Clinical and Experimental Investigations of Spontaneous Impedance Changes of the Middle Ear

The major symptoms of glomus tympanicum tumors are pulsatile tinnitus and spontaneous impedance changes (SICs) of the middle ear. On the other hand, SICs often occur even in the absence of pathological findings. The aim of this study was to analyze the occurrence of SICs in patients and healthy volunteers. We retrospectively evaluated 184 patients with SICs and/or complaints of periodic tinnitus. Most of them (n = 134) showed pulse-synchronous SICs. Pathological findings were recorded in only 66 patients. Binaural SICs were registered significantly (p = .03) more frequently in patients with arterial hypertension (63% versus 18%). Because of the positive correlation between arterial hypertension and the occurrence of SICs, the influence of increasing blood pressure (systolic blood pressure > 160 mm Hg after physical activity) on the occurrence of SICs was investigated in a prospective trial in healthy test subjects (n = 42). In 17 of them, pulse-synchronous SICs occurred for the first time or were registered at a lower sensitivity level after an increase in blood pressure. In summary, only half of the patients with pulse-synchronous SICs showed pathological findings. a significant correlation between high blood pressure and binaural pulse-synchronous SICs was demonstrated in patients with arterial hypertension and healthy volunteers after physical activity.

The ‘red Ear Syndrome’ Revisited: Two Cases and a Review of Literature

The first description of what subsequently came to be known as the red ear syndrome (RES) was by Lance in 1994 (1) (Table 1, cases 2-4). Subsequently he reported a total of 12 patients with what he called the red ear syndrome (2) (Table 1). The syndrome was characterized by attacks of unilateral ear discomfort or burning during which the ear became red. The discomfort often extended beyond the ear. He reported an association with upper cervical disorders, glossopharyngeal and trigeminal neuralgia, temporomandibular joint (TMJ) dysfunction, and a thalamic syndrome. In two of the 12 cases (Table 1, cases 11 and 12) no cause was apparent. In some cases the episodes were spontaneous and in others they were precipitated by touch, exertion, heat or cold, neck movements, stress, cleaning the ear, washing hair or brushing it the wrong way, and eating or drinking. While some of their patients had a history of headaches (including migraines), a consistent relationship to migraine headaches was not identified.

URGENT X-RAY DIAGNOSTICS OF INTRACRANIAL PYOINFLAMMATORY OTORHINOSINUSOGENIC COMPLICATIONS

An analysis of the results of X-ray CT and MR-imaging was made in 46 patients aged from 13 to 78 years old. The patients were admitted to multifield hospitals in Kursk at the period from 2005 to 2015. The research included the nasal cavity, paranasal sinuses, mastoid and pyramid of the temporal bones and the brain. The study could be repeated with bolus contrast medium infusion. The condition of the patients was evaluated in dynamics at intervals of 5-7 days and these data was associated with clinical picture. The authors presents a complex of symptoms and an algorithm of differentiated X-ray diagnostics of diseases of the ENT organs and the main nosological forms of pyoinflammatory diseases of arachnoid membrane and substances of the brain.

HEAR MAPS a classification for congenital microtia/atresia based on the evaluation of 742 patients

OBJECTIVE

Describe anatomical and radiological findings in 742 patients evaluated for congenital aural atresia and microtia by a multidisciplinary team. Develop a new classification method to enhance multidisciplinary communication regarding patients with congenital aural atresia and microtia.

METHODS

Retrospective chart review with descriptive analysis of findings arising from the evaluation of patients with congenital atresia and microtia between January 2008 and January 2012 at a multidisciplinary tertiary referral center.

RESULTS

We developed a classification method based on the acronym HEAR MAPS (Hearing, Ear [microtia], Atresia grade, Remnant earlobe, Mandible development, Asymmetry of soft tissue, Paralysis of the facial nerve and Syndromes). We used this method to evaluate 742 consecutive congenital atresia and microtia patients between 2008 and January of 2012. Grade 3 microtia was the most common external ear malformation (76%). Pre-operative Jahrsdoerfer scale was 9 (19%), 8 (39%), 7 (19%), and 6 or less (22%). Twenty three percent of patients had varying degrees of hypoplasia of the mandible. Less than 10% of patients had an identified associated syndrome.

