Management of acquired cholesteatoma in patients with craniofacial anomalies: An institutional experience

PURPOSE

To analyze the surgical management of cholesteatoma in patients with craniofacial abnormalities, cleft lip/palate by reviewing the institutional experience. The secondary aim was to identify and describe the epidemiological profile of the collected data, and to relate the cleft palate and cholesteatoma.

DESIGN AND METHODS

This retrospective chart review includes 97 patients with craniofacial abnormalities and acquired cholesteatoma with anatomopathological proven in 118 ears. The following data were collected from the medical records between 1994 and 2018.

RESULTS

The first surgery performed on 76 of the 118 ears (64.4%) was the wall up mastoidectomy, while 42 of the 118 ears (35.5%) received the wall down technique. During the follow-up period of these patients, which ranged from 2 to 29 years, with an average of 13.4 years (±5.88), 77 wall up (40.3%) and 114 wall down (59.6%) mastoidectomies were performed. This brought the total to 191 mastoidectomy surgeries in 118 ears of 97 patients. Of the wall up mastoidectomies, 65 of the 77 (84.4%) presented with cholesteatoma recurrence. In the wall down mastoidectomies follow up, there were new surgical approaches in 15 of the 114 procedures (13.1%), with 6 patients (5.2%) having anatomopathologically proven cholesteatoma recurrences and 9 (7.8%) having clinical instability for cavity cleaning without identification of disease recurrence.

CONCLUSIONS

Early approach with wall down/modified techniques guided by specific indication criteria may be more resolute, prevent multiple procedures, and preserve the bone pathway to facilitate possible future hearing rehabilitation in these patients.

Health Related Quality of Life after the Bony Obliteration Tympanoplasty for COM with Cholesteatoma using the COMQ12 - A Disease Specific PROM

OBJECTIVES

This study aimed to investigate the effect of canal wall up with bony obliteration tympanoplasty (CWU-BOT) on the health-related quality of life (HRQOL) in patients with chronic otitis media with cholesteatoma by using the chronic otitis media questionnaire 12 (COMQ-12).

MATERIALS AND METHODS

This study is a retrospective analysis of the COMQ-12 of 26 patients who completed the COMQ-12 before and after a CWU-BOT with eradication of cholesteatoma followed by obliteration of the mastoid and paratympanic space with bone chips and bone pâté and reconstruction of the tympanic membrane and ossicular chain.

RESULTS

All patients were operated upon in our institute between 2014 and 2017. The median score of the 12 questions was preoperatively and postoperatively calculated, and then compared. A large effect was observed in the total score and the questions about running ear, discharge, and visits to the general practitioner. A medium positive size effect was observed in the questions about hearing in noisy surroundings, discomfort, dizziness, tinnitus, medication use, and the mental aspect of the patient. In the questions about the hearing at home and quality of life and impact on work, we noted a small positive size effect. In 50% of patients, the HRQOL became normal; the remaining 50% improved to a level very close to normal.

CONCLUSION

Canal wall up with bony obliteration tympanoplasty (CWU-BOT) showed a clear decrease in the severity of the symptoms, life and work impact, and health care after surgery.

Intracranial Complications of Chronic Otitis Media: Why Does It Still Occur?

Intracranial complications secondary to chronic otitis media (COM) include otogenic brain abscess and sinus thrombosis. Intravenous antibiotics and imaging have significantly reduced the incidence of intracranial complications secondary to COM. However, the same does not apply to a developing country like Malaysia, which still experiences persisting otogenic complications. This case series describes 3 patients with COM and intracranial complications. All 3 patients had COM with mastoiditis, with 1 of the 3 having a cholesteatoma. Postulated reasons for the continued occurrence include poor access to health care, poor compliance with medication, and the lack of pneumococcal vaccination during childhood. In conclusion, public awareness and a timely specialty referral can reduce the incidence of intracranial complications of COM.

Decision making in patients with natural myringostapediopexy: A study of the contralateral ear

Naturally occurring myringostapediopexy frequently results in minimal hearing loss and is asymptomatic. Management decisions in such ears, however, often hinge on an appraisal of evolution toward cholesteatoma. The study of the contralateral ear has been used by our research team to infer the progression of chronic otitis media. This cross-sectional, comparative study describes the clinical findings of the contralateral ear in a series of patients with myringostapediopexy. This study included a historical and current sample of 46 patients divided into a pediatric (≤18 years) and an adult group. Patient distribution according to sex was similar (52.2% male), and 56.5% were adults. Mean conductive hearing loss ranged from 14.1 to 21.2 dB in ears with myringostapediopexy and from 16.0 to 26.6 dB in the contralateral ears according to the frequency assessed. The contralateral ear was normal in only 19.6% of the cases of myringostapediopexy. Central tympanic membrane perforation was found in 6.5% of the cases; perforation-retraction, in 17.4%; moderate or severe retraction, in 28.3%; and cholesteatoma, in 28.3%. The prevalence of cholesteatoma in the contralateral ear in the pediatric and adult groups was not significantly different (p = 0.5; χ(2) test). The presence of significant abnormalities, particularly cholesteatoma, in the contralateral ears suggests a probable unfavorable progression in cases of myringostapediopexy and may influence management decisions.

Conductive Hearing Loss and Otopathology in Cleft Palate Patients

OBJECTIVES: Assess incidence of conductive hearing loss, ear pathology, and associated communicative disorders in cleft palate patients.

STUDY DESIGN: Retrospective chart review of 101 patients all treated at a tertiary facility since birth.

