Diagnosis and management of facial nerve palsy secondary to granulomatosis with polyangiitis - A systematic review

OBJECTIVE

Granulomatosis with polyangiitis is associated with otolaryngologic complaints in 70-95 % of cases, with the most common being serous otitis media. In rare cases, patients may experience facial nerve palsy in conjunction with otologic or nasal symptoms; and, often, initially present to an otolaryngologist. It is important for healthcare professionals to be able to recognize the nuisances of facial nerve palsy as a potential presentation of granulomatosis with polyangiitis.

STUDY DESIGN

Systematic review.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol, PubMed and MED-LINE Databases were queried for articles published from January 2007 to December 2022 describing facial nerve palsy in the context of Granulomatosis with polyangiitis, formerly known as Wegener's Granulomatosis. The keywords included "facial nerve palsy", "facial palsy", "granulomatosis with polyangiitis", "Wegener's granulomatosis", "ANCA positive" in the title/abstract. All full-text articles available in English were screened, including single case presentations. Abstracts, commentaries, and publications deemed outside the scope of our study aims were excluded from review. After removal of duplicate articles, a total of 85 articles were screened. After applying inclusion and exclusion criteria, 14 articles were included in the review.

RESULTS

There were a total of 28 reports of facial nerve palsy in the literature in patients who were eventually diagnosed with granulomatosis with polyangiitis. The patients' ages ranged from 14 to 68 years old. None of the patients had been previously diagnosed with GPA, and a majority of them presented initially with other otologic symptoms. Hearing loss was reported in 24 patients (86 %), otalgia was present in 11 patients (39 %), and otorrhea was present in 6 patients (21 %). Bilateral facial paralysis was reported in 10 patients in the literature (36 %). In total, 16 patients underwent surgery for facial paralysis: 6 tympanomastoidectomies, 4 mastoidectomies, 2 explorative tympanotomies. Surgery was generally considered ineffective in resolving facial weakness. All patients ended up receiving some combination of steroids and immunosuppressant, most commonly prednisolone and cyclophosphamide or rituximab, which was eventually transitioned to azathioprine for maintenance. Unlike auditory thresholds, which remained decreased in two patients, all patients recovered facial function following appropriate medical treatment of their vasculitis.

CONCLUSIONS

Facial nerve paralysis in patients with granulomatosis with polyangiitis is a rare but treatable phenomenon. In patients with intractable otitis media, unresolving facial palsy, or a combination of otologic issues, it is important to consider GPA as a possible source. The prognosis for facial function appears to be excellent in patients who undergo appropriate treatment for vasculitis, but further studies are needed for confirmation.

Eustachian Tube Balloon Dilation: A Comprehensive Analysis of Adverse Events

BACKGROUND

Eustachian tube balloon dilation (ETBD) has been Food and Drug Administration (FDA) approved for refractory Eustachian tube dysfunction since 2016. While ETBD is generally seen as safe, the complication profile has not been well defined.

OBJECTIVE

The objective of this study was to utilize the FDA manufacturer and user facility device experience (MAUDE) database to better assess adverse events (AE) related to ETBD.

METHODS

This is a study of a multiinstitutional database maintained by the U.S. FDA. A database analysis was performed via the collaboration of multiple clinicians at tertiary referral centers. The FDA MAUDE database was queried for all medical device reports (MDR) related to ETBD devices from January 2012 to November 2022. Eighty-eight unique MDR were identified, 16 of which met inclusion criteria.

RESULTS

Three MDRs were classified as device-related (18.8%); none resulted in an AE. Thirteen MDRs (81.3%) were patient-related; all were classified as AEs. The most common AE was postoperative subcutaneous emphysema (n = 6, 46.2%). Of the patients with subcutaneous emphysema, there was a wide range of severity. The most severe AE (n = 1, 6.3%) was postoperative stroke secondary to carotid artery dissection.

CONCLUSION

Though ETBD is generally seen as a safe procedure, there have been several concerning AEs reported to date. Increased awareness of ETBD complications can serve as a primer for improved patient education and counseling during the informed consent process and aid surgeons in clinical decision-making. Future studies with standardized reporting protocols are warranted to create a central registry for ETBD.

Assessing Patient Barriers to Cochlear Implantation

OBJECTIVE

Evaluate barriers that deter adult patients from following through with cochlear implantation.

STUDY DESIGN

Retrospective chart review and phone survey.

SETTING

Single tertiary referral center.

PATIENTS

Between January 2019 and August 2021, 113 patients, without a previous cochlear implant (CI), were determined to be candidates for cochlear implantation. Thirty-eight (33.6%) patients deferred cochlear implantation. Survey response rate was 61.1% (22/36).

INTERVENTION

None.

MAIN OUTCOME MEASURES

Demographic, socioeconomic, otologic history, and comorbidity factors associated with deferment of cochlear implantation. Patient survey assessment of factors that had the greatest impact, rated on a scale of 1 to 10 (10 being the most impactful), on their decision to defer a CI.

RESULTS

Out of the 113 patients who met inclusion criteria, 75 (66.3%) underwent cochlear implantation and 38 (33.6%) patients deferred. Comparing implanted versus deferred groups, there was no statistical difference in age (67.1 y versus 68.5 y; p = 0.690) or male sex (53.3% versus 57.9%; p = 0.692). The deferred group had higher mean neighborhood disadvantage state decile (5.3 versus 4.3; p = 0.064) and national percentile (73.0 versus 66.2; p = 0.106) scores, although neither were statistically significant. A greater proportion of the deferred group were not living independently at time of CI evaluation (13.2 versus 2.7%; p = 0.017). Fear of losing residual hearing was rated the highest among the survey respondents (mean rating of 5.1), followed by general medical health (4.9) and cost and financial concerns (3.6).

CONCLUSION

The greatest concern among the patients was the fear of losing residual hearing. Spending greater time educating patients about the success and failure rates of cochlear implantation may reduce patient hesitancy with implantation.

Neural activity during attentional conflict predicts reduction in tinnitus perception following rTMS

BACKGROUND

Subjective idiopathic tinnitus is an intrusive, distracting, and potentially disabling disorder characterized by phantom perception of sounds. Although tinnitus has no approved pharmacologic treatment, recent evidence supports the use of repetitive transcranial magnetic stimulation (rTMS) to alleviate tinnitus symptoms.