CONCLUSION

Patients with congenital aural atresia and microtia often require the intervention of audiology, otology, plastic surgery, craniofacial surgery and speech and language professionals to achieve optimal functional and esthetic reconstruction. Good communication between these disciplines is essential for coordination of care. We describe our use of a new classification method that efficiently describes the physical and radiologic findings in microtia/atresia patients to improve communication amongst care providers.

Applying one-vs-one and one-vs-all classifiers in k-nearest neighbour method and support vector machines to an otoneurological multi-class problem

We studied how the splitting of a multi-class classification problem into multiple binary classification tasks, like One-vs-One (OVO) and One-vs-All (OVA), affects the predictive accuracy of disease classes. Classifiers were tested with an otoneurological data using 10-fold cross-validation 10 times with k-Nearest Neighbour (k-NN) method and Support Vector Machines (SVM). The results showed that the use of multiple binary classifiers improves the classification accuracies of disease classes compared to one multi-class classifier. In general, OVO classifiers worked out better with this data than OVA classifiers. Especially, the OVO with k-NN yielded the highest total classification accuracies.

[Dehiscence of the superior semicircular canal: approach and CT scan classifications]

The syndrome of dehiscence of the superior semicircular canal (DCSS) is primarily associated with vertigo and/or hearing loss. The dehiscence may be completely asymptomatic and represent an incidental finding on radiological investigation.

OBJECTIVES

To demonstrate the advantages of a volume rendered CT study of the petrous temporal bone of patients with hearing loss, and to demonstrate the effectiveness of its systematic application in the protocols of examination. To propose a radiological classification of DCSS with a therapeutic application.

MATERIAL AND METHOD

The examination technique which was performed in incremental mode (axial and frontal sections) and in "volume rendered" mode, on a high resolution apparatus is described. The authors studied 154 scans of the petrous temporal bone obtained by this technique. They correlated the cases of DCSS with the indications for the radiological examination. Each 3d CT scan was studied and the type of fistula described. The authors propose a classification of fistulae into three types, depending on 3d CT scan appearance.

RESULTS

Out of 154 CT scans of the petrous temporal bone (77 patients), 13 cases of DCSS were discovered. DCSS was bilateral in 4 cases. The primary indication for investigation was the assessment of conductive or mixed hearing loss. The "volumetric" technique was compared with standard imaging techniques and/or reconstructed images in the superior canal plane. The correlation was perfect in all the cases. The description of the fistulae allowed a classification into 3 types: Type I (symmetrical fistula, 8 cases); Type II (asymmetrical fistula, 3 cases) corresponding to the canal dome; Type III (2 cases) involving the foot of the canal.

CONCLUSION

The increased frequency of DCSS in this series (prevalence of 17% against 0.5% in post mortem studies) is probably explained by the selection bias of the patients and also by the systematic application of this novel radiological technique. We propose to include this protocol in all CT scans of the temporal bone, particularly when investigating symptoms consistent with a syndrome of Minor or the Tullio phenomenom. This system of classification makes it possible to describe the fistula and to specify its location. This should prove to be a valuable aid for pre-operative planning and intra-operative localisation of the fistula.

The Erasmus atelectasis classification: proposal of a new classification for atelectasis of the middle ear in children

OBJECTIVES

Atelectasis presents a challenging, often progressive, problem in children. Because of the lack of a clinically practical classification, we introduce a new classification, which in our opinion is more useful in the pediatric age group. This alternative classification enables a more clinically relevant correlation between stage of disease and clinical sequelae and technical difficulty at surgery.

STUDY DESIGN

Observational study of patients seen and operated at the Sophia Children's Hospital in Rotterdam, The Netherlands between 1989 and 2005.

METHODS

Based on clinical appearance, each ear was placed into one of the five groups of the proposed classification and into one of the four stages of Sadé's classification. Preoperative air and bone conduction thresholds and air-bone gaps (ABG) were calculated using the four-tone pure-tone (500, 1,000, 2,000, and 4,000 Hz) averages for bone and air conduction.

RESULTS

: Of the 248 ears in the study group, 72 were in stage I, with an ABG of 18.2 +/- 12.3 dB. Twenty-two were in stage II, with an ABG of 12.9 +/- 9.5 dB. In stage III, there were 32 ears, with an ABG of 11.6 +/- 10.0 dB. Thirty-one ears were in stage IV, with an ABG of 16.1 +/- 11.5 dB. Eighty-five ears were in stage V, with an ABG of 26.1 +/- 13.3 dB. When grouped according to Sadé's classification, 92 ears could not be classified.

