Etiology and definitive microsurgical treatment of hemifacial spasm. Operative techniques and results in 47 patients

The clinical and operative findings are reviewed in 47 patients with intractable hemifacial spasm. The syndrome was classical in its features in 45 patients and atypical in two. Mechanical compression distortion of the root exit zone of the facial nerve was noted in all 47 patients. In 46 the abnormality was vascular cross-compression, usually by an arterial loop. In one patient, a small cholesteatoma was discovered and removed. Morbidity and postoperative results are discussed.

Radicular cyst affecting a root-filled human tooth: a long-term post-treatment follow-up

Apical periodontitis is caused primarily by microorganisms residing in the root canals of affected teeth. Nevertheless, there is convincing evidence implicating other independent factors that adversely affect the outcome of conventional root canal therapy. In this paper, morphological evidence is presented in support of the potential role of two endogenous factors that may interfere with post-endodontic healing of the periapex. The specimens consisted of a surgical biopsy of an asymptomatic periapical lesion which persisted for a follow-up period of 44 months. The biopsy was processed for correlated light and electron microscopy. The lesion was characterized by the presence of a large central lumen lined by a stratified squamous epithelium. The most striking feature of the lesion was the presence of vast numbers of cholesterol crystals which congregated in the connective tissue surrounding the cyst cavity. Extensive light and electron microscopic investigation of the apical part of the root canal and the lesion failed to reveal the presence of microorganisms. These findings strongly suggest that intrinsic factors like the accumulation of certain tissue break-down products such as cholesterol crystals, and the cystic condition of the lesion itself, can adversely affect the healing process of the periapex following root canal therapy. Consequently, such apical lesions can remain refractory to conventional endodontic therapy for long periods of time.

Atelectasis and secretory otitis media

That condition where the tympanic membrane is displaced toward the promontory is termed atelectasis. Thirty-seven patients (61 ears) showing various degrees of atelectasis graded from stage 1 to stage 4 were studied. Atelectatic drums are an inflammatory phenomenon occurring in underventilated ears. This conclusion is reached by considering the reversibility of the atelectasis upon ventilation; while the inflammatory factor can be deduced from the history and histopathology of the atelectatic drum, as well as the histology of the necrosed incus, the latter occurs in over a third of our cases. Also pneumatization of the mastoid is almost never present. Twelve (21%) of the ears treated did indeed develop a perforation at one time or another (two had cholesteatomas). Chronic granulating external otitis with specific features occurred in 15% of cases. The characteristics of these ears and their case histories lead us to view atelectatic ears as part of the otitis media syndrome, where their place is somehow transitional between secretory otitis media on the one hand and chronic otitis media on the other.

Cholesteatoma surgery: management of the labyrinthine fistula--a report of 97 cases

Preoperative, operative and postoperative findings in 97 cases of labyrinthine fistula are presented. Most of these patients had had symptoms of chronic otitis media for 20 years or more and manifested some degree of sensorineural hearing impairment. Two-thirds had experienced dizziness. The fistula was limited to the lateral semicircular canal in 83 cases and involved the labyrinth more extensively in 14 instances. The intact canal wall technique was used in less than 60% and an open cavity technique in 25% of the cases. Severe or total sensorineural hearing impairment developed postoperatively in 8% of the lateral canal cases and in over half of the extensive fistula cases. Five percent had incapacitating dizziness for up to six months postoperatively. When a labyrinthine fistula is encountered in an only hearing ear we usually recommend a classical modified radical mastoidectomy. In other instances the procedure performed will vary with the status of the opposite ear, the extent of the fistula, the sensorineural function of the involved ear and the size of the mastoid.

Cholesteatoma in children

The 65 cholesteatomas operated on in children showed a more expansive and rapid growth than those in adults. In one fifth of the cases cholesteatoma filled the whole air-cell area, which was wide in half of the children. Fifty-two ears of these children had an attic or a posterosuperior perforation. One case was complicated by a fistula in the horizontal semicircular canal, and the ossicular chain was unbroken in 23 cases (35%). Thus, the findings support the idea of the primary soft-tissue spread of cholesteatoma in children. Five ears (8%) discharged postoperatively, and three ears (5%) were reoperated on and showed residual tympanal cholesteatoma. Cavity obliteration with canal wall down technique proved safe, even in the cases of the most extensive and active cholesteatoma.