OBJECTIVE/HYPOTHESIS

Repetitive TMS delivered over the middle superior temporal gyrus (STG) may alter ratings of tinnitus awareness and annoyance more than loudness due to change in attentional processing. STG has reciprocal connections to regions of the prefrontal cortex that mediate attention. To probe the hypothesized influence of STG stimulation on attention, a subset of patients with tinnitus enrolled in an rTMS clinical trial [n = 12, 9 male, mean (sd) age = 49 (15) years] underwent an attentional conflict task before and after rTMS treatment in a repeated-measures functional magnetic resonance imaging (fMRI) study.

METHODS

The Multi-Source Interference Task (MSIT), a Stroop-based visual attentional conflict fMRI task, was used to map participants' neural processing of attentional conflict prior to rTMS intervention (Baseline) and after three rTMS intervention arms: Sham, 1 Hz, and 10 Hz (four sessions per arm, 1800 pulses per session, delivered @110% of the motor threshold over the posterior superior temporal gyrus).

RESULTS

All measures of tinnitus severity (awareness, loudness, and annoyance) improved with 1 Hz rTMS intervention; however, the greatest and most robust changes were observed for ratings of tinnitus awareness (mean 16% reduction in severity from Baseline, p < 0.01). The MSIT elicited a similar pattern of neural activation among tinnitus participants at Baseline compared to an independent sample of 43 healthy comparison adults (r = 0.801, p = 0.001). Linear regression with bootstrap resampling showed that greater recruitment of bilateral prefrontal and bilateral parietal regions by MSIT at Baseline corresponded with poorer treatment response. Individual regions' activities explained 37-67% variance in participant treatment response, with left dorsolateral prefrontal cortex's MSIT activity at Baseline explaining the greatest reduction in tinnitus awareness following 1 Hz stimulation. Although left dorsolateral prefrontal cortex activity at Baseline also predicted reduction in tinnitus loudness and annoyance (∼50% variance explained), these symptoms were more strongly predicted by right middle occipital cortex (∼70% variance explained) - suggesting that the neural predictors of symptom-specific treatment outcomes may be dissociable.

CONCLUSION

These candidate neural reactivity markers of treatment response have potential clinical value in identifying tinnitus sufferers who would or would not therapeutically benefit from rTMS intervention.

Influence of Behavior on Complications of Osseointegrated Bone Conduction Devices in Children

OBJECTIVE

Compare incidences of complications following implantation of osseointegrated bone conduction devices (OBCD) between children with and without behavioral disorders.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center otology and neurotology practice.

PATIENTS

Pediatric patients who underwent implantation of OBCD between May 2009 and July 2014 at Arkansas Children's Hospital.

INTERVENTIONS

Implantation with Cochlear BAHA 200 series, Cochlear BAHA BI300, or Oticon OBCD.

MAIN OUTCOME MEASURES

Osseointegration failure (OIF) with resulting loss of flange-fixture and/or skin and soft tissue reactions.

RESULTS

The total rate of complications was 66.2%, with the majority being minor complications (39.4%). There was no difference in the total rate of complication (p = 0.461), minor complications (p = 0.443), major complications (p = 0.777), and minor and major complications (p = 0.762) between the control group and children with behavioral disorders.

CONCLUSION

Behavior was not observed to influence the incidence of OIF or skin/soft tissue reactions after implantation of OBCD in pediatric patients.

Therapeutic Mastoidectomy in the Management of Noncholesteatomatous Chronic Otitis Media

Objective

Despite evidence that therapeutic mastoidectomy does not improve outcomes in noncholesteatomatous chronic otitis media, it remains widely performed. An up-to-date systematic review is undertaken and conclusions drawn regarding the best evidence-based practice of its management.

Data Sources

PubMed, Google Scholar, Medline Embase, Cochrane, and Web of Science.

Review Method

A combination of the following words was used: chronic otitis media, chronic suppurative otitis media, COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retraction, tympanic perforation, and therapeutic.

Results

From 1742 studies, 7 were selected for full analysis with respect to the benefit of mastoidectomy in the management of active and inactive mucosal chronic otitis media. Most were retrospective studies, with 1 prospective randomized controlled trial available. Overall, there was no evidence to support routine mastoidectomy in conjunction with tympanoplasty in chronic otitis media. For ears with sclerotic mastoids, the evidence suggested that there may be some benefit as a staged procedure. Two studies were analyzed for the benefit of mastoidectomy in addition to tympanoplasty for the management of the atelectatic ear (inactive squamous chronic otitis media). The conclusion was also that mastoidectomy added no benefit.

Conclusions

Examination of the available literature supports the notion that therapeutic mastoidectomy does not lend any additional benefit to the management of noncholesteatomatous chronic otitis media. This has implications for patient care, both clinically and financially. Further research, ideally in the form of a prospective, multi-institutional, geographically wide, ethnically diverse, randomized controlled trial, is needed to further support this notion.

TORP Ossiculoplasty Outcomes with and without a Stapes Footplate Prosthesis

Objective

The titanium stapes footplate prosthesis (FPP) was designed to ensure a stable connection of a total ossicular replacement prosthesis (TORP) to the stapes footplate and maximize acoustic coupling by centering the footplate on the oval window. Our goal was to assess the impact of the FPP on TORP ossiculoplasty outcomes.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects

Adult patients undergoing TORP ossiculoplasty with (n = 53) or without (n = 108) a stapes FPP.

Methods

Rate of prosthesis displacement and audiologic outcomes were tabulated for statistical analysis.

Results

A lower rate of prosthesis displacement and statistically better audiologic outcomes were seen in FPP patients. The pure-tone average air-bone gap (PTA-ABG) was closed to <20 dB in 69.8% (37/53) of patients in the study arm and 44.4% (48/108) of patients in the control arm ( P = .003). The PTA-ABG was decreased by a mean ± SD of 19.3 ± 11.7 dB and 12.6 ± 11.0 dB in the study and control groups, respectively ( P = .0012).

Conclusions

Use of the titanium stapes FPP during TORP ossiculoplasty provides a statistically significant advantage in short-term PTA-ABG closure and a higher rate of successful rehabilitation of conductive hearing loss. Further studies are necessary to assess any long-term advantages a FPP may offer.

Total Ossiculoplasty Outcomes with and without a Stapes Footplate Prosthesis

Objectives:

Compare audiologic outcomes of total ossicular replacement prosthesis (TORP) ossiculoplasty performed with and without the placement of a stapes footplate prosthesis (FPP).

Methods:

A retrospective chart review was performed to identify adult patients undergoing TORP ossiculoplasty by the same surgeon at a tertiary care center between 1998 and 2012. Indications for surgery included cholesteatoma, atelectasis/perforation, chronic otitis media, and glomus tumor. Patients with a history of stapes surgery on the ear of interest were excluded from the study.