CONCLUSIONS

We found the currently proposed classification more useful in that it follows the natural progression of the disease and is more practical in determining operative procedures at each stage.

Medial canal fibrosis: surgical technique, results, and a proposed grading system

OBJECTIVE

To report the hearing and surgical results in patients with medial canal fibrosis. To describe the surgical technique for removal of medial canal fibrosis and to propose a classification for grading postoperative surgical outcome and to correlate this with hearing results.

SETTING

Tertiary university referral center.

STUDY DESIGN

Retrospective case review.

METHODS

Twenty-one patients with mature medial canal fibrosis underwent a total of 26 operations at our institution from February 1994 to June 2003. Four patients underwent surgery for bilateral disease and another had a second operation for recurrence.

RESULTS

According to the proposed grading system, 10 (38.5%) of the 29 ears operated on achieved a Grade I result (normal self-cleaning ears) and three (11.5%) had recurrence (Grade III). One patient was found to have external ear canal cholesteatoma. Postoperatively, 15 ears demonstrated closure of the air-bone gap to within 10 dB or improvement on four-frequency average pure-tone audiogram to better than 25 dB. The mean preoperative air-bone gap was 28.7 dB compared with 12.5 dB postoperatively (p < 0.001). When hearing results were correlated with postoperative grade, 90.0% of the ears with a Grade I result had significant hearing improvement, 46.2% in patients with Grade II and 33.3% in patients with Grade III results. Four patients complained of temporomandibular joint pain postoperatively.

CONCLUSION

Surgery remains the treatment of choice for mature medial canal fibrosis. With proper surgical technique and meticulous postoperative care, a patent and functioning external ear canal can be achieved in a majority of patients. Absence of recurrence does not equate with improved hearing thresholds.

Auditory symptoms in whiplash patients - could earwax occlusion be a benign cause?

BACKGROUND

Excess cerumen (earwax) in the external auditory canal is associated with symptoms of earache, fullness in the ears, and diminished hearing. These symptoms, and tinnitus, are commonly associated with whiplash injury.

METHODS

Eighty-six whiplash patients were examined to determine if there was a correlation between symptoms of earache, fullness in the ear, diminished hearing, and tinnitus, and the degree of cerumen occlusion. Cerumen occlusion was measured by visualisation of the tympanic membrane and graded according to a 4 point scale.

RESULTS

Of 71 subjects reporting no acute onset (within 7 days of the collision that caused their whiplash) earache, fullness in the ears, hearing loss, or tinnitus, 62 had little or no cerenum occlusion. Of seven subjects reporting tinnitus but no other auditory symptoms, none had greater than moderate cerenum occlusion. Of eight subjects reporting one or more of acute onset earache, fullness in the ears, diminished hearing, and tinnitus, seven had complete cerenum occlusion in the affected ear.

DISCUSSION

The findings suggest high grade cerumen occlusion frequently occurs in the ear affected by acute auditory symptoms. However, tinnitus alone has no apparent association with cerumen occlusion. It is possible that a significant number of acute onset auditory symptoms reported in whiplash patients have a benign cause.

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.

Classification of the External Auditory Canal Cholesteatoma

OBJECTIVES/HYPOTHESIS

The external auditory canal cholesteatoma (EACC) is a rare disease in the field of otolaryngology. Only 1 in 1,000 new otologic patients present with this entity, which was first described by Toynbee. The aim of this article is to classify EACC by different histopathologic and clinical findings of patients presenting to the Department of Otolaryngology at the University of Mannheim, Germany.

METHODS

From 2000 to 2004, 17 patients presented to our clinic with EACC. The cholesteatoma were treated surgically, and the specimens were investigated histologically. Clinical findings were also recorded. We classified four stages: stage I with hyperplasia of the canal epithelium, stage II including periosteitis, Stage III including a defective bony canal, and stage IV showing an erosion of adjacent anatomic structure.

RESULTS

Eight patients presented with stage II, five patients with stage III, three with stage I, and only one patient presented with erosion of the mastoid cells, which was determined as stage IV.

CONCLUSION

In summary, our classification serves to describe the different histopathologic and clinical stages of EACC.