A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: the closed vs. the open technique

Cholesteatoma has long been a formidable adversary to the otologic surgeon. The surgical treatment has been basically by two methods, open and closed. It was felt that a study should be undertaken to compare the results obtained over a long period of time, utilizing these two methods. A need for this study existed as the same number of new cases of cholesteatoma was presenting each year. In reviewing the literature, it is found that new advancements have not yet been made in the prevention of the disease and the medical and surgical management has remained essentially the same. The ideal goal of successful surgery, namely an ear without disease, with normal hearing, and an intact drum and posterior canal wall, has been difficult to achieve in a high percentage of cases. To achieve this goal, two main surgical methods have evolved: the classical "open method," and the more recent "closed method." In the open method cases, the hearing results were often poor and the cavity presented a management problem. In the closed method there has been a fairly high occurrence of residual, and/or recurrent cholesteatoma which mecessitated a second procedure. These two methods were compared by reviewing a large number of histologically proved cholesteatoma cases 10 years after surgery, to determine the incidence of recurrence of cholesteatoma and the residual hearing function. The results of this study show conclusively that the hearing was better using the closed method, but the recurrence rate was considerably higher. This paper presents a practical method of approach to the management of all presenting cases of cholesteatoma.

Cholesteatoma in children

The surgical management of cholesteatoma in children remains a controversial subject. Many authors hold that the disease itself is more aggressive than that seen in adults. Furthermore, there appears to be a consensus that intact canal wall procedures, if used at all, should be reserved for adults only. The purpose of this paper is to study a group of children and adults who underwent the surgical removal of their cholesteatoma by intact canal wall tympanoplasty at the Otology Group between March 1, 1971 and March 1, 1977. A comparison of the results and complications in the two groups is presented in detail.

Tympanosclerosis: review of literature and incidence among patients with middle-ear infection

The aim of the study was to review the literature of tympanosclerosis especially its pathogenesis, to study the general incidence of tympanosclerosis among patients with chronic suppurative otitis media (CSOM), its association with cholesteatoma and also the type of hearing loss as well as its relation to the degree and site of tympanosclerosis. Seven hundred and seventy-five patients with CSOM were studied retrospectively. A full history was taken and thorough ENT examinations were carried out. Pure tone audiograms (PTA) of all patients were done and analysed. The operative finding of tympanosclerosis as well as middle-ear status were inspected. The incidence of tympanosclerosis was found to be 11.6 per cent (90 patients out of 775 CSOM cases). Most tympanosclerosis cases had dry ear, (85.6 per cent). Of the 57.8 per cent who had myringosclerosis, their PTA showed an AB gap 20-40 dB. When sclerosis affect both the tympanic membrane and middle ear, 61 per cent of patients had an AB gap > 40 dB. The association of cholesteatoma and tympanosclerosis may be regarded as uncommon, 2.2 per cent. The exact aetiology and pathogenesis of tympanosclerosis is as yet not well known. Our study concentrated on the clinical picture of tympanosclerosis among patients with CSOM. The majority of hearing loss associated with tympanosclerosis was of the conductive type.

Causes of failure of mastoidectomy for chronic otitis media

The operative findings of 66 patients who underwent revision mastoid surgery for recurrent chronic otitis media were analyzed for the causes of failure of the primary procedures. Recurrent cholesteatoma was found in 41% of the canal wall down and 70% of the canal wall up procedures requiring revision. Additional causes of failure included granulation tissue in unexenterated cells, particularly in the tegmental cells (41% of all cases and 64% of cases without cholesteatoma) and cells of the sinodural angle (38% of all cases and 58% of cases without cholesteatoma). The need for thorough exenteration of cells, particularly the tegmental cells and cells of the sinodural angle, mastoid tip, and facial recess, and the importance of lowering the facial ridge in canal wall down procedures were stressed. Following these principles, the success rate in creating a dry ear in 48 patients who had undergone from one to three previous mastoid procedures was 85% (mean follow-up three years).

Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy--changing trends in a developing country

OBJECTIVES

To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy.

DESIGN

A prospective case series.

SETTING

An academic tertiary referral center in India.

PATIENTS

Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning.

INTERVENTION

Concurrent craniotomy and mastoidectomy.

RESULTS

Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery.

CONCLUSIONS

In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.