Results:

A lower rate of prosthesis displacement and statistically better audiologic outcomes were seen in FPP patients. The pure-tone average air-bone gap (PTA-ABG) was closed to <20 dB in 69.8% (37/53) of patients in the study arm and 44.4% (48/108) of patients in the control arm ( P < .001). The PTA-ABG was decreased by an average of 19.3 dB ± 11.7 dB (standard deviation, SD) and 12.6 dB ± 11.0 dB (SD) in the study and control groups, respectively ( P = .0014).

Conclusions:

Use of the titanium stapes FPP during TORP ossiculoplasty was associated with a statistically significant advantage in short-term PTA-ABG closure and a higher rate of successful rehabilitation of conductive hearing loss in this study. A lower rate of prosthesis displacement was seen in the FPP group, but further studies and longer follow-up periods are needed to validate this observation.

Cholesteatoma Surgery: An Update

Program Description:

The goals of cholesteatoma surgery are the complete removal of disease while minimizing the risk of recurrence. A secondary goal is to optimize postoperative hearing. This miniseminar features distinguished experts in the field who will present well-established methods of cholesteatoma surgery. Important topics, such as intact-canal-wall versus canal-wall-down surgery, recurrence prevention, use of cartilage, and management of labyrinthine fistula will then be discussed in a case-based format. The role of endoscopes and use of magnetic resonance imaging for detection of recurrence will be discussed. Finally, ossiculoplasty techniques will be presented.

Educational Objectives:

(1) Perform cholesteatoma surgery as practiced by experts in the field. (2) Examine advantages and disadvantages of endoscopic techniques. (3) Incorporate various methods for preventing recurrence.

Build a Better Ear: What’s New in Chronic Ear Disease

Program Description:

There is a growing interest in implementing surgical techniques and using novel materials for tympanic membrane perforation repair. Bioactive materials, cartilage and fascia grafts derived from the recipient patient, novel partial ossicular replacement prostheses and total ossicular replacement prostheses, and novel technologies (ie, otoendoscopy) are in continuous evolution, striving for higher quality and longer duration and stability in otologic surgery grafting. The presenters will provide descriptions and show videos demonstrating the function of these different materials and techniques. In addition, a non-committee panel will present an evidence-based medicine (EBM) algorithm for treatment:”What Literature says—an EBM decision Algorithm as Key to Success.”

Educational Objectives:

1) Describe the variety of grafting materials, protheses, and different techniques available for surgical repair of tympanic membrane perforations. 2) Discuss the advantages and limitations of using these technologies and materials. 3) Assess the validity of the studies presented to evaluate the efficacy of these surgical tools.

Determining benchmarks in hearing preservation surgery for vestibular schwannoma

Objectives The objectives of this study were to determine minimal benchmarks of success in vestibular schwannoma hearing preservation surgery, wherein the likelihood of having preserved hearing in a single patient is at least as likely as having created a poor facial nerve outcome for a single patient. Design This is a statistical analysis of published literature. Setting Academic Tertiary Medical Center. Main Outcome Measures Based on published natural history data, the number needed to treat (NNT) equation was used to calculate the minimally acceptable hearing preservation rates within various hearing classification schemes. Results Given good facial nerve outcome rates of 85, 90, and 95%, the corresponding hearing preservation rates at 4.7 years that are likely to preserve classes A and B hearing (American Academy of Otolaryngology-Head and Neck Surgery classification) in a single patient as to cause a poor facial nerve outcome are 70, 65, and 60%, respectively. If surgery is limited exclusively to intracanalicular tumors, these rates drop to 62, 57, and 52%, respectively. If the word recognition scoring classification is used, required hearing preservation rates are higher. Conclusion It is possible to use the NNT equation alongside projected facial nerve outcomes to estimate benchmarks of minimally acceptable hearing preservation rates.

Outcomes of cartilage tympanoplasty in the pediatric population

OBJECTIVE

To justify the successful use of a patient selection algorithm based on age for primary cartilage tympanoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

We performed a retrospective chart review of patients between ages 4 and 13 years who underwent cartilage tympanoplasty for tympanic membrane perforations from August 2005 to November 2011. Demographics, complication data, and auditory outcomes were collected.

RESULTS

Patients were subdivided into 3 age groups. Group 1 consisted of patients younger than 7 years (n = 43); group 2, ages 7 to 10 years (n = 40); and group 3, ages 10 to 13 years (n = 36). Mean follow-up was 595 days (range, 48-1742). Complication rates respective to the 3 groups were as follows: remnant perforation (6.97%, 5.00%, 2.78%), revision tympanoplasty (2.33%, 2.50%, 0%), and need for tympanostomy tubes (4.65%, 2.50%, 0%). Logistic regression models were used to evaluate complication rates between groups. No significant differences were found (remnant perforation, P = .710; repeat tympanoplasty, P = .998; tympanostomy tubes, P = .875). No significance was found among audiological outcomes between the 3 groups.

CONCLUSION

These data suggest cartilage tympanoplasty can be performed effectively in young children when appropriate conditions exist.

Outcomes of Cartilage Tympanoplasty in Pediatric Patients

Objective: To determine whether a relationship exists between successful outcomes of cartilage tympanoplasty and age at repair.

Method: A retrospective chart review of patients between ages 4 and 13 who underwent cartilage tympanoplasty for tympanic membrane perforations from August 2005 to November 2011 was preformed. Demographics, complication data, and auditory outcomes were collected.

Results: Patients were subdivided into 3 age groups. Group 1 consisted of patients less than 7 years of age (n = 43), group 2 ages 7 to 10 (n = 40), and group 3 ages 10 to 13 (n = 36). Mean follow-up was 595 days (range = 48-1742). Complication rates respective to the 3 groups were as follows: Eustachian tube dysfunction (ETD) or fluid causing a conductive hearing loss (9.3%, 10%, 5.6%), need for tympanostomy tubes (4.7%, 2.5%, 0%), remnant perforation (7%, 5%, 2.8%), and revision tympanoplasty (2.3%, 2.5%, 0%). Resolution of ETD or fluid on subsequent visits precluded tube placement. A 1-way analysis of variance (ANOVA) was performed to evaluate complication rates between groups. No significant differences were found (remnant perforation, P = .70, repeat tympanoplasty, P = .64, tympanostomy tubes, P = .42, and ETD or fluid, P = .76). Improvement in pure tone average was 10.23, 12.5, and 3.95, respectively.