The external ear: More attention to detail may aid syndrome diagnosis and contribute answers to embryological questions

The human pinna has a complex shape and yet the basic components of normal structure are remarkably constant between individuals. It is precocious in its appearance during embryogenesis and it has been subject to many developmental and surgical studies, yet questions remain as to its primary embryogenesis and the causes of its malformations. Unfortunately, the vast majority of clinical reports of syndromes and of individuals with dysmorphic signs provide limited and inadequate description of the external ear. Given the intricate pattern of the pinna, and hence its potential for morphological variation, we think that more attention to the specific description of ear anomalies may lead to a better appreciation of the etiology and embryology of the malformations. Furthermore, in some cases correlation with specific syndromes may provide an aid to diagnosis. Towards those ends this paper reviews some of the controversy concerning the embryology of the pinna, and discusses a number of the better-defined anomalies of the external ear. Although it has been suggested that anomalies of the insertion and orientation of intrinsic muscles of the pinna may be responsible for variations in external ear morphology, we think it likely that in many cases the anomalous insertions may be secondary.

Diseases of the ear pinna

In conclusion, there are a wide variety of dermatologic diseases that can affect the ear pinnae. Most of these disorders are manifestations of a generalized dermatosis. Therefore, when pinnal lesions are present, a thorough diagnostic workup is indicated.

Minimally Invasive Laser Contraction Myringoplasty for Tympanic Membrane Atelectasis*

OBJECTIVE: We sought to develop a minimally invasive surgical technique using the CO2 laser to reduce or eliminate tympanic membrane atelectasis in a select group of patients.

STUDY DESIGN: Thirty-seven ears with varying degrees of tympanic membrane atelectasis underwent CO2 laser myringoplasty with the patients under intravenous sedation in the operating room setting. Atelectasis severity was graded for each patient and documented before and after laser myringoplasty through photodocumentation. Patients were followed for 1 year with comparison tympanic membrane photography.

SETTING: The study was conducted in a tertiary care private otology-neurotology practice.

RESULTS: Laser myringoplasty significantly reduced retraction pocket severity in most patients. No patients required resection of the retraction pocket or tympanoplasty. The most favorable outcomes were observed in patients with atelectasis addressed early rather than later in its more advanced stages.

CONCLUSION: Laser contraction myringoplasty can reduce or eliminate atelectatic areas of the tympanic membrane through immediate contraction and “tightening” of the tympanic membrane tissues. Clinicians should use a standardized tympanic membrane atelectasis grading format.

SIGNIFICANCE: A minimally invasive surgical technique for addressing tympanic membrane atelectasis is described, and a tympanic membrane at-electasis grading system is presented based on size, location, and depth of the atelectatic region.

[Stenosis of the external auditory canal: etiology, classification and management]

Stenosis of the external auditory canal is uncommon, poly-etiological pathology of the external auditory canal. The management of stenosis of the external auditory canal is difficult because of re-stenosis and danger of postoperative complications. The purpose of this article is to present modern classification, etiopathogenesis of the external auditory canal stenosis, indications for the surgical management, some aspects of the surgical management, using the modern literature and clinical cases.

Congenital cholesteatoma: classification, management, and outcome

OBJECTIVES

To assess whether a classification system for congenital cholesteatoma (CC) can be derived from analysis of a large clinical sample of cases and to assess whether such a classification system is a reliable guide for surgical intervention, reexploration, and hearing outcome.

DESIGN

A retrospective review of clinical and surgical records of 119 patients with CC.

SETTING

Four tertiary care children's hospitals.

PATIENTS

One hundred nineteen children with CC (age range, 2-14 years).

RESULTS

Congenital cholesteatomas in the anterior mesotympanum were treated successfully with exploratory tympanotomy. Congenital cholesteatomas involving the posterior superior quadrant and the attic usually had concurrent involvement of the incus and stapes and often required a canal wall up tympanomastoidectomy and a second look for its control. Congenital cholesteatoma involving the mastoid usually involved all of the ossicles, was inconsistently controlled with canal wall up tympanomastoidectomy, and had a poor prognosis for restoration of conductive hearing loss. The mean +/- SD age of children with CC was 5.6 +/- 2.8 years, while that of children with acquired cholesteatoma was 9.7 +/- 3.3 years.