RESULTS: The median patient age was 19 years old (range 8–25) at last follow-up, 35% female. Median age of cleft palate repair was 16 months (range 12–60). Median number of myringotomy tubes was 3 (range 1–7). Conductive hearing loss (CHL) greater than 20 db PTA was found in 25% of patients at last follow-up. Severity of CHL was mild in 75%, moderate in 21%, and severe in 4%. Cholesteatoma was identified in 5.9%. The mean age at resolution of CHL was 5 years (range 3–19). Risk factors associated with CHL at last follow-up included middle ear surgery ( P = 0.016), cholesteatoma ( P = 0.003), and 4 or more myringotomy tube insertions ( P = 0.030). Associations between CHL and age at cleft repair, speech impairment, or learning disabilities were not found.

CONCLUSIONS: Children requiring increased number of myringotomy tubes and middle ear surgery and found to have cholesteatoma are at increased risk for long-standing CHL.

EBM rating: C-4

SIGNIFICANCE: Cleft palate children requiring multiple tube insertions should be monitored closely for CHL.

Expression levels of receptor activator of nuclear factor-κB ligand and osteoprotegerin are associated with middle ear cholesteatoma risk

CONCLUSION

Overexpression of receptor activator of nuclear factor-κB ligand (RANKL) and low expression of osteoprotegerin (OPG) are typical features in middle ear cholesteatoma patients. The altered RANKL/OPG protein ratio suggests that alterations in the RANKL-OPG pathway may be major factors in the pathogenesis of middle ear cholesteatoma.

OBJECTIVE

Our meta-analysis explored the contribution of one important cytokine pathway, the RANKL and OPG pathway, in the development of middle ear cholesteatoma.

METHODS

We screened Embase, the Cochrane Library, CISCOM, CINAHL, Google Scholar, China BioMedicine, China National Knowledge Infrastructure, PubMed, and Web of Science for relevant articles. RANKL expression and ratio of RANKL/OPG were analyzed using Comprehensive Meta-Analysis Version 2 software.

RESULTS

The electronic literature search identified five studies that contained information on the correlation of RANKL and OPG expression with middle ear cholesteatoma. Increased RANKL expression positively correlated with middle ear cholesteatoma, while OPG expression showed an inverse association (p < 0.05). The ratio of RANKL/OPG in middle ear cholesteatoma cases was higher than in healthy controls, indicating that our observations are applicable to each individual case. Subgroup analysis based on country of study revealed that OPG levels decreased in China and Korea, and high RANKL expression was found in Poland, China, and Korea (all p < 0.05).

Cholesteatoma and osteoradionecrosis after radio­therapy of the temporal bone: Surgical aspects

INTRODUCTION

The treatment for head and neck cancer with radiotherapy can cause different alterations of the auditory system. We report two cases of chronic otitis of the external and middle ear secondary to osteoradionecrosis of the temporal bone. This article aims to report the experience of the surgical approach in such condition.

CASES REPORT

The first patient was treated with radiotherapy in his childhood for a cerebellar tumor. He developed years later a cholesteatoma which invaded the mastoid cavities through a destruction of the external auditory canal. The second was treated for a malignant parotid tumour 15 years before by surgery and radiotherapy. She developed a chronic otorrhea with a partial destruction of the bony external auditory canal. Both patients were treated by surgery with reconstruction including bone, cartilage, fascia and skin grafts. The outcome was good in both cases. Osteo­radio­necrosis of the temporal bone is a rare but serious complication of radiotherapy for head and neck cancer. This complication can occur even many years after the treatment. Our two cases demonstrate a way to solve this pathology. A long term supervision with regular cares is essential in order to get a good healing. Due to the improvement of the radiation therapy we could expect less complications of this type in the future.

Cholesteatoma behind a normal tympanic membrane after trauma (Blast)

OBJECTIVES

One of theories concerning the origins of cholesteatoma, is the barotraumatic etiology. It suggests blast perforation of the tympanic membrane, and secondary implantation of epithelium in the tympanic cavity, as a cause of middle ear cholesteatoma. We report a case of cholesteatoma after spontaneous healing of a tympanic membrane perforation by blast, and revue the literature about this etiology of cholesteatoma.

CASE REPORT

We report the case of a 38 year-old man with a history of bilateral blast injury trauma 4 years earlier. The blast caused a bilateral tympanic perforation. The right tympanic membrane healed spontaneously and a left tympanic perforation remained. A cholesteatoma was encountered on the right side, behind a scared tympanic membrane, during preoperative imaging study for surgery for the left side. The literature describes an incidence of 3 to 12% cholesteatoma after blast injury, rarely behind a closed tympanic membrane. We discuss the best imaging methods to detect cholesteatoma in these cases.

CONCLUSIONS

After a blast injury, a cholesteatoma may arise behind a spontaneously healed tympanic membrane. For this reason, spontaneous healing of the perforation does not mean the end of the follow-up. It is essential to plan a follow-up with imaging test one year after the blast trauma. We consider that in cases of traumatic tympanic membrane perforations due to blast injury with spontaneous healing of the perforation, HRCT scan offers a better diagnostic performance and a higher spatial resolution for cholesteatoma detection (as it relates to an aerated mastoid and tympanic cavity) than DW MRI. Furthermore, it is available in the great majority of health centers.

[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.

[Cholesteatoma by osteoma of the external auditory canal]

Osteoma in the external auditory canal (EAC) is an uncommon benign tumor. The association of a cholesteatoma with an osteoma of EAC is extremely rare. We report a case of a 26-year-old woman with an osteoma of the left EAC that was complicated by a cholesteatoma in the EAC between the osteoma and left tympanic membrane. Surgical removal of the osteoma and cholesteatoma proved successful by postauricular approach. The follow up without recurrence is 24 months. Osteoma of the EAC is a solitary, unilateral, and slow-growing bony benign tumor. The foremost differential diagnosis is exostose that is multiple and bilateral. Cholesteatoma of the EAC is uncommon. Its basic pathogenesis is a chronic occlusion of the EAC. Surgical treatment avoids complications related to local aggressiveness of cholesteatoma.