Conclusion: A trend for slight increase in complications in children under the age of 10 was found but was not statistically significant. There were significant group differences in hearing improvement with younger patients demonstrating better outcomes. The implications for these findings will be discussed. These data suggest cartilage tympanoplasty can be performed effectively in young children when appropriate conditions exist.

Pharmaceutical countermeasures have opposite effects on the utricles and semicircular canals in man

INTRODUCTION

Sensory conflicts in the vestibular system lead to motion sickness of which space motion sickness (SMS) is a special case. SMS affects up to 70% of the astronauts during the first 3 days in space. The search for effective countermeasures has led to several nonpharmacological and pharmacological approaches. The current study focuses on the effects of lorazepam (1 mg), meclizine (25 mg), promethazine (25 mg), and scopolamine (0.4 mg) on the vestibular system, with special focus on the canal and otolith functions separately.

METHODS

The study had a placebo-controlled, single blind, repeated measures design. Sixteen healthy volunteers were subjected to a total of 7 test sessions, the first and last being without intake of medication. Semicircular canal function was evaluated by means of electronystagmography and otolith function with unilateral centrifugation. The horizontal semicircular canal function was characterized by the vestibulo-ocular reflex (VOR) gain measured during earth vertical axis rotation as well as the total caloric response. The function of the utricles was represented by the utricular sensitivity, reflecting the ocular counter roll relative to the virtual induced head tilt.

RESULTS

Promethazine significantly decreased the semicircular canal and utricular parameters. Both scopolamine and lorazepam caused only a decrease in the utricular sensitivity, whereas meclizine only decreased the semicircular canal-induced VOR gain.

DISCUSSION

The results show that the drugs affected different areas of the vestibular system and that the effects can thus be attributed to the specific pharmacological properties of each drug. Meclizine, as an antihistaminergic and weak anticholinergic drug, only affected the VOR gain, suggesting a central action on the medial vestibular nucleus. The same site of action is suggested for the anticholinergic scopolamine since acetylcholine receptors are present and utricular fibers terminate here. The global vestibular suppression caused by promethazine is probably a consequence of its anticholinergic, antihistaminergic, and antidopaminergic properties. Based on the fact that lorazepam increased the affinity of gamma-aminobutyric acid (GABA) for the GABA(A)-receptor and its effects on the utriculi, the site of action seems to be the lateral vestibular nucleus.

CONCLUSION

Meclizine, scopolamine, and lorazepam selectively suppress specific parts of the vestibular system. Selective suppression of different parts of the vestibular system may be more beneficial for alleviating (space) motion sickness than general suppressive agents. Additionally, this knowledge may help the clinician in his therapeutic management of patients with either semicircular canal or otolith dysfunction.

Tympanoplasty: Best Method of Grafting, Medial, Lateral, Medio-Lateral, or Cartilage

Program Description: Although there are well-established surgical techniques for tympanoplasty to repair chronic tympanic membrane perforation, surgical methods remain varied, often based more on local traditions than on scientific research. Successful tympanoplasty continues to pose a significant challenge to the otolaryngologist. The goal of this miniseminar is to present the best surgical technique of this common procedure. Toward these ends, we have assembled a panel of respected and experienced otologists from the East coast, Midwest, South, and West coast of the US. Following a brief introduction, each panelist will present his preferred surgical technique of tympanoplasty for tympanic membrane perforation that works best whether media, lateral, medio-lateral, or cartilage graft method. The remaining time will be devoted to case presentations to discuss on best graft method for particular cases. This miniseminar will provide information that should improve the ability of each participant to perform successful tympanoplasty for chronic tympanic membrane perforation in different clinical situations.

Educational Objectives: 1) Learn best grafting method in tympanoplasty for reconstruction of chronic tympanic membrane perforation. 2) Understand to use different method grafting depending on the location of tympanic membrane perforation. 3) Be able to perform better tympanoplasty in different clinical situations.

Comparison of traditional bone-conduction hearing AIDS with the Baha system

BACKGROUND

Little research exists to demonstrate efficacy and verification measures of the Baha system versus traditional bone-conduction hearing aids. This study gives statistical data about 10 children who have used traditional bone-conduction hearing aids, Baha coupled to a Softband, and the Baha system implanted.

PURPOSE

The purpose of this study was to compare functional gain at 500, 1000, 2000, and 4000 Hz for infants and children with bilateral conductive hearing loss who were initially fit with traditional bone-conduction devices then progressed to Baha with Softband and finally to unilateral Baha implants.

RESEARCH DESIGN

Retrospective five-year chart review.

STUDY SAMPLE

10 children with bilateral conductive hearing loss due to congenital atresia and/or microtia. Participants ranged in age from 6 mo to 16 yr; three were male and seven were female. Two participants were African-American, five Caucasian, and three Hispanic.

INTERVENTION

The intervention was the Baha system used in children via a Softband or implanted as compared to traditional bone-conduction hearing aids.

DATA COLLECTION AND ANALYSIS

Single-factor, repeated analyses of variance were run to examine the amount of functional gain delivered by the various devices as well as the threshold measures with each device at each frequency.

RESULTS

Participants in this study showed a statistically significant improvement when using the Baha Softband over traditional bone-conduction hearing aids. An implanted Baha has statistically as much gain as a bone-conduction transducer at all frequencies tested.

CONCLUSIONS

The Baha system is a valid treatment in conductive hearing loss via a Softband or implanted. It statistically outperforms the traditional bone-conduction hearing aids and should be used as a first choice in intervention rather than a last option for inoperable conductive hearing loss.

Otogenic cerebellar abscess: a case report

This case report describes the gradual deterioration of a healthy, highly functioning man who initially presented with a draining right ear. The patient's indolent neurologic decline and referral to an otologist ultimately led to the diagnosis and treatment of an otogenic cerebellar abscess, an increasingly rare intracranial complication of otitis media. We report this case to illustrate that severe complications of chronic otitis media still occur in the United States, to stress the importance of clinical suspicion in the postantibiotic era, and to review the literature regarding the most appropriate time to perform the otologic portion of the surgery.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND

Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus.

METHODS

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes.

RESULTS

Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated.

CONCLUSIONS

Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

Repetitive transcranial magnetic stimulation for tinnitus: a pilot study

OBJECTIVES/HYPOTHESIS

Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been shown to alleviate tinnitus perception, presumably by inhibiting cortical activity associated with tinnitus. We conducted a pilot study to assess effectiveness of neuronavigated rTMS and its effects on attentional deficits and cortical asymmetry in four patients with chronic tinnitus using objective and subjective measures and employing an optimization technique refined in our laboratory.