CONCLUSIONS

The sequence of spread of CC, involving 3 sites, suggests a natural classification system. The CC usually originates in the anterior superior quadrant, but does not consistently remain there, and may variably occupy the middle ear and mastoid and result in ossicular destruction and conductive hearing loss. The location of CC and the involvement of the ossicles is an accurate predictor of the type of surgery necessary for its control and for the success of hearing restoration.

Classification of patients on the basis of otoneurological data by using Kohonen networks

Machine learning methods such as neural networks, decision trees and genetic algorithms can be useful to aid in the classification of patients. We tested Kohonen artificial neural networks, which are known to be effective for classification tasks. Our sample included patients with six different diseases. The Kohonen network algorithm recognized the four largest groups reliably, but the two smallest groups were too small for the method. Neural networks seem to be promising for the computer-aided classification of otoneurological patients provided that the number of patients used is sufficiently large.

On classification capability of neural networks: a case study with otoneurological data

We investigated the capability of multilayer perceptron neural networks and Kohonen neural networks to recognize difficult otoneurological diseases from each other. We found that they are efficient methods, but the distribution of a learning set should be rather uniform. Also it is important that the number of learning cases is sufficient. If the two mentioned conditions are satisfied, these neural networks are similarly efficient as some other machine learning methods. The conditions are known in the theory of neural networks [1,2], but not often taken seriously in practice. Both networks functioned as well, excluding the case with several input variables, where the Kohonen neural networks surpassed the perceptron.

[Classification of the 1st and 2nd branchial arch syndromes]

1000 cases of the 1st and 2nd branchial arches syndrome and abnormalities of the floor of the auricle associated with this syndrome provided evidence for design of their classification.

Comparison of inference results of two otoneurological expert systems

In this paper, two different otoneurological expert systems, Vertigo and One, the latter developed by us, are considered. The expert systems are evaluated as regards their correctness in reasoning diagnoses. In the light of our data collected from randomly selected test patients, One, being a newer technique, is more effective, since it could infer more cases than vertigo did. All the data was also evaluated and diagnosed by otoneurological specialists, independently of the expert systems, to guarantee objectivity in evaluation of the results of the expert systems.

Pathogenesis of attic retraction pocket and cholesteatoma as studied by computed tomography

It is hypothesized that blockade of the tympanic isthmus causes isolation of the attic and the adjacent middle ear spaces and that subsequent building up of the negative pressure in these spaces results in retraction of the pars flaccida, leading to formation of attic retraction pockets and cholesteatomas. To examine this theory, computerized tomographic (CT) findings of these conditions were evaluated in a series of 53 ears with retractions of the pars flaccida (attic retractions of Tos type II or deeper), including both retraction pockets and cholesteatomas. In 26 of 28 ears with attic retraction pockets, at least a portion of attic was aerated, and in 22 of these 26 ears, the mastoid antrum was also aerated. In contrast, in the 25 cases with attic cholesteatomas, these numbers decreased to 10 and 5, respectively, and the lack of aeration of the attic was demonstrated in 15 of 25 (60%) of the cases. In three cases of cholesteatoma, follow-up CT revealed either growth of a cholesteatoma from a retraction pocket or development of a small cholesteatoma into a large one. In these ears it was seen that the well-pneumatized attic and mastoid antrum seen in the initial CT was depleted by the growth of cholesteatoma that took place over a period of 4 months to 2 years. These results, showing good patency of the aditus and a pneumatized antrum in early stages of most cases of retraction pockets and cholesteatomas, are not in agreement with the hypothesis that the blockade of the tympanic isthmus is responsible for the pathogenesis of retraction pockets and cholesteatomas originating in the pars flaccida.

[Vertigo and middle ear pathology]

The association of vertigo and diseases of the middle ear is not uncommon. It occurs especially during the course of chronic or acute otitis but can also occur as a sequela. Vestibular involvement is due to several pathophysiological mechanisms that influence the choice of treatment. The same is true for expansive processes of the tympanic cavity. When associated to otospongiosis, vertigo occurring during Ménière's disease can transiently contraindicate an operation on the tapes. On the contrary, vertigo resulting from traumatic lesion of the middle ear can suggest surgical intervention. Surgery of the middle ear can itself cause severe vertigo which sometimes requires a new operation. Lastly, the fortuitous association of disease of the middle ear with labyrinth disease, especially retrolabyrinthic such as eighth cranial nerve neurinome, is not uncommon, but can be long overlooked if it is not routinely suggested in the presence of labyrinth type symptoms.