[Revision surgery for chronic otitis media: evaluation of indications and results]

OBJECTIVES

In patients who underwent primary and revision surgery for chronic otitis media, the types of revision surgery, most frequently observed regions of cholesteatoma, hearing results and the status of graft membrane were evaluated.

PATIENTS AND METHODS

Forty-three of 495 patients (21 males, 22 females; mean age 38.4+/-15.2 years; range 15 to 76 years) with chronic otitis media who underwent revision surgery in our clinic between May 2003 and March 2009 were evaluated retrospectively. Indications for revision surgery were recurrence of the disease in 32 patients (74.4%) and reconstruction of hearing in 11 patients (25.6%). Forty patients (93.0%) underwent revision surgery once and three patients (7.0%) underwent revision twice. Over an average of 3.2 (range 1 to 6) years follow-up after primary and revision surgery, the types of revision surgery, the most frequently observed regions of cholesteatoma, hearing results and the status of graft membrane were assessed.

RESULTS

Recurrence of cholesteatoma in revision surgery was seen in 28 patients (65.1%). Out of 27 patients, 23 patients (85.1%) showed intact graft membranes and four patients (14.8%) showed perforated graft membranes.

CONCLUSION

In revision surgery, the first goal is to eliminate the disease. The management of chronic otitis media with cholesteatoma is surgery. Because of high postoperative recurrence rates, long-term follow-up is necessary.

External auditory canal cholesteatoma: a rare complication of tympanoplasty

The author describes a rare case of external auditory canal cholesteatoma. This particular case occurred in a 20-year-old woman who had undergone a tympanoplasty 1 year earlier. Previous tympanoplasty is one of several known predisposing factors for external auditory canal cholesteatoma. The mass was excised, and it was diagnosed on histopathology. The patient recovered uneventfully.

Functional effects of repeated pressure loads upon the tympanic membrane: mechanical stiffness measurements after simulated habitual sniffing

In experimental studies it was found that otitis media causes stiffness loss in the tympanic membrane, possible precursors to retraction pockets and cholesteatoma. Besides otitis media habitual sniffing behaviour is associated with the development of retractions. The present study aims to test the hypothesis that repeated sniffing manoeuvre may cause not only structural, epithelial tympanic membrane changes presumed to be possible precursors to retractions, but also tympanic membrane stiffness loss, another possible mediator for the development of retractions. An experimental model with a pressure chamber was used to mimic the pressure conditions for the tympanic membrane in habitual sniffers' ears. The stiffness properties of twelve Mongolian gerbil tympanic membranes were measured with moiré interferometry after varying time up to 12 days with repeated pressure loading. Three days later, lower overall displacement were obtained in two ears; after 7-12 days the displacement readings were normal. This study with maximum of 12 days of pressure loading did not verify the hypothesis that habitual "sniffing" impairs the stiffness of the tympanic membrane.

Magnetic resonance imaging of cholesteatoma: an update

OBJECTIVE

To report on the value and limitations of new MRI techniques in pre- and post-operative MRI of cholesteatoma. The current value of magnetic resonance imaging (MRI) in diagnosing congenital, acquired, and post-operative recurrent or residual cholesteatoma is described.

METHODOLOGY AND RESULTS

High resolution computed tomography (HRCT) is still considered the imaging modality of choice for detecting acquired or congenital middle ear cholesteatoma. However, MRI may provide additional information on the delineation and extension of cholesteatoma and on potential complications. Detecting post-operative residual or recurrent cholesteatoma with HRCT was shown to be inaccurate due to the technique's low sensitivity and specificity.

CONCLUSIONS

Recently, improvements in MRI techniques have led to a more accurate diagnoses of cholesteatoma using delayed contrast enhanced T1-weighted imaging and diffusion-weighted imaging.

Cholesteatoma--diagnosing the unsafe ear

BACKGROUND

Cholesteatoma represents the most common destructive disease of the ear, affecting the adult and paediatric population alike.

OBJECTIVE

This article describes the pathogenesis of cholesteatoma and provides a guide to the examination and management of this common disease.

DISCUSSION

Despite advances in surgery and imaging, the diagnosis of cholesteatoma is often delayed. A favourable outcome following treatment of a cholesteatoma rests in part on an early diagnosis, and in reducing significant complications and associated morbidity. Primary care physicians should maintain a high index of suspicion for the presence of cholesteatoma, awareness of otoscopic findings and promptly refer for investigations and management.

Diagnosis of pediatric cholesteatoma

Cholesteatomas are abnormal collections of squamous epithelium and keratin debris that usually involve the middle ear and mastoid. Although histologically benign, they have the ability to expand and destroy bone. Cholesteatomas are treated surgically. The success of such surgery is highly dependent on the extent of the lesion. This article presents information and images to aid the general pediatrician in the early recognition of cholesteatomas, both congenital and acquired, in hopes of improving the outcome for children with this treatable disorder.

Séquelles otologiques dans les fentes palatovélaires. Analyse et prise en charge

As early as in 1878, medical teams managing children born with a velopalatine cleft had noted the prevalence of middle-ear pathologies largely related to anatomic and inflammatory Eustachian tube dysfunction. The aim of this study was to describe otologic sequels related to a velopalatine cleft and to suggest an adapted management. These sequels are evolving presentations of chronic serous otitis; they worsen the functional prognosis (hypoacousia) and more rarely the vital prognosis (cerebral or infectious complications of cholesteatoma). We must stress the importance of prevention: during the initial management, by Eustachian tube rehabilitation, and by ENT (Ear, Noseand Throat) follow-up allowing to prevent these sequels and to bring hearing to normal as soon as possible, so as to support cognitive development, language skills, and sociofamilial integration of the children.

Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma

Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.

[Post-traumatic cholesteatoma of temporal bone]

Posttraumatic cholesteatoma of the middle ear is a rare condition that may present years after temporal bone fracture. We present the 36 years old woman with acquired cholesteatoma of the middle ear and perilymphatic fistula six years after a temporal bone fracture. CT scan was extremely helpful in determining the sites of fracture and fasioning the surgical approach. The middle ear was cleaned with cholesteatoma, perilymphatic fistula was sealed with 3 layers of tissues and the ossicular chain was reconstructed in one stage. The presence of fracture lines in temporal bone years after trauma may prove hindered healing, which promotes migration of epithelium from external ear canal into the middle ear. We recomend long term follow-up in any patient with longitudinal temporal bone fracture with CT for any new otologic complaints.

Clinico-epidemiological study of complicated and uncomplicated chronic suppurative otitis media

INTRODUCTION

This study aimed to compare the clinical and epidemiological profiles of cases of complicated and uncomplicated chronic suppurative otitis media, based on their prognostic factors.

MATERIALS AND METHODS

This was a prospective, cross-sectional study conducted in a tertiary care medical college hospital over a period of two and a half years. The study group comprised 187 ears, out of which 62 had complications while 125 did not. The two groups were compared with respect to nine prognostic variables: age distribution, sex, patient's domicile, literacy status, duration of ear discharge at presentation, ear pathology, predisposing disease focus in the nose or throat, ear swab microbiology, and hearing loss.

RESULTS

Patients in the complicated chronic suppurative otitis media group had a higher male predominance and were younger. Rural and illiterate patients had a higher risk of developing complications. Cholesteatoma and granulation tissue were potential risk factors in the complicated chronic suppurative otitis media group. Ears with complications were more prone to develop sensorineural hearing loss. Age, sex, duration of ear discharge, predisposing disease focus in nose or throat, and ear swab microbiology were all less useful prognostic indicators of complications.

CONCLUSION

Early detection and timely treatment of chronic suppurative otitis media in rural and illiterate patients may prevent life-threatening complications and reduce their incidence. Ears that harbour relatively large quantities of both cholesteatoma and granulation tissue together require more urgent surgical intervention and more extensive disease clearance in order to prevent complications.

Complications of chronic otitis media and cholesteatoma

The incidence of complications of chronic otitis media and cholesteatoma has decreased since the proliferation of antibiotics early in the twentieth century. However, these complications continue to occur, and can be lethal if they are not identified and treated properly. Therapy for the complications associated with chronic otitis media, unlike that of acute otitis media, usually involves surgical intervention. As medical (antibiotic) therapy continues to improve, and new imaging techniques are introduced, less invasive treatment modalities may be shown to be as effective as the classic, time-tested, surgical options.

Revision mastoidectomy

The first three priorities in surgery for chronic otitis media are (1) the elimination of progressive disease to produce a safe and dry ear, (2) modification of the anatomy of the tympanomastoid compartment to prevent recurrent disease, and (3) reconstruction of the hearing mechanism. The indications for revision following mastoidectomy for chronic otitis media thus involve failure to achieve any of these goals, including recurrent cholesteatoma, recurrent suppuration, recurrent perforation, or recurrent or residual conductive hearing loss. The focus of this article is the management of recurrent cholesteatoma or suppuration; that is, failure to achieve either of the first two priorities.

Middle ear injury through the external auditory canal: a review of 44 cases

We performed a retrospective review of 44 patients with middle ear injury incurred through the external auditory canal. Twenty-two of the 44 patients had presented to our center within 1 month of their injury (early group), and 22 presented later (delayed group); the mean interval from the time of the trauma to presentation was 6 days in the early group and 7 years in the delayed group. The causes of injury were penetrating trauma (70% of cases), thermal insults (20%), and explosive and nonexplosive blasts (9%). Purulent otorrhea, cholesteatoma, and ossicular discontinuity were more common in the delayed group. Otologic surgery was required in 9 early-group patients (41%) and in all 22 delayed-group patients (100%). Two patients in the early group developed a dead ear. The mean pure-tone averages (PTAs) at presentation were 30.7 and 52.2 dB in the early and delayed groups, respectively; after management, the corresponding mean PTAs were 21.0 and 42.5 dB. The respective mean air-bone gaps in the two groups were 14.6 and 28.2 dB at presentation and 8.0 and 17.2 dB after management. We conclude that middle ear injury incurred as a result of trauma sustained through the external auditory canal is associated with considerable morbidity. Patients who present in a delayed fashion have significantly poorer hearing at presentation and after management. Patients who do not develop a dead ear generally derive benefit from reconstruction of the middle ear sound-conduction mechanism.

Family cluster of cholesteatoma

Objective: We report an extremely rare case of family clustering of cholesteatoma.

Method: Case reports and a review of the world literature concerning cholesteatoma and heredity are presented.

Results: The family consists of parents and seven siblings of whom the mother and three sons have been surgically treated for cholesteatoma. All cholesteatomas in the family are acquired and all have a history of otitis media. Cholesteatomas occur with an incidence of 5/100 000 in Greenland, corresponding to two to three new cholesteatoma patients per year among the 57 000 inhabitants of Greenland. The family is very exceptional and interesting for further research concerning heredity in the pathogenesis of acquired cholesteatoma.