STUDY DESIGN

Randomized, placebo-controlled (sham stimulation) crossover study.

METHODS

Patients received 5 consecutive days of active, low-frequency rTMS or sham treatment (using a 45-degree coil-tilt method) before crossing over. Subjective tinnitus was assessed at baseline, after each treatment, and 4 weeks later. Positron emission tomography/computed tomography (PET/CT) scans were obtained at baseline and immediately after active treatment to examine change in cortical asymmetry. Attentional vigilance was assessed at baseline and after each treatment using a simple reaction time test.

RESULTS

All patients had a response to active (but not sham) rTMS, as indicated by their best tinnitus ratings; however, tinnitus returned in all patients by 4 weeks after active treatment. All patients had reduced cortical activity visualized on PET immediately after active rTMS. Mean reaction time improved (P < .05) after active but not sham rTMS.

CONCLUSIONS

rTMS is a promising treatment modality that can transiently diminish tinnitus in some individuals, but further trials are needed to determine the optimal techniques required to achieve a lasting response. It is unclear whether the improved reaction times were caused by tinnitus reduction or a general effect of rTMS. PET/CT scans immediately after treatment suggest that improvement may be related to reduction of cortical asymmetry associated with tinnitus.

Transcranial magnetic stimulation and tinnitus: implications for theory and practice

Transcranial magnetic stimulation: a possible treatment modality for tinnitus?

Cartilage tympanoplasty

This chapter describes two techniques for cartilage reconstruction of the tympanic membrane: the perichondrium/cartilage island flap, which uses tragal cartilage, and the palisade technique, which uses cartilage from the tragus or cymba. The perichondrium/cartilage island flap is preferred for management of the atelectatic ear and the high-risk perforation. The palisade technique is preferred in cases of cholesteatoma and when ossicular reconstruction is needed in the malleus-present situation. Descriptions of the modifications that should be taken in response to specific surgical indications are also provided and include the high-risk perforation, the ear requiring ossiculoplasty, the atelectatic ear, cholesteatoma, and pervasive Eustachian tube dysfunction.

Retrograde Mastoidectomy

The retrograde mastoidectomy technique with canal wall reconstruction is described as a primary treatment for modality for cholesteatoma. This synthesis of canal wall up (CWU) and canal wall down (CWD) techniques involves removal of a portion of the canal wall for exposure and extirpation of the cholesteatoma, followed by reestablishment of the canal wall and ossicular chain during reconstruction. This technique is possible as a single stage in over 90% of cases, including children, with recurrence rates similar to CWD surgery, but with anatomic preservation similar to CWU. Recurrent disease occurred in 16% of cases reviewed in a longer term (8 year) follow-up study. Tobacco use was associated with a higher long-term complication rate.

Repetitive transcranial magnetic stimulation for tinnitus: a case study

OBJECTIVES/HYPOTHESIS

Correlate subjective improvements in tinnitus severity with restoration of cortical symmetry and sustained attention after neuronavigated low-frequency, repetitive transcranial magnetic stimulation (rTMS).

STUDY DESIGN

Case study.

METHODS

Positron emission tomography and computed tomography imaging (PET-CT) guided rTMS was performed on a 43-year-old white male with more than a 30 year history of bilateral tinnitus. rTMS was administered to the area of increased cortical activation visualized on PET-CT at a rate of 1 Hz for 30 minutes (1,800 pulses/session) for each of 5 consecutive days, with optimization applied on day 5 using single pulses of TMS to temporarily alter tinnitus perception. Subjective tinnitus severity was rated before and after rTMS using the tinnitus severity index with analogue scale. Attention and vigilance were assessed before and after therapy using the psychomotor vigilance task (PVT), a simple reaction time test that is sensitive to thalamocortical contributions to sustained attention. Posttherapy PET-CT was used to evaluate any change in asymmetric cortical activation.

RESULTS

The most marked reduction in tinnitus severity occurred after rTMS optimization; this persisted up to 4 weeks after rTMS. PVT testing showed the patient exhibited a statistically significant improvement in mean slowest 10% reaction times after rTMS (P = .004). PET-CT imaging 2 days after the cessation of rTMS showed no changes in cortical blood flow or metabolic asymmetries.

CONCLUSIONS

Low-frequency rTMS applied to the primary auditory cortex can reduce tinnitus severity, with rTMS optimization yielding the most favorable results. Beneficial changes occurring in the patient's slowest reaction times suggest that attentional deficits associated with tinnitus may also respond to low-frequency rTMS.

Contact Dermatitis to Silicone after Cochlear Implantation

Complications, although rare, do occur with cochlear implantation. We present a 2-year old with persistent erythema and pruritus over the implantation site with serous discharge from the implanted ear. Patch testing revealed contact dermatitis to silicone LSR-30 encasing the Nuclear Contour-24 device. Hypersensitivity was also noted to silicone LSR-30 in the Med-el device but not to silicone LSR-70 in the Advance Bionics device. Device explantation resulted in complete resolution of symptoms. The patient was then successfully reimplanted with the Advance Bionics device. Erythema and irritation at the implantation site, without leukocytosis, should prompt evaluation for silicone contact dermatitis.

Success of cartilage grafting in revision tympanoplasty without mastoidectomy

OBJECTIVE

Candidates for revision tympanoplasty have experienced at least one failed attempt at repair of the tympanic membrane and are, therefore, at higher risk for subsequent repair failure. The adjunctive use of mastoidectomy with tympanoplasty in those patients with noncholesteatomatous chronic otitis media is often used to decrease the risk for subsequent failure. However, at this institution, where we use cartilage tympanoplasty, mastoidectomy is rarely performed in the absence of cholesteatoma. Our objective was to assess outcomes in patients undergoing revision tympanoplasty without mastoidectomy using cartilage grafting.

STUDY DESIGN

We conducted a retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

A total of 95 patients (42 female, 53 male; 5-81 yr of age) with a recurrent perforation who were treated surgically with cartilage tympanoplasty without mastoidectomy were included in the chart review. Patients must have undergone at least one previous tympanoplasty without mastoidectomy and had to have complete audiologic and chart follow up.

INTERVENTIONS

An underlay tympanoplasty technique using either a tragal cartilage-perichondrium island graft or palisaded concha cymba cartilage was used. Ossiculoplasty was performed as needed.

MAIN OUTCOME MEASURE

Main outcome measures were incidence of reperforation of the grafted tympanic membrane, hearing result, and prevalence of other complications.

