best grafts for tympanic membrane closure. It is unclear whether double-layer grafts are superior to single-layer and whether single-layer cartilage is superior to fascia or perichondrium alone. The objective of the current study was to examine the relative efficacy of single-layer versus double-layer tympanic membrane grafting techniques.

Materials and Methods:

A retrospective review of the medical records was used to address the objective of the study. Patients operated on in an over/under technique by the same surgeon underwent single-layer perichondrium or single-layer perichondrium with a cartilage island, or a double-layer of perichondrium combined with periochondrium with a cartilage island. The outcomes assessed were tympanic membrane reperforation and hearing improvement.

Results:

A total of 135/177 (76%) perichondrium grafts had no reperforation, and 43/55 (78%) perichondrium with cartilage island grafts had no reperforation; 352/390 (90%) of the double-layer closures had no reperforation. There was no statistically significant difference in reperforation rates between the 2 single-layer techniques ( P = .926). The difference in reperforation rates after the double-layer closure versus the perichondrium single-layer closure was statistically significant ( P = .001), as was the difference in reperforation rates after the double-layer closure versus the cartilage island single-layer closure ( P = .02). All 3 groups showed statistically significant hearing improvement postoperatively ( P < .0001). Preoperative hearing levels ( P = .179), postoperative hearing ( P = .857), and decibels of hearing improvement ( P = .356) were the same for all 3 groups.

Conclusion:

Double-layer closure gives lower tympanic membrane reperforation rates than does single-layer closure, as well as similar hearing outcomes.

Cochlear implant electrode array exposure: A delayed complication

Exposure of the cochlear implant electrode array as a late complication has been reported rarely in the literature. A retrospective analysis revealed 4 patients presenting with exposure of their cochlear implant electrode arrays from 2 to 17 years after implantation. Data collected from these 4 patients were surgical implantation approach, type of implant, age at implant, interval between implant and complication, surgical correction of the problem, pathology at the time of correction, and length of follow-up after intervention. All 4 patients presented with otitis or mastoiditis. Each had undergone a transmastoid approach with facial recess and cochleostomy and full implant insertion. In 3 cases, the tympanic membrane had retracted to expose the electrode array. In 1 patient, the electrode array had eroded through the external canal, lateral to the facial recess. The exposed arrays were addressed surgically, including explantation/reimplantation for 1 patient. Cochlear implant electrode arrays can become exposed by relative migration of the array and the tympanic membrane. Implant surgeons and audiologists need to be aware of the possibility of this complication. Closure of the ear canal appears to be the most effective surgical intervention.

High-Density Otologic Camps in Regions of Sparse Expertise

Aims/Purpose: When 2 models of otologic surgery instruction in Ethiopia are compared, high-density otologic surgery campaigns are more effective for accelerated skills transfer in areas of sparse expertise than the standard outpatient clinic/OR model.

METHODS

A continuously operating otolaryngology/head and neck surgery department in a large public hospital is compared with a nonprofit specialty hospital where outpatients are selected for weeklong surgical campaigns. The number and variety of otologic visits and operations in each setting, presence of expert supervision, and resident-trainees' surgical progress were tallied.

RESULTS

The public hospital saw 84 otologic operations in 1 full year. Meanwhile, the ear specialty surgical campaign site saw 185 otologic operations in 6 surgical campaign weeks. All operations at both sites were performed primarily by trainees. Experienced otologists supervised 40% of operations at the public hospital and 100% at the surgical campaign site. At the end of the year, none of the 10 resident-trainees in the public hospital were able to perform a simple underlay tympanoplasty, compared to 6 of 12 resident-trainees in the campaign setting.

CONCLUSIONS

Where otologic expertise is sparse, otologic surgical campaigns allow the most effective use of resources-patient pathology, medical facilities, trainee attendance, and imported instructors.

Ossicular Chain Reconstruction in a Developing Country

Objectives:

In Ethiopia, 2-stage operations with middle ear prostheses are economically unfavorable. We hypothesized that single-stage autologous ossiculoplasty results in acceptable tympanic membrane (TM) and hearing improvements in a setting of limited resources.

Methods:

One hundred eighty-eight patients (197 ears) who underwent 1-stage autologous ossiculoplasty for ossicular dysfunction are presented. All but 14 of these ears also had perforations of the TM. Conditions of the middle ear were granulation tissue, ossicular disruption only, tympanosclerosis, and cholesteatoma. Reconstructions of the ossicular chain were performed with autologous ossicles only.

Results:

The closure rate of TM perforations was 95%. Preoperative air bone gaps were 27 to 60 dB (mean [SD] = 44 [7] dB); postoperative air bone gaps were 0 to 50 dB (average [SD] = 23 [10] dB), for an average improvement of 21 dB across all reconstruction types ( P < .001). The largest favorable changes in air bone gaps were with incus and malleus columellas from the footplate to the TM (33 and 23 dB, respectively) ( P < .001). No patient had worsening of sensorineural hearing levels or extrusion of the reconstructed ossicles.