Conclusion: To our knowledge this is the first report in the world literature of family clustering of acquired cholesteatoma. This case indicates that hereditary factors interplay with other factors in the pathogenesis of cholesteatoma.

Iatrogenic cholesteatoma in children with OME in a training program

PURPOSE

To report the occurrence of cholesteatoma following myringotomy and insertion of ventilating tube (VT) in a residency training program.

MATERIALS AND METHODS

Nine hundred and eighty-four children who were operated for grommet insertion with or without adenotonsillectomy during the year 1999-2003 were included in the study. Children were divided into two groups: group 1 (648 children) operated by residents and group 2 (305 children) operated by consultant. All procedures were carried out under general anesthesia using Ziess operating microscope. Shah ventilating tubes were used in most cases and Goody T tube in some others.

RESULTS

Nine ears developed cholesteatoma, six with perforation and three with pearl cholesteatoma cyst and intact tympanic membrane. The rate of iatrogenic cholesteatoma occurrence was 0.62% when done by residents (group 1) and 0.33% when operated by consultants (group 2). The overall prevalence was 0.48%.

CONCLUSION

Iatrogenic cholesteatoma occuring as a complication following VT insertion is not uncommon. It occurs more often following surgery done by inexperienced surgeons. Excessive manipulation may cause meatal wall and drum surface epithelium injury. This epithelium might be pushed with the VT into the middle ear.

Cell cycle inhibitory protein p27 in human middle ear cholesteatoma

AIM

To evaluate the immunohistochemical and molecular presentation of protein p27 in cholesteatoma.

METHODS

42 cholesteatoma samples and 6 external ear canal skin (EECS) specimens were investigated and analyzed taking into consideration congenital, acquired, recurrent cholesteatoma, and EECS.

RESULTS

The expression of p27 was found in 16 (38.1%) out of 42 specimens of cholesteatoma and in 5 (83.3%) out of 6 specimens of EECS. There was a significant difference in p27-positive staining rate between EECS and cholesteatoma epithelium (p < 0.008). The presence of p27 was detected in 10 cases of acquired cholesteatoma, 2 cases of congenital and 3 cases of recurrent cholesteatoma. There was no significant difference between the presence of p27 in cholesteatoma and EECS (p = 0.01).

CONCLUSION

The down-regulation of p27 is a key player in cell cycle control and plays an undefined role in the pathogenesis of all types of cholesteatoma.

Toll-like receptors 2, 3 and 4 (TLR-2, TLR-3 and TLR-4) are expressed in the microenvironment of human acquired cholesteatoma

Human toll-like receptors (TLR 1-10) are crucial in the induction and activation of innate immunity in the course of an infection. They are expressed mainly on the cells of the immune system, and also on some epithelia and endothelia. Their ligands so called pathogen associated molecular patterns are abundant on invading microbes. TLR-ligand binding results in cell signal transduction and subsequent production of various proinflammatory cytokines such as IL-1 and TNF-alpha. Acquired cholesteatoma is formed during chronic otitis media in the proportion of cases. It has adverse effects on ear structures, resulting in osteolysis and bone resorption. Its formation and pathogenesis are not fully understood. The current study attempted to search the possible role of TLRs in this somewhat awkward pathological condition. Surgical specimens of human acquired cholesteatoma (n=15) and normal external auditory canal skin (n=5, control tissues) were tested by immunohistochemistry for the presence of TLRs. Three TLRs were examined: TLR-2, TLR-3 and TLR-4. All TLRs tested were demonstrated in matrix (layer of keratinizing epithelium) and perimatrix (granulation tissue) of this inflammatory tumour. Expression of particular TLRs within the keratinizing epithelium was distinct and uneven. In the perimatrix, numerous T (CD3+) cells were seen and relatively few macrophages (CD11c+, HLA-DR+). There was a weak expression of all TLRs on normal (non-inflammatory) skin. Expression of TLR-3 both on the epithelium and some cells within the perimatrix and the presence of T cells may suggest that apart from innate immune responses, mechanisms of adaptive immunity also operate in cholesteatoma. Weak expression of these receptors on normal skin may also suggest the important role of TLRs in the etiopathogenesis of cholesteatoma.

Apoptosis in the pathogenesis of cholesteatoma in adults

The aim of this study was to determine the distribution and apoptotic capacity in the various layers of cholesteatoma epithelium compared to the normal skin. Cholesteatomas were collected during surgical procedures of the ear. Normal skin specimens taken from the retroauricular area served as controls. Apoptosis was detected by using highly specific antibodies against APO2.7 antigen. The Membstain Apoptosis kit Direct based on in situ labeling of nuclear DNA fragmentation (Tolt-mediated dUTP nick and labeling TUNEL staining) was used. The distribution of apoptotic cells in the layer of the cholesteatoma epithelium and the epidermis was determined. The percentage of apoptotic cells was then counted per 100 cells of cholesteatoma epithelium and the normal epidermis in three different areas of each section and expressed in terms of mean +/- SD. An automatic analyzing system was used for counting. In normal epidermis, the apoptotic cells were observed in the granular layer of the epidermis. The percentage of these cells was 28.5 +/- 8.1%. A significantly greater number of apoptotic cells was observed in the suprabasal layers of the cholesteatoma epithelium (47.39 +/- 6.2%). A statistically significant difference was obtained for APO2.7-positive cells in the cholesteatoma epithelium as compared to the skin (P < 0.05) as determined by Student's t-test and the Mann-Whitney U test. Apoptotic activity is mainly observed in the suprabasal layer of cholesteatoma epithelium. It is not seen in the basal layer. Apoptosis plays an important role in the pathogenesis of cholesteatoma. It seems to be part of the differentiation and accumulation of keratin debris within the middle ear and expansion of cholesteatoma.