RESULTS

Successful closure without reperforation was obtained in 90 of 95 patients (94.7%). Average postoperative pure-tone average air-bone gap was 12.2 +/-7.3 dB compared with 24.6+/-13.8 dB preoperatively (p <0.001).

CONCLUSIONS

Revision tympanoplasty with cartilage provided equivalent results to tympanoplasty with mastoidectomy. Thus, mastoidectomy may not be necessary in revision tympanoplasty in the absence of cholesteatoma if the repair is made with cartilage.

Effects of drug countermeasures for space motion sickness on working memory in humans

Space motion sickness (SMS) is a problem during the first 72 h of space flight and during transitions from different gravity environments. There currently are no effective drug countermeasures for SMS that also accommodate the retention of optimal cognitive function. This creates a dilemma for astronauts because cognitive skills are particularly important during gravity transitions (e.g., take-off and landing). To quantify the cognitive side effects of potential drug countermeasures, an automated delayed matching-to-sample (DMTS) procedure was used to assess visual working memory before and after drug countermeasures (meclizine 25 mg, scopolamine 0.4 mg, promethazine 25 mg, or lorazepam 1 mg, given orally approximately 45 min prior to testing) and/or the induction of SMS by vestibular stimulation in a rotary chair (spinning). Sixty-seven normal healthy volunteers (mean age, in years, 26.6+/-4.8 S.D.; 24 females and 43 males) each participated in two test sessions, one 'off' drug and one 'on' drug. Spinning by itself significantly decreased task accuracy (Acc) and choice response speed, especially at longer recall delays. Meclizine alone had no effect on Acc or speed with or without spinning. Scopolamine alone decreased Acc, and with spinning, slowed speed. Promethazine alone had no adverse effect, but combined with spinning, decreased Acc and speed. Lorazepam alone decreased speed, and with spinning, decreased Acc. The data suggest that, at clinically useful doses, the rank order of the drugs with the best cognitive profiles is meclizine>scopolamine>promethazine>lorazepam.

Retrograde Mastoidectomy with Canal Wall Reconstruction: A Follow-up Report

OBJECTIVE

To evaluate long-term results of retrograde mastoidectomy with canal wall reconstruction as a single-stage technique for cholesteatoma removal.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Forty-six patients, representing 50 ears (20 pediatric and 30 adult), who had undergone surgery for cholesteatoma removal with said technique and had an average follow-up of 7.8 years.

INTERVENTIONS

Temporary removal of the upper canal wall, in association with a retrograde-type mastoidectomy, for full exposure and extirpation of the disease, followed by reconstruction of the canal defect using cymba cartilage.

MAIN OUTCOME MEASURES

Preoperative and short- and long-term postoperative audiogram, obtained as four-frequency pure-tone average air-bone gap. Complications, including presence of recurrent or residual cholesteatoma, need for tube insertion, perforation, and poor hearing requiring revision surgery, were also reported and correlated with the patient's tobacco use.

RESULTS

The average preoperative, short-term postoperative, and long-term postoperative pure-tone average air-bone gap was 25.6+/-11.2 dB, 11.0+/-5.7 dB, and 12.4+/-6.4 dB, respectively. There were significant differences between the pre- and postoperative values (p < 0.5), but there was no significant difference between short- and long-term hearing results. Recurrent cholesteatomas were seen in eight ears (16%); pressure-equalizing tube insertion was performed postoperatively in nine ears (18%); a perforation was seen in one ear (2%); and two ears (4%) had poor hearing results requiring second-look surgery. The long-term complication rate of smokers was 79% (15 of 19), compared with 16% (5 of 31) for nonsmokers.

CONCLUSION

This single-stage technique for cholesteatoma removal and canal wall reconstruction showed acceptable long-term results, but tobacco use was associated with a higher long-term complication rate.

The use of demineralized bone matrix for mastoid cavity obliteration

OBJECTIVE

To evaluate the use of demineralized bone matrix as a graft material for mastoid cavity obliteration in the treatment and prevention of problematic mastoid cavities.

STUDY DESIGN

The study is a retrospective review of patients identified using a computerized otology database.

SETTING

Tertiary care referral center.

PATIENTS

Patients were included in this study if they underwent mastoid obliteration using demineralized bone matrix.

INTERVENTION

Mastoid obliteration was performed for revision of a problematic mastoid cavity (n = 8) or primarily after canal wall down mastoidectomy for recurrent cholesteatoma (n = 3).

MAIN OUTCOME MEASURES

Data were collected to evaluate the ability to achieve a dry ear canal. Postoperative healing time and hearing results were also assessed.

RESULTS

A dry ear canal was achieved in all patients with a follow-up of 6 to 20 months (average, 14.5 mo). Eight patients (73%) had a well-healed, dry ear canal by their first postoperative visit (9 wk). One patient required 12.5 weeks to heal. Two patients (18%) had more prolonged granulation at the ear canal incision, which resolved in 17 and 28 weeks, respectively. The average preoperative pure-tone average air-bone gap was 47 +/- 14.9 dB (mean +/- SD), compared with postoperative values of 27.6 +/- 12.8 dB (p = 0.0033; paired t test). This represents an average pure-tone average air-bone gap closure of 20 dB.

CONCLUSION

The use of demineralized bone matrix as a graft extender in mastoid obliteration allowed creation of a dry, smooth-contoured canal in all patients studied. A significant improvement in hearing was also obtained. Demineralized bone matrix is an acceptable graft alternative for mastoid obliteration.

Effects of rotation on the sleep state-dependent midlatency auditory evoked P50 potential in the human

Sopite syndrome, characterized by loss of initiative, sensitivity to normally innocuous sensory stimuli, and impaired concentration amounting to a sensory gating deficit, is commonly associated with Space Motion Sickness (SMS). The amplitude of the P50 potential is a measure of level of arousal, and a paired-stimulus paradigm can be used to measure sensory gating. We used the rotary chair to elicit the sensory mismatch that occurs with SMS by overstimulating the vestibular apparatus. The effects of rotation on the manifestation of the P50 midlatency auditory evoked response were then assessed as a measure of arousal and distractibility. Results showed that rotation-induced motion sickness produced no change in the level of arousal but did produce a significant deficit in sensory gating, indicating that some of the attentional and cognitive deficits observed with SMS may be due to distractibility induced by decreased habituation to repetitive stimuli.