[The Wittmaack temporal bone collection and possibilities for cataloguing with electronic data processing]

Karl Wittmaack, head of the otology department at Greifswald (1904-1908) and professor of otorhinolaryngology at the universities of Jena (1908-1925) und Hamburg (1926-1946) created a unique histological collection of human and animal temporal bones that is thought to be the largest of its kind in the world. The serial sections of more than 1700 human temporal bones still represent current otological problems--many of which are now rare but are still encountered--such as tuberculosis, lues or diphtheria of the ear. Complications following acute otitis--which were much more frequent and dangerous in the pre-antibiotic era--can be studied in detail. There are numerous cases of labyrinthitis, meningitis, sinus thrombosis, brain abscess etc.--complications which must always be borne in mind to this day. The same is true for tumors like acoustic neurinomas or even malignant tumors, metastases, or manifestations of leukemia. Differences in pneumatization or changes of the bone structure as in otosclerosis have been the subjects of studies dating from Wittmaack's time until very recently. In spite of its topicality, the true value of the collection has only be appreciated by a limited group of persons, which may be due in part to difficulties in orientation within this vast amount of material. Although there are catalogues, it may be difficult to find the appropriate preparations for particular questions. Searching for such specimens often requires rummaging through the whole collection, sometimes resulting in damage or loss of slides or handwritten notes.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of cholesteatoma and retraction pockets

Treatment of retraction pockets (RP) and cholesteatomas depends on their nature and evolvement and the size of mastoid pneumatization. RP are secondary to vacillating middle ear negative pressure. Treatment when necessary consists of placing a ventilating tube, excision of the RP or both. In most children and adults, cholesteatoma is derived from RP (or "atelectasis") of the tympanic membrane, where it can be termed "retraction pocket" cholesteatoma or "secondary" cholesteatoma. This type of cholesteatoma is associated with a non-pneumatized mastoid coupled by negative pressure. Approximately one-third of children's cholesteatomas present clinically behind an intact drum despite a pneumatized mastoid. Pathogenetically this type may be "congenital" or "metaplastic" and should be best termed "primary" cholesteatoma. Central perforations associated with cholesteatoma are probably derived from continuous tympanic membrane destruction by infection in cases of RP cholesteatomas or due to a primary cholesteatoma bursting out from the tympanic cavity. Canal-up surgery of cholesteatoma fails in 60% of cases at Tel Aviv University because of the inherent tendency of the tympanic membrane to retract once again. Residual disease was found in our cases to be a lesser cause for failure. Treatment depends on the type of cholesteatoma, emphasizing small "radicals" in sclerotic mastoids. When a pneumatized mastoid is encountered, a posterior tympanotomy should be considered.

Evoked otoacoustic emissions in the study of adult sensorineural hearing loss

In the present report the applicability of evoked otoacoustic emissions (EOAEs) in the clinical field for studying adult sensorineural hearing loss is discussed. Three topics are considered: (1) EOAEs replacing a testing procedure, (2) EOAEs integrating into the test battery thus validating the diagnostic outcome, (3) EOAEs implementing new diagnostic possibilities. The authors conclude that: (a) EOAEs could only be applied to replace pure-tone audiometry for assessing functional deafness, (b) EOAEs are a useful diagnostic tool complementing the audiological test battery, (c) EOAEs are a unique method that studies the efferent auditory pathways. It is suggested that EOAEs should be applied as a routine audiological test for adult sensorineural hearing loss not only in cases with a well-defined diagnostic profile, but also in those cases with a less clear diagnostic pattern, in order to collect more data and possibly gain better knowledge about the pathophysiology of the inner ear.

The effect of mastoid surgery on atelectatic ears and retraction pockets

Forty children and 53 adults with a total of 111 atelectatic ears were operated on and followed up. Eight-four ears underwent tympanoplasty, while 27 ears underwent both a tympanoplasty and a mastoid operation. There were no statistically significant differences between the two operation groups as far as their age groups and the extent of the disease present. After follow-up of over 4 years, aeration of the middle ear was found to be better in the tympanoplasty group alone when compared with ears with also had mastoid operations.