Some considerations about acquired adult and pediatric cholesteatomas

Authors debate about cholesteatomas, from the first time this word was employed, by Muller, in 1838, until the recent updates. They dissert about its definition, etiology and pathology and present basic concepts about its biology. They also make a wide review about pediatric cholesteathoma, its epidemiology and biology, and compare it with adult cholesteatoma. Finally, they describe some articles about ossicle chain erosion and its correlation with cholesteatoma perimatrix, collagen and collagenase.

Mastoid subperiosteal abscess: a review of 51 cases

OBJECTIVE

To present a large study on subperiosteal abscess (SA) that represents the most frequent complication of acute mastoiditis.

METHOD

A retrospective study was conducted on 49 patients who underwent mastoidectomy for SA.

RESULTS

The patients ranged in age from 8 months to 21 years. Two patients were re operated on the same side due to recurrent abscess. Forty-five percent of the patients were treated using antibiotics at home and 58.8% of patients had no history of middle ear infection prior to admission. CT underestimated abscess in two patients who were operated on based on their clinical signs. Perisinus abscess was drained during mastoidectomy in one child. Purulent discharge was obtained from the abscess in 41 cases. The most common isolated pathogens were Streptococcus pyogenes and Staphylococcus aureus. Cholesteatoma was found during mastoidectomy in six patients (11.3%). Twenty-four patients (49%) developed postoperative sequela including various middle ear infections, mastoiditis, recurrent SA and impaired hearing.

CONCLUSIONS

Mastoid SA is a unilateral mainly children's disease that can recur. Cholesteatoma can associate the abscess and could be found in older children and recurrent abscess. High morbidity rate requires long-term follow-up for these patients.

Evaluation of Attic Retraction Pockets by Microendoscopy

OBJECTIVE

Attic retraction pockets (RPs) are one of the important sequelae of otitis media with effusion and are classified on the basis of the findings of otoscopy or otomicroscopy. It is unclear when and how RPs turn into cholesteatomas. We compared the findings of RPs obtained with the use of a microendoscope with those from an otomicroscope to determine the extension of RPs.

STUDY DESIGN

Comparative study.

PATIENTS

Twenty-seven attic RPs (Tos type III or IV) and 10 precholesteatomas previously classified under an otomicroscope were reexamined.

MAIN OUTCOME MEASURES

A high-resolution, fine, rigid microendoscope with an outer diameter of 1.0 mm was used to observe the extension of a retraction. In addition, to confirm the extent of the RP, computed tomography (CT) scans using water as the contrast media were performed in representative cases.

RESULTS

Endoscopy with the microendoscope revealed that in 59%, the RP was deeper than indicated by the initial otomicroscopic estimation, suggesting that the extension of the RP was underestimated. The findings of water-enhanced CT scans were comparable with the endoscopic findings. The bottom was observable with the microendoscope and the otomicroscope in 20 (74%) and 11 (41%) of 27 RPs, respectively. Seven ears had a deeper RP, which extended beyond the incudomallear joint. Of the 10 precholesteatoma cases, in which the bottoms were not visible with an otomicroscope or conventional endoscopes, the microendoscope revealed the bottom in 5 (50%).

CONCLUSION

On the basis of the observations of our study, we suggest that reexamination of cases of RP classified as Tos type III or IV, preferably with a microendoscope, if available, and assessment of the depth of the RP using water-enhanced CT, would be useful and that careful follow-up is necessary for deep RPs because of a potential risk of development into cholesteatoma.

A new experimental model of acquired cholesteatoma

OBJECTIVE

Cholesteatoma is a recurrent disease that is difficult control by otologists. This study aims to develop an experimental model of cholesteatoma that is easy to reproduce, using latex to induce the inflammatory reaction and propylene glycol as the foreign body in the middle ear.

STUDY DESIGN

We used a new experimental model in which an intentional perforation was performed on the tympanic membrane of rats, followed by the introduction of a latex biomembrane.

METHODS

A control group was submitted only to perforation of the tympanic membrane. Propylene glycol with latex was used in experimental group 1 and latex alone in experimental group 2. The rats were killed during the eighth week and their tympanic bullae were stained with hematoxylin and eosin.

RESULTS

Eighty percent of the animals in group 1 and 90% in group 2 developed a cholesteatoma. No formation of cholesteatomas or inflammatory tissue occurred in the control group.

CONCLUSION

The presence of inflammatory cells may provoke the production of cytokines (IL-1, IL-2, IL-6, IL-8) and growth factors, which, together with the latex biomembrane, which is known to contain a protein that favors vascular growth, may cause chemotactic migration of the squamous epithelium from the external auditory meatus to the middle year of the rat, causing a cholesteatoma. The induction of an experimental cholesteatoma in rats with latex and latex plus 50% propylene glycol was effective, representing an excellent experimental model. The theory of epithelial migration in the genesis of cholesteatomas was confirmed by our observations in rats. The latex induced an acute and chronic inflammatory reaction when in contact with the mucosa of the middle ear.

Course and long-term outcome of 'refractory' secretory otitis media

OBJECTIVE

The course and the long-term outcome of 'refractory' secretory otitis media (SOM), defined as continuous SOM for more than 6 years, were studied in 52 young patients. They had during childhood been treated for bilateral SOM on average for 12 years (range 6 to 26 years). The mean interval between resolution of SOM and examination was 7 years.

METHODS

At follow up the patients' medical records were scrutinized with regards to transmyringeal ventilation tubes, adenoidectomy, sequelae and complications, and a questionnaire was filled in to document other diseases.