Conclusion:

Autologous ossiculoplasty performed well in this setting. Acceptable TM closure rates and improvement of air bone gaps were seen in 1-stage operations without the use of prostheses.

HIV Positivity per se Does Not Affect Tympanoplasty Outcomes

BACKGROUND

The English language literature finds no clear protocols for otologic surgery for HIV+ patients.

OBJECTIVE

To demonstrate that simple tympanoplasty and type III tympanoplasty in HIV+ patients with CD4 >400 cells/cc results in tympanic membrane closures and hearing improvements equivalent to the same procedures in controls.

MATERIALS AND METHODS

This retrospective review documents the otologic conditions and operative results of 32 HIV+ patients and 32 controls. The controls were healthy and had no opportunistic infections or other medications.

RESULTS

Genders, ages, sizes of tympanic membrane perforations, severity of air bone gaps, and type of operation were equivalent between the HIV+ and the control groups. Thirty of 32 patients in each group had closure of their perforations after 1 operation. Air bone gaps improved significantly for each group ( P = .001): 22 dB (SD = 11 dB) in the HIV+ group and 26 dB (SD = 10 dB) in the control group. And there was no statistically significant difference in change in hearing between the 2 groups. There were no complications of infection, wound dehiscence, worsened sensorineural levels, dizziness, or facial weakness in either group.

CONCLUSION

HIV+ patients whose CD4 counts are above 400 cells/cc can undergo simple tympanoplasty or type III tympanoplasty with acceptable outcomes.

Interactive iPhone/iPad App for Increased Tympanic Membrane Familiarity

INTRODUCTION

Otology relies on clinical examination to teach anatomy of the ear. The purpose of this report is to introduce the Buckingham Virtual Tympanum iPhone app as an adjuvant educational tool to teach the anatomical details of the tympanic membrane (TM).

MATERIALS AND METHODS

This app, available free at the Apple Store, was constructed using archival photographs of normal and abnormal TMs, stratified by difficulty. Each image has 4 labeled structures, linked to questions to encourage active learning. Third-year medical students then used the app to familiarize themselves with the TM.

RESULTS

The free app was readily accessible and functioned without technical issues. By being interactive, it forced the user into the role of active learner. This pilot study found that students who used the app understood images of the TM better than those who did not use it.

DISCUSSION

We introduce an interactive, iPhone-based smartphone application that we found to be a useful adjunct for teaching TM anatomy.

Middle Cranial Fossa Dehiscence as an Incidental Finding on CT

OBJECTIVES

This retrospective chart review demonstrates that the prevalence of middle cranial fossa (MCF) dehiscence on computed tomography (CT) scans increases with age.

METHODS

High-resolution temporal bone CT scans, which had been obtained for any otologic complaint, were reviewed independent of all clinical history. Scans showing soft tissue, fluid, trauma, or previous operations were excluded. The CTs from 183 patients (296 ears) were reviewed, blinded for age and body mass index (BMI). The MCF floor was divided into 7 regions and systematically inspected. Ages and BMIs of the patients were subsequently extracted from the medical record.

RESULTS

Logistic regression analysis confirmed increasing MCF dehiscence with age (P < .05, odds ratio [OR] = 1.07, R = .584). Over all ages (range, 1-88 years; average, 38.5), 32% of MCF floors were dehiscent at any 1 site. For age 60 and over, 55% were dehiscent. The most common sites of MCF dehisence were directly above the malleus head and above the additus ad antrum (35% and 28%, respectively). Superior canal dehiscence (SCD) was seen in 7% of all patients and only in the context of MCF dehiscence. The prevalence of MCF dehiscence increased with age when patients were analyzed by BMI <25, BMI = 25-30, and BMI >30 (P < .003, P < .04, P = .03).

CONCLUSION

The increase of middle cranial fossa dehiscence with respect to age is statistically significant. Over all ages, approximately 32% of ears show dehiscence. Over 60 years, approximately 55% show dehiscence. The odds of having dehiscence double with a 10-year difference in age. The most common sites along the MCF floor are in the epitympanum over the malleus head and the additus ad antrum. There was a statistically significant increase in MCF dehiscence with age when patients with equivalent BMIs are compared.

Hearing in static unilateral vestibular schwannoma declines more than in the contralateral ear

OBJECTIVE

To determine the effect of static vestibular schwannomas on hearing.

STUDY DESIGN

Retrospective review of audiometric measures in 15 patients with documented nongrowth of internal auditory canal and cerebellopontine angle enhancing masses.