Effects of rotation on the sleep state-dependent midlatency auditory evoked P50 potential in the human

Sopite syndrome, characterized by loss of initiative, sensitivity to normally innocuous sensory stimuli, and impaired concentration amounting to a sensory gating deficit, is commonly associated with Space Motion Sickness (SMS). The amplitude of the P50 potential is a measure of level of arousal, and a paired-stimulus paradigm can be used to measure sensory gating. We used the rotary chair to elicit the sensory mismatch that occurs with SMS by overstimulating the vestibular apparatus. The effects of rotation on the manifestation of the P50 midlatency auditory evoked response were then assessed as a measure of arousal and distractibility. Results showed that rotation-induced motion sickness produced no change in the level of arousal but did produce a significant deficit in sensory gating, indicating that some of the attentional and cognitive deficits observed with SMS may be due to distractibility induced by decreased habituation to repetitive stimuli.

Atrial natriuretic peptide receptor upregulation in the rat inner ear

The purpose of this study was to further examine whether fluid homeostasis in the endolymphatic system could be regulated by a locally effective paracrine system involving atrial natriuretic peptides (ANPs) and their receptors. We assessed the biologic activity of the 3 ANP receptors (ANP-A, ANP-B, ANP-C) in the rat inner ear by measuring receptor upregulation after inner ear administration of ANPs. After appropriate anesthesia, female Lewis rats were injected with ANP via the round window. The animals were sacrificed 24 hours later, and RNA was isolated for reverse transcription-polymerase chain reaction (RT-PCR). Electrophoresis of RT-PCR products showed the presence of all 3 ANP receptor genes in both injected and control animals. Gene expression was significantly higher 24 hours after injection. These findings demonstrate that ANP receptors in the inner ear can be upregulated after injection of ANPs.

Hearing results with a hydroxylapatite/titanium bell partial ossicular replacement prosthesis

OBJECTIVES/HYPOTHESIS

To study the preliminary hearing results in patients receiving a hybrid hydroxylapatite/titanium bell partial ossicular replacement prosthesis (PORP) and compare these with a cohort of patients receiving a HAPEX PORP. We hypothesized that the design of the hybrid PORP would enhance its acoustic properties. In particular, the titanium bell, which allows the prosthesis to be freestanding, would obviate the need for Gelfoam, preventing fibrosis.

STUDY DESIGN

A retrospective study was made of two cohorts of patients.

METHODS

A computerized otologic database was used to identify all patients implanted with either PORP. The four-frequency (500, 1000, 2000, and 3000 Hz) pure-tone average air-bone gap (PTA-ABG) and ABG values for individual frequencies were compared using the Student test.

RESULTS

The PTA-ABG for the titanium bell prosthesis was 9.8 +/- 5.7 dB, compared with 13.2 +/- 8.3 dB for the HAPEX PORP, which was statistically significant ( P<.05). The average ABG values at 500 and 1000 Hz were also statistically significantly improved with the titanium bell PORP ( P<.05).

CONCLUSIONS

The titanium bell PORP showed improved postoperative results for the PTA-ABG and at 500 Hz and 1000 Hz. The prosthesis is freestanding and may provide better coupling with the capitulum, factors which may lead to improved hearing results in the lower frequencies.

Bioactive glass ceramic particles as an alternative for mastoid obliteration: results in an animal model

HYPOTHESIS

This study was conducted to evaluate the use of the bioactive glass ceramic particulate NovaBone Bioglass as a graft material for mastoid cavity obliteration in an animal model.

BACKGROUND

Canal wall down procedures in otologic surgery may result in a problematic mastoid cavity. Mastoid cavity obliteration can potentially prevent or correct this problem. Many techniques and implant materials have been used for mastoid obliteration, but no single graft material has proved to be ideal.

METHODS

Mongolian gerbils received tympanic bulla obliteration using the NovaBone Bioglass particulate. Nine weeks after implantation, the animals were killed, and histologic sections were prepared. Histologic evaluation was performed to evaluate new bone formation within the implant.

RESULTS

Wound healing occurred without complication. Mature trabecular bone was observed throughout the entire thickness of the implant material. Extensive neovascularity was observed within the graft material. There was no histologic evidence of inflammatory reaction or short-term resorption.

CONCLUSIONS

The extensive new bone formation obtained with bioactive glass ceramic particles in this study makes this material a potential alternative resource as a graft material for mastoid obliteration.

Tympanoplasty results in patients with cleft palate: an age- and procedure-matched comparison of preliminary results with patients without cleft palate

OBJECTIVE

Because of continued eustachian tube abnormalities, the presence of a cleft palate repair has been thought to be associated with poor outcomes after tympanoplastic surgery. However, little published data exist regarding the results of major otologic surgery in patients with cleft palate. The objective of this study was to review our results of otologic surgery in these patients and compare results with those of age- and procedure-matched controls.

METHODS

Our otologic database was used to identify patients with a repaired cleft palate who underwent otologic surgery between March 1994 and December 1999. Two control patients were identified for each cleft palate patient. Results of hearing, graft take, and need for postoperative pressure-equalizing tubes were compared.

RESULTS

No significant difference existed between patients with a repaired cleft palate and control patients with regard to postoperative air-bone gap (P = 0.6805), graft survival rate (P = 1.00), and need for postoperative intubation (P = 0.457).

CONCLUSION

Results in patients with cleft palate appear to be similar to those in patients without cleft palate.

Natriuretic peptide receptors in the human endolymphatic sac

OBJECTIVE

To examine human endolymphatic sac (ELS) tissue for atrial natriuretic peptide (ANP) receptor subtypes A, B, and C.

DESIGN

Pilot study.

METHODS

Immunohistochemical analysis of human ELS tissue specimens. The ANP receptors were characterized using the peroxidase/antiperoxidase method and polyclonal antibodies directed against each receptor subtype. The identity of the stain regarding receptor subclass was masked from the observer. Human kidney tissue known to contain all 3 receptor subtypes was used as a control. Presence of the receptor subclasses was confirmed using reverse transcriptase-polymerase chain reaction (RT-PCR) techniques.

SUBJECTS

Samples of ELS tissue were obtained at autopsy from 3 fresh cadaver specimens (6 ears) and as surgical specimens from 3 patients (1 for immunohistochemical analysis and 2 for RT-PCR) undergoing acoustic neuroma resection using the translabyrinthine approach.

RESULTS

The ANP type B receptors demonstrated moderate to strong reactivity in all 7 specimens, and mild to moderate staining to the ANP type C receptor was also noted. No appreciable reactivity to the ANP type A receptor was detected using immunohistochemical techniques. All 3 receptor subclasses were detected using RT-PCR.