RESULTS

The onset of SOM showed two peaks, one at the age of one year and one at the age of 3.5 years. Patients whose onset of SOM was related to an episode of acute otitis media (AOM) were younger at SOM onset than those who had no such relation. Otorrhoea and AOM episodes were more frequent during the SOM periods, with blocked or expelled tubes, than during periods with patent tubes. Cholesteatoma were seen in 3 per cent and perforations in 5 per cent of patients.

CONCLUSIONS

Extremely long-standing SOM does not necessarily result in myringeal perforation or cholesteatoma to a greater extent than that seen in patients with shorter durations of SOM. However, at follow up one-third of the patients reported hearing impairment and a majority felt discomfort when flying or diving.

Cytokeratin expression pattern in congenital and acquired pediatric cholesteatoma

Pediatric cholesteatoma can be classified as congenital or acquired based on clinical criteria. We studied the expression patterns of five distinctive cytokeratins in both types of cholesteatoma in order to improve understanding of their pathogenesis and origin. A comparable expression pattern for CK10, CK14, CK18, CK19 and 34betaE12 antigens was found in the matrix of congenital and acquired pediatric cholesteatoma. Our results demonstrate that congenital and acquired pediatric cholesteatoma exhibit an identical cytokeratin distribution pattern, suggesting that they share a common origin. Therefore, it seems possible that a portion of the so-called "acquired" cholesteatoma may actually originate from advanced congenital cholesteatoma with secondary destruction of the tympanic membrane in the pediatric patient population.

[Expression of hypoxia-inducible factor-1alpha in middle ear cholesteatoma]

OBJECTIVE

To explore the pathogenetic mechanism of middle ear cholesteatoma, the aim of this study is to detect the expression of Hypoxia-inducible factor-1alpha in middle ear cholesteatoma and normal external ear canal skin.

METHOD

We used the technology of immunohistochemistry to examine the expression of Hypoxia-inducible factor-1alpha in thirty-one middle ear cholesteatomas and ten samples of normal external ear canal skin.

RESULT

The expression of HIF-1alpha was extremely higher in middle ear cholesteatomas than in normal external ear canal skin (P <0.05).

CONCLUSION

We found that the higher expression of Hypoxia-inducible factor-1alpha in middle ear cholesteatomas, so we think that Hypoxia-inducible factor-1alpha play an important role in the pathogenetic process of middle ear cholesteatoma, and hypoxia may be an incentive in the pathogenetic mechanism of middle ear cholesteatoma.

Subjective evaluation of post-tympanoplasty hearing in relation to the pure tone threshold

OBJECTIVE

In the year 2000, the Otological Society of Japan proposed a new criteria to assess the levels of hearing known as Criteria 2000. However, these criteria are intended to assess pure tone threshold after tympanoplasty and the results do not necessarily reflect the hearing condition from the patient's perspective. Thus, it is essential to study the relationship between the subjective evaluation of post-operative hearing based on the patient's own assessment and the objective assessment by audiometry.

METHODS

The present study is a questionnaire-based survey on the levels of post-operative hearing in 460 patients whose degree of satisfaction with their levels of hearing was assessed by visual analogue scale (VAS). The hearing level was assessed based on the Criteria 2000 established by the Otological Society of Japan.

RESULTS

The post-operative results indicated a success rate of 78.7%. According to the questionnaire-based survey, 64.4% patients considered their hearing as "improved". The average VAS score was the highest in the "improved" group and gradually decreased when in the "deteriorated" group. The highest success rate was obtained in patients who assessed their hearing as "improved" and the lowest rate was seen in those who assessed their hearing as "deteriorated". On the other hand, the success rate in the three groups, "slightly improved", "unchanged", and "slightly deteriorated", was almost similar and did not relate to the objective audiometry findings. Therefore, except for the "improved" and deteriorated" groups, there is no relation between the subjective self-assessment and the objective post-operative hearing.

CONCLUSION

A bi-directional approach, one from an audiological (objective) and one from the patient's perspective (subjective), especially using VAS, is quite useful for the post-operative assessment of hearing.

Otologische Befunde von Erwachsenen mit isolierter Gaumenspalte oder Lippen-Kiefer-Gaumen-Spalte

BACKGROUND

Children with cleft palate often develop middle ear ventilation disorders due to chronic Eustachian tube dysfunction. This may lead to hearing loss. The insertion of ventilation tubes is a widely accepted measure to avoid sequelae of middle ear ventilation disorders and hearing loss. On the other hand, long-term therapy with ventilation tubes may inflict iatrogenic complications. The objective of the study was the evaluation of otoscopic and audiometric long-term findings in adult cleft patients who had been treated with ventilation tubes since childhood when chronic otitis media with effusion had been observed.

PATIENTS AND METHODS

Ninety-two cleft palate patients had been followed up otoscopically and audiometrically for years. The average age was 19.3 years (minimum: 14, maximum: 39 years) at the time the last status was taken.

RESULTS

Otoscopy revealed a perforation of the tympanic membrane in 3.8% of the 184 ears. 12% of the patients developed cholesteatoma, however three quarters of these occurred after age 11. 86.4% of the 92 patients had normal hearing in pure tone audiometry.

CONCLUSION

Compared with adult cleft patients who did not receive ventilation tubes, our patients had a similar low incidence of eardrum perforations but a higher incidence of cholesteatomas while hearing loss occurred less often. Whether the higher incidence of cholesteatomas is caused iatrogenically or due to a longer follow-up period remains unclear. Whether the use of long-lasting ventilation tubes affects the incidence of cholesteatomas must be proved in further studies.

[Cholesterol granuloma media: 8 cases report]

OBJECTIVE

To investigate the etiology, pathogenesis diagnosis and therapy of cholesterol granuloma media.