The influence of ventilating tubes on the surgical treatment of atelectatic ears

Forty children and 53 adults having 111 atelectatic ears were operated on and followed up. All patients underwent a tympanoplasty operation, while 27 patients underwent concomitant various mastoid operations. A ventilating tube was inserted in 55 out of the 111 atelectatic ears, while in 56 ears the tympanoplasty was left without a ventilating tube. After an average of 53.1 months of post-operative follow-up we found that all ears were adequately aerated as long as a ventilating tube was in place. However, at the final check, once all ventilating tubes extruded, it was found that insertion of a ventilating tube at operation did not change the natural evolution of the atelectatic condition after surgery. Our conclusion is that the only way to overcome the atelectatic prone condition is to reinsert a ventilating tube whenever atelectasis reformation occurs.

Interactive inner-ear/middle-ear disease, including perilymphatic fistula

Pathologic interactions between the middle ear and inner ear occur with 1) congenital anomalies, 2) trauma, 3) infection/inflammation, 4) tumors, 5) granulomas, 6) ototoxic eardrops, 7) cochlear implants, 8) otosclerosis, 9) Meniere's disease (decompensated) and Meniere's disease (with perilymphatic fistula), and 10) perilymphatic hypertension. Clinical and pathological characteristics are briefly categorized in this survey. Comments are made concerning the clinical utility of exploratory tympanotomy in diagnosis and treatment of pathologic conditions in the middle ear and pathologic conditions that are interactive between middle ear and inner ear.

The N.I.F. classification of ossicular disorders

The authors present their classification of ossicular disorders. It is felt to be easy to use, and self-explanatory, and it lends itself conveniently to analysis of data by computer. Examples are shown of its use in analyzing data in relationship to the ossicular status, in quantifying the effects of different ossicular situations, and in comparing our results with those of other authors. Using the N.I.F. classification, these factors are surprisingly easy to manipulate. It is hoped that this classification will be of use to others engaged in the same type of studies.

My current cholesteatoma techniques

Correct treatment of cholesteatoma should always be based on a good knowledge of its pathogenesis. The basic process consists of the ectopic presence of a basal malpighian-like epithelium in the middle ear. Different types of cholesteatoma exist, ranging from the cystic to the invasive form. The most appropriate surgical techniques for each type will be discussed by the author.

Late results of surgery in different cholesteatoma types

Our series of 740 cholesteatomas, operated during the period 1969 to 1980, were seen at follow-up several times with a median observation period of 9.2 years (range 3-21 years). There were; 273 attic cholesteatomas with retraction (perforation) of Shrapnell's membrane; 271 sinus cholesteatomas with superioposterior retraction (perforation) of pars tensa, and 196 tensa retraction cholesteatomas extending from a retraction of the whole pars tensa. The late results were analyzed for each type separately, and compared. The recurrence rate was lowest (6.6%) in attic cholesteatoma and highest (13.3%) in tensa retraction cholesteatoma. In all three types no residual cholesteatomas were detected after the 4th postoperative year, whereas recurrent cholesteatomas occurred up to 10 years after surgery. The reoperation rate was lowest (15%) in attic cholesteatoma and almost the same (21%) in sinus and tensa retraction cholesteatoma. The hearing results were best in attic cholesteatoma and poorest in tensa retraction cholesteatoma. It is concluded that cholesteatoma surgery should be individualized and that both the canal wall up and canal wall down methods have their place in cholesteatoma surgery.

Cholesteatoma staging

Manuscripts reporting results of surgery for chronic otitis media would be more meaningful if standardized nomenclature were used in describing the type of surgery performed and if standardized classifications were used for the disease process. Standardized nomenclature for surgery type and classifications for chronic otitis media exists. A Classification for cholesteatoma, based on pathophysiology, location, eustachian tube function, ossicular defects, and presence or absence of complications is proposed. Congenital cholesteatoma is that which has its nidus of trapped squamous epithelium present at birth. Primary acquired cholesteatoma is associated with a defect in the pars flaccida, while secondary acquired cholesteatoma is associated with a defect in the pars tensa. Tertiary acquired cholesteatoma is defined as that which occurs behind a normal appearing tympanic membrane as the result of implantation or an antecedent middle ear inflammation.