METHODS

Data from patients seen in an ambulatory tertiary care setting between the years of 2002 and 2012 with a diagnosis of acoustic neuroma or vestibular schwannoma were reviewed. Exclusion criteria included preexisting otologic disease, prior therapy for the schwannoma, and tumor growth. Radiology reports were reviewed to ensure nongrowth and were confirmed by taking magnetic resonance imaging (MRI) measurements ourselves. Audiologic measurements included pure tone average, enhanced pure tone average (average of .5, 1, 2, and 4 KHz thresholds), 4 KHz threshold, 8 KHz threshold, and speech discrimination. The data were analyzed using mixed effect model with unstructured variance-covariance structure.

RESULTS

Difference in audiometric measures between ears significantly (P<.05) increased for all measures except 8 KHz.

CONCLUSION

Spontaneous decline in hearing relative to time is exaggerated in the affected ear despite no vestibular schwannoma growth. This finding can be useful for patient counseling and treatment decision making.

Middle Cranial Fossa Dehiscence as an Incidental Finding on CT

Objectives:

Determine the prevalence of middle cranial fossa (MCF) dehiscence on computed tomography (CT) scans and establish its increase with age.

Methods:

All high-resolution temporal bone CT scans completed at a tertiary care center from 2011 to 2013, ordered by 1 otologist for any reason, were reviewed. Scans showing soft tissue, fluid, trauma, or previous operations were excluded. A total of 183 patients (296 ears) were reviewed blinded for age. The MCF floor was divided into 7 regions and systematically inspected. Ages of the patients were subsequently extracted from the medical record.

Results:

Logistic regression analysis confirmed increasing MCF dehiscence with age ( P < .05, odds ratio [OR] 1.07, R = 0.584). Overall ages (1-88 years; average 38.5 years), 32% of MCF floors were dehiscent at any one site. For age 60 years and over, 55% were dehiscent. For 226 paired ears, if one ear was dehiscent, there was a 66% chance the other ear was dehiscent as well. Superior canal dehiscence (SCD) was seen in 7% of all patients, and only in combination with MCF dehiscence. SCD occurred in 16% of dehiscent ears. The most common sites were directly above the malleus head and above the additus ad antrum (36% and 28%, respectively).

Conclusions:

The incidence of MCF dehiscence increases with age. Over all ages, approximately 32% of ears show dehiscence. Over 60 years, approximately 55% show dehiscence. The increase of dehiscence with age is statistically significant. The most common sites along the MCF floor are in the epitympanum over the malleus head and additus ad antrum.

Is simultaneous bilateral mastoidectomy ever advisable?

Introduction:

We report our experience with bilateral, simultaneous tympanomastoidectomies and the results of an opinion survey of otologists.

Methods:

A chart review of 116 tympanomastoidectomies revealed 12 patients who underwent bilateral, simultaneous tympanomastoidectomies. An opinion survey generated 121 responses.

Results:

Of the 12 patients, none suffered any outcome which would have been avoided by staging the procedures. Twenty-three of 24 operated ears had the same or better hearing post-operatively. Of the survey respondents, 74 felt that performing bilateral, simultaneous tympanomastoidectomies was unsafe, largely because of the risk of bilateral sensorineural hearing loss.

Discussion:

Although bilateral, simultaneous tympanomastoidectomies carry double the risk of unilateral sensorineural hearing loss, compared with the unilateral procedure, the risk of bilateral sensorineural hearing loss is only 0.006–0.2 per cent, as derived mathematically from historical data. Respondents to the survey were mostly opposed to bilateral, simultaneous tympanomastoidectomies, but even those opposed gave indications for simultaneous procedures. This finding probably reflects an ambivalence about the theoretical risks of the operation versus the potential patient benefits. A decision tree for proceeding to the second case is presented.

Headache with unilateral pulsatile tinnitus in women can signal dural sinus thrombosis

OBJECTIVES

Dural sinus thrombosis commonly presents with headache, and rarely with tinnitus. These thromboses can progress to neurologic impairment and death. We are sharing recent clinical experiences with these thromboses as they present to the otologist.

METHODS

We report the presentation, physical examination, and imaging studies of 4 patients.

RESULTS

Four women had thrombotic occlusion of the sigmoid sinus. Their only symptoms were focal headache in all 4 patients, and unilateral pulsatile tinnitus in 2 of them. Imaging studies had to be repeated or alternative testing performed in order to conclusively identify the problem.

CONCLUSIONS

It is important to be vigilant for the possibility of sigmoid sinus thrombosis in women who complain of unilateral head pain or unilateral pulsatile tinnitus. Appropriate imaging must be performed.

Tuberculous otitis media with mastoiditis and central nervous system involvement

Tuberculosis of the middle ear and mastoid is currently a rare disease in developed countries, but this disease still occurs and may cause serious consequences. We report a case of disseminated tuberculosis involving the middle ear, mastoid, lung and central nervous system. Tuberculosis should be considered in the differential diagnosis of chronic ear drainage, especially in young children.