METHOD

Eight cases (9 ears) of middle ear cholesterol granuloma were retrospectively reviewed. Nine ears all have a speciality of conductive deafness with a light to middle level, blue eardrum and tympanogram all showing B type (except one case of eardrum perforation in the tension part). Seven cases (8 ears) were cured by tympanic cavity exploration opening epitympanum, tympanic antrum, mastoid cells and thoroughly eliminating granulation tissue. Grommet insertion and modified radical mastoidectomy were performed on 5 cases and 2 cases, respectively. The other one case was only carried out with eardrum puncture.

RESULT

Seven cases (8 ears) after operation were followed up for six monthes to six years. Six cases (7 ears) were cured out without recurring; one case (1 ear) recurred. One case was not followed up.

CONCLUSION

Otoblennorrhea of blood without obvious reason and blue eardrum should be coupled with CT to enhance the diagnosis rate before operation. CG should be treated by operation to clean disease location, air and drainage tympanicus cavity and mastoid.

Proliferation activity and apoptosis in granulation tissue and cholesteatoma in middle ear reoperations

The aim of the study was to find out the potential prognostic value of proliferation activity and apoptosis in cholesteatoma and granulation tissue removed during middle ear reoperation in recurrent middle ear inflammation. Granulation tissues and recurrent cholesteatoma were analysed after being surgically removed from the middle ear in a group of 25 patients qualified for middle ear reoperation procedure. Paraffin sections were stained with haematoxylin and eosin according to Mallory's method. Immunohistochemical reaction Anti-PCNA was performed. Apoptosis was evaluated using the TUNEL method. The percentage of PCNA-positive cells was 42-95% in the matrix of the cholesteatoma and 29-81% in the perimatrix. In the granulation tissue it was 35-75%. The percentage of apoptotic cells was 12-73% in the matrix of the cholesteatoma, 5-72% in the perimatrix and 1-65 % in the granulation tissue. The prognostic value of the parameters studied in the recurrent middle ear inflammatory process is questionable, probably due to the small number of cases under examination.

Etiopathogenesis of cholesteatoma

Cholesteatoma is a destructive lesion of the temporal bone that gradually expands and causes complications by erosion of the adjacent bony structures. Bone resorption can result in destruction of the ossicular chain and otic capsule with consecutive hearing loss, vestibular dysfunction, facial paralysis and intracranial complications. Surgery is the only treatment of choice. The etiopathogenesis of cholesteatoma, however, is still controversial. This review was designed to understand the reasons for these disparities and to reduce or eliminate them. Future studies focused on developmental, epidemiological, hormonal and genetic factors as well as on treatment are likely to contribute to further understanding of cholesteatoma pathogenesis.

Mastoid and Tympanic Membrane as Pressure Buffers: A Quantitative Study in a Middle Ear Cleft Model

HYPOTHESIS

The tympanic membrane (TM) and mastoid air cells are measurable pressure buffers of the middle ear (ME).

BACKGROUND

Pressure homeostasis of the ME is maintained approximately atmospheric by mechanisms that neutralize (buffer) pressure fluctuations, two of which are the TM and mastoid.

MATERIALS AND METHOD

Negative pressures were induced by volume changes in an artificial ME model. Those were recorded directly while using a rigid or a flexible TM with "mastoids" of various sizes.

RESULTS

In the rigid TM model, the volume changes correlated linearly with the induced pressures and were confirmed to fit Boyle's law. In the flexible TM model, the pressure/volume correlation was nonlinear up to -50 mmH2O, where the TM was maximally displaced (approximately 25 mm3), became rigid, and constituted 75%, 41%, and 33% of the buffering gained in tandem with the "mastoid" in a model having a "mastoid" of 0, 5, and 10 mL, respectively. Altogether, a large "mastoid" required a greater volume change than a small one to induce the same pressure.

CONCLUSIONS

The mastoid air volume "dilutes" pressure changes relatively to its size: the volume change required to alter a given pressure in an average (6 mL) mastoid is six-fold that which is needed in a small (1 mL) mastoid. ME volume reduction by TM retraction buffer negative ME pressures. This maximal ME volume change is constant for a "normal" TM. Therefore, it is the ME with the small mastoid that is most vulnerable to pressure changes and may develop compensatory buffering mechanisms, e.g., additional TM retraction (atelectasis) and/or ME volume reduction by fluid accumulation.

[Sinus tympani in surgery of the middle ear and skull base]

Tympanic sinus is located at the medial wall of the tympanic cavity. It's visualisation is difficult from most of approaches. Tympanic sinus is often filled with cholesteatoma in course of chronic otitis. Intraoperative assessment of tympanic sinus was performed in 29 patients with facial recess cholesteatoma, and in 20 patients with acoustic neuroma operated with translabyrinthine approach. In the group of patients with cholesteatoma four patients underwent canal wall up tympanoplasty with posterior tympanotomy, 25 underwent canal wall down tympanoplasty. Tympanic sinus was assessed during surgery with 30 degrees endoscope. In all cases depth of the sinus was measured with the use of calibrated hook. In 11 patients depth of the sinus exceeded 4 mm. In 6 among these features of bone destruction was found.

First branchial cleft sinus presenting with cholesteatoma and external auditory canal atresia

First branchial cleft abnormalities are rare. They may involve the external auditory canal and middle ear. We describe a 6-year-old girl with congenital external auditory canal atresia, microtia, and cholesteatoma of mastoid and middle ear in addition to the first branchial cleft abnormalities. Clinical features of the patient are briefly described and the embryological relationship between first branchial cleft anomaly and external auditory canal atresia is discussed. The surgical management of these lesions may be performed, both the complete excision of the sinus and reconstructive otologic surgery.