Some considerations on middle ear cholesteatoma in 'foreign workers'

The treatment of cholesteatoma in patients without a permanent residence or in medically underdeveloped countries presents a serious problem in middle ear surgery. Methods which erradicate disease safely and reduce the risk of recurrence to a minimum are necessary. We differentiate 3 clinical types of cholesteatoma: 1 Retraction of Shrapnell's membrane or in the postero-superior quadrant with very little cholesteatoma lateral to the ossicles. A transcanal technique is used to evert the cholesteatomatous pocket into the meatus intact, followed by reconstruction of the outer attic wall. 2 Circumscribed cholestatoma lateral and often also medial to the ossicles. Combined approach tympanoplasty is used in such cases. 3 Marginal perforations with large cholesteatomas, situated medial to the ossicular chain. For these ears, classical radical mastoidectomy is the method of choice. (Radical mastoidectomy also has to be performed in all cases of type II, where luxation of the matrix in toto has failed.)

RESULTS

No recurrence has been detected in cases where follow-up was possible.

Tympanoplasty: the fundamentals of the concept

The development of tympanoplasty based on a fundamental understanding of the mechanisms of the middle ear in health and disease is described as it evolved. As a consequence of problems arising from the creation of an open cavity further developments led to the concept of a 'closed' operation which in turn has its own disadvantages. These are principally concerned with aeration of the tubotympanic cleft. The most recent phase of tympanoplasty is concerned with limiting the extent of the procedure to what is required to expose the disease process and re-establish function.

[A proposal of a T.N.M. type of classification of the ear. O.P.A.C. classification of chronic surgical otitis]

With the advent of modern otology, cophosurgeons anxious to compare their results soon became aware of the need for a "T.N.M" type of classification for the ear. The classification described here by the authors is, in principle, a classification of the "T.N.M" type: that is, a purely descriptive classification without prognostic, pathogenetic or therapeutic pretensions. This "O.P.A.C." classification is based on a description of 4 main characteristics: 1) the existence and characteristics of potential otorrhoea, described under the letter C; 2) the characteristics of potential perforation of the tympanum, described under the letter P; 3) the appearance of the middle ear, excluding the ossicular chain, described under the letter A; 4) the condition of the ossicular chain when the surgeon has completed his exploration of the lesions, described under the letter C. Two years experience seems to have proved the convenience and usefulness of this purely clinical classification, providing otologists with a common language. While they are aware of the objections and criticisms to which it may give rise, the authors hope, on time, to improve in this classification.

Tympanometric pattern classification in relation to middle ear effusions

Tympanometric evaluation using an otoadmittance meter and X-Y plotter was performed on 129 ears of 70 children with history of recurrent acute otitis media, or evidence otoscopically of persistent middle ear effusion, or both. Myringotomy, performed immediately following the tympanometric procedure, confirmed the presence or absence of effusion. Following myringotomy, tympanometric patterns, as shown by susceptance and conductance tracings at 220 and 660 Hz, were identified and middle ear pressures and otoadmittance peak values were determined. These findings were compared and criteria were developed which best determined the presence or absence of effusion. The results revealed the following: 1) High negative middle ear pressure is not necessarily a reliable indicator of middle ear effusion. 2) Tympanometry can be used reliably as an indicator of effusion. A combination of pattern classification and susceptance criteria enabled correct prediction of effusion in 93% of these children. One pattern at B660 was found to be pathognomonic of effusion. 3) In general, otoadmittance at 660 Hz appears to be a better indicator of effusion than 220 Hz.

Connective tissue disorders in otolaryngology

Connective tissue disorders may present with various otolaryngologic symptoms. The manifestations may represent vasculopathy, arthopathy, neuropathy or a combination of pathological processes. Rheumatoid arthritis may involve the middle ear, temporomandibular joints and larynx with mild symptoms or may be life-threatening in instances of cricoarytenoid arthritis. Dermatomyositis with its cutaneous and muscular symptoms prevalent in the head and neck is frequently associated with malignancy in patients over 40. Scleroderma not only affects the gastrointestinal tract but can also produce significant limitations of respiratory function. Systemic lupus erythematosus, polyarteritis modosa, Wegener's granulomatosis and giant cell arteritis produce numerous vascular changes in structures of otolaryngologic significance. In this puzzling group of disorders, protean symptoms may precede the development of a fulminant, widespread and fatal disease.