Treatment of labyrinthine fistula

This cholesteatoma series comprises 84 ears, 81 of which had a labyrinthine fistula and 3 a horizontal semicircular canal opening that arose as a surgical complication. In 49 ears (58.3%), the operation was a primary one; in 35 ears (41.7%), it was a revision. Of all ears, 21 (25%) were deaf preoperatively. The fistula was located in the horizontal canal in 76 ears (90.4%). The matrix was removed in all these ears, and the fistula was covered with fibrin glue and fascia or periosteum. Hearing was preserved in all 57 ears in which matrix removal was carried out as the planned last stage. These included three ears in which the membranous canal was cut deliberately. Surgery that was performed against established rules caused deafness in three ears. Accidental opening of the horizontal canal caused no sensorineural loss in two ears as the fistulas were sealed immediately, while one ear in which the opening was not immediately recognized became deaf.

Cellular and subcellular events of bone resorption in human and experimental cholesteatoma: the role of osteoclasts

An ultrastructural study of the interface between aural cholesteatoma and adjacent bone was performed on specimens obtained from human and experimental gerbilline cholesteatoma. When an enlarging cholesteatoma contacted bone, a large number of monocytes and macrophages accumulated in the area of contact. The intervening middle ear mucosa degenerated and bone erosion occurred. Anatomic evidence is provided which indicates that bone erosion in both human and experimental cholesteatoma occurred as a result of the action of multinucleated osteoclasts. These osteoclasts had the ultrastructural appearance of normal osteoclasts with a well developed ruffled border and large numbers of mitochondria. These cells stained readily with acid phosphatase stains. Although many other mononuclear cells were seen in the vicinity of the eroded bone, only the multi-nucleated osteoclasts were associated with disappearance of the bone surface. Osteoclasts were commonly found in experimental cholesteatoma, but were infrequent in human cholesteatoma biopsies, presumable because patients undergoing cholesteatoma surgery ara often treated with topical installations of corticosteroids which inhibit osteoclasts.

The natural history of congenital cholesteatoma

OBJECTIVES

To describe the natural history of congenital cholesteatoma (CC) and to determine whether such a description provides clues about the origins and end points of these lesions.

DESIGN

A retrospective qualitative analysis of intraoperative illustrations of 34 consecutive patients with 35 CCs (1 bilateral).

SETTING

Two tertiary care children's hospitals.

PATIENTS

Thirty-four children with CC, mean age, 5.6 years (range, 2-13 years).

RESULTS

Congenital cholesteatoma originates generally, but not universally, in the anterior superior quadrant. The progression of growth is toward the posterior superior quadrant and attic and then into the mastoid. Contact with the ossicular chain generally results in loss of ossicular continuity and in conductive hearing loss.

CONCLUSIONS

Congenital cholesteatoma appears to have a predictable trajectory of growth, starting as a small pearl in the middle ear, eventually growing to involve the ossicles and mastoid, and causing varying degrees of destruction and functional impairment. The clinical picture of a young child with otorrhea, conductive hearing loss, tympanic membrane perforation in a nontraditional location, and a mastoid filled with cholesteatoma may represent the end point in the natural history of CC, despite the fact that this type of lesion is outside the accepted definition of CC.

Postinflammatory acquired atresia of the external auditory canal: treatment and results of surgery over 27 years

Postinflammatory, acquired atresia of the external auditory meatus is a relatively rare consequence of chronic otitis media or recurrent external otitis with an annual incidence of 0.6 cases per 100,000 inhabitants. Primary and late results after operative treatment of this condition in 53 ears over 27 years are presented. Perioperative findings are described, and an outline of applied surgical technique is given. Six patients had bilateral involvement. The male-to-female ratio was 1:2, median age at surgery was 46 years, and the median follow-up period was 5 years (range, 4 mo to 13 y). In 11% of the cases, recurrent atresia developed. Early operation is recommended, because cholesteatoma behind the atresia was found in 9%. Hearing improvement has been considerable after removal of the atresia with primary closure of airbone gap within 20 dB in 90% of the cases.

Acute otomastoiditis and its complications: role of CT

Acute bacterial (suppurative) otomastoiditis responds to antibiotic treatment; radiologic study is required only when there is clinical suggestion of coalescent mastoiditis, intracranial complications, or an underlying chronic disease. Computed tomography (CT) is the method of choice for evaluating otogenic intra- or extra-cranial complications. CT scans can show stages of disease progression when infection has spread by way of soft tissue, blood, and bone pathways into the dural venous sinuses, meninges, labyrinth, facial nerves, epidural and other intracranial spaces. When there is clinical suggestion of acute coalescent mastoiditis, a CT scan of the temporal bone can confirm the presence of rarefying osteitis, coalescence of the air cells, and subperiosteal abscess.