CONCLUSIONS

The ANP receptors are found within the human ELS, with a predominance of ANP type B based on the intensity of staining. The ANPs may be involved in fluid homeostasis in the inner ear. Based on these findings, C-type natriuretic peptide may be a more effective peptide within the human ELS for fluid regulation because its binding affinity is virtually exclusive for the ANP type B receptor.

Cancer of the external auditory canal and temporal bone

Malignant neoplasms involving the temporal bone are a relatively rare and often misdiagnosed disease. Staging of temporal bone cancer has proven difficult because of the small number of patients with this condition, the various histopathologic and histologic findings reported, and a lack of randomized trials. Of the various staging systems that have been proposed, the Pittsburgh classification appears to be the most widely accepted. A retrospective study of 31 patients with temporal bone malignancy at the University of Arkansas for Medical Sciences has led us to propose a modification of the Pittsburgh classification for early-stage lesions. This modification places more emphasis on the site of disease in the canal and less on the size of the primary tumor or degree of bony invasion. This review discusses this staging system, the management of these tumors in a multidisciplinary team approach, reconstructive options, and auditory rehabilitation.

Demineralized bone matrix as an alternative for mastoid obliteration and posterior canal wall reconstruction: results in an animal model

HYPOTHESIS

This study was conducted to evaluate the use of Grafton human demineralized bone matrix as a graft material for mastoid cavity obliteration and canal wall reconstruction in an animal model.

BACKGROUND

Canal wall down procedures in the treatment of cholesteatoma may result in a problematic mastoid cavity. Elimination of the mastoid cavity by obliteration or canal wall reconstruction can prevent or correct this problem. Many techniques and implant materials have been used for this application, yet no single material has proven to be ideal.

METHODS

Athymic rats received tympanic bulla obliteration and lateral bulla wall reconstruction utilizing the Grafton Putty and Flex formulations, respectively. Wound healing was monitored twice a week. Auditory brainstem evoked responses were obtained 8 weeks after implantation. Nine weeks after implantation, the animals were killed, and histologic sections were prepared. A histologic bone formation score (range 0-4) was determined for each implant.

RESULTS

Wound healing occurred without complication. Auditory brainstem response thresholds (average 23.5) fell within the normal range for all ears tested. The average histologic bone formation score for all implants was 3.7. The average scores for obliteration implants and wall reconstruction implants were 3.5 and 3.9, respectively. All wall reconstruction implants underwent partial or total collapse into the bulla.

CONCLUSIONS

The high level of bone formation obtained by the use of Grafton implants in this study makes this material a promising resource for use in mastoid obliteration. The use of the material for canal wall reconstruction will likely require a sturdier preparation to prevent collapse into the mastoid cavity.

Prognostic Factors in Ossiculoplasty: A Statistical Staging System

OBJECTIVE

To determine factors that predict hearing results using a standard prosthesis system.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

All patients undergoing ossiculoplasty with the Dornhoffer HAPEX partial and total ossicular replacement prostheses (PORP and TORP) from February 1995 to May 1999 who had documented postoperative follow-up and no congenital atresia or stapes fixation. A total of 185 patients (200 ears), 105 men and 80 women, were evaluated.

INTERVENTIONS

Ossiculoplasty with the Dornhoffer prostheses.

MAIN OUTCOME MEASURES

Hearing results using a four-frequency pure-tone average air-bone gap (PTA-ABG). Multivariate statistical analysis determined the effect of mucosal status, ossicular chain status, and type of reconstruction techniques on hearing.

RESULTS

The PTA-ABGs were 13.4+/-8.1 dB and 14.0+/-8.4 dB for the PORPs (n = 114) and TORPs (n = 86), respectively, which was not statistically different. When the malleus handle was present (n = 126), the PTA-ABG was 11.6+/-6.2 dB, compared with 16.9+/-10.1 dB when it was absent (n = 74), which was statistically significant (p < 0.05). Mucosal fibrosis, drainage, revision ear surgery, and type of surgical procedure had a significant detrimental impact on hearing. The type of pathologic process (perforation vs. cholesteatoma) had no significant impact on hearing results.

CONCLUSIONS

The revised staging system, the Ossiculoplasty Outcome Parameter Staging Index, more adequately predicts hearing outcome in this series of 200 cases.

Pathophysiological mechanisms in immune inner ear disease

Immune inner ear disease is a somewhat controversial entity which describes cochleovestibular dysfunction that is related to immune-mediated mechanisms. The diagnosis of this disease is based on clinical presentation and response to various treatment protocols. Unfortunately, the presentation is variable and the treatment empirical, and this has caused much confusion in the diagnosis and management of the condition. To elucidate the variable nature of the disease, it is important to understand that more than one mechanism of immune injury may be involved. This paper attempts to classify clinical and experimental cases of immune inner ear disease with regard to the Gell and Coombs classification scheme of immune-mediated injury. By understanding the different pathophysiological mechanisms involved, the clinician should be better able to diagnose and manage this difficult problem in a directed fashion. The ramifications of the proposed classification system on the diagnosis, treatment and future research of immune inner ear disease are discussed.

Retrograde mastoidectomy with canal wall reconstruction: a single-stage technique for cholesteatoma removal

The goal of this retrospective study was to report the preliminary results of the retrograde mastoidectomy technique with canal wall reconstruction used as a primary treatment method for cholesteatoma. This synthesis of canal wall up (CWU) and canal wall down (CWD) techniques was performed in 70 patients (75 ears; 35 pediatric, 40 adult) with an average 45-month follow-up. Surgical intervention involved removal of a portion of the canal wall for exposure and extirpation of the cholesteatoma, followed by reestablishment of the canal wall during reconstruction in a single stage. This leaves the mucosa relatively undisturbed and limits the extent of canal wall removal, facilitating mastoid aeration and preservation of anatomy. Recurrent disease occurred in 5% of cases. The hearing improvement was statistically significant (p < .05), with an average preoperative 4-frequency pure tone average air-bone gap of 27.2 dB improving to 11.5 dB. No patient had a worsening of hearing. The surgery takes less time than traditional techniques, is reproducible and easily taught, and can be universally applied to all cholesteatoma patients as primary treatment.

A case of barotrauma-induced pneumolabyrinth secondary to perilymphatic fistula

We report the case of a 62-year-old woman who experienced pneumolabyrinth associated with a perilymphatic fistula. Her condition was diagnosed with the help of computed tomography, which detected the presence of an air bubble in the labyrinth, and middle ear exploration, which revealed that clear fluid was emanating from the round window niche in a manner consistent with the presence of a perilymphatic fistula. The niche was repaired with tragal perichondrium and bolstered with Gelfoam.