Pathogenesis of tympanosclerosis

In spite of the wealth of information on the clinical, histologic, and pathologic aspects of tympanosclerosis, the pathogenesis of tympanosclerosis is still unclear. In an attempt to understand the pathogenesis, 319 human temporal bones from 196 individuals with otitis media were studied. The extent and nature of tympanosclerosis and the characteristics of the otitis media associated with it were studied. Forty-five temporal bones from 35 individuals with otitis media were found to have tympanosclerosis, giving an incidence of 14.1%. It was seen most commonly in individuals over 40 years of age (86.7%). The male-to-female ratio was 1.6:1. The most common site of occurrence was the tympanic membrane (88.9%). Tympanosclerosis was seen more often in the anterior and posterior inferior quadrants of the tympanic membrane and that, too, in a central position. Tympanosclerosis was seen more commonly in temporal bones with irreversible inflammatory changes, and in this group, late plaques were more commonly seen than early or intermediate plaques. Audiometric charts failed to show any direct relationship between extent of tympanosclerosis and the severity of hearing loss. The only audiometric finding of any consequence was a mixed hearing loss in the presence of middle ear tympanosclerosis.

Cholesteatoma in the pediatric age group

The diagnosis and management of cholesteatoma in children remains controversial. In the past 15 years, the senior author (S.C.P.) has treated 320 patients with cholesteatoma. Patients 18 years and younger composed 40% (125) of the overall group and are the basis for this report. The patient data were compiled using the history, physical examination, audiograms, radiographs, patient questionnaires, surgical findings, and postoperative observations. The surgical treatment selected was determined by the extent of disease, the configuration of the mastoid, and a clinical assessment of eustachian tube function. A middle ear tympanotomy approach was used in 17% of the patients, a canal wall up procedure in 31%, and a canal wall down procedure in 52.3%. The average clinical follow-up was 3.9 years, with the range being from 3 months to 13.5 years. Hearing was maintained or slightly improved in a majority of cases. Residual disease occurred in 8% of patients, and recurrent disease in only 3%.

Complications of mastoiditis with special emphasis on venous sinus thrombosis

Two children with intracranial venous sinus thrombosis complicating mastoiditis prompted review of the experience with these disorders at the The Children's Memorial Hospital in Chicago over the past decade. Fifteen patients, 1.5 to 14 years of age, with mastoiditis were identified, including nine cases categorized as acute and six as chronic, the latter without fever but with chronic otorrhea. All six patients with chronic, but none with acute, mastoiditis were found to have cholesteatomas. Venous sinus thrombosis developed in four children and intracerebellar abscess in one child. Contrast-enhanced computerized tomography has proved valuable in the diagnosis of these rare, serious complications of mastoiditis in recent patients. Arteriography is still desired to confirm venous patency or occlusion prior to surgery because of well-documented developmental variations in venous drainage patterns. Optimal therapy of mastoiditis and its complications generally requires surgical drainage in addition to administration of antibiotics.

Intact canal wall tympanoplasty in the management of cholesteatoma

There are presently two schools of thought on the proper surgical management of cholesteatoma associated with chronic ear disease: one feels that the ear should be exteriorized and left "open"; the other takes the position that the disease can be removed, and the ear left in its normal anatomical and functional state. The latter group are known to favor a "closed" or more conservative procedure. The purpose of this paper is to review a series of patients who have had cholesteatoma managed by an intact canal wall procedure that prevents a postoperative cavity. Out of a series of 590 chronic ear surgeries performed between January 1, 1970, and December 31, 1974, there were 179 done for cholesteatoma (30 percent). There were 153 patients, 26 of whom had bilateral disease. Twenty-three patients were lost to follow-up, giving an overall total of 154 surgeries with from one to five-year information. The overall follow-up rate was 85 percent. Recurrent cholesteatoma was the most bothersome complication and occurred in 14 percent of the series. Residual cholesteatoma was managed by doing all procedures in two stages. The authors feel that the intact canal wall tympanoplasty is a procedure that will gain acceptance and will be more widely used in the future.

The unsafeness of 'safe' ears

Active chronic otitis media affects 0.5 per cent of adults and has two main variants. The first is when there is a squamous epithelial retraction pocket or cholesteatoma. The second variant is when the disease is primarily of the mucosa of the middle ear and mastoid air-cell system. Classically a cholesteatoma is considered 'unsafe' because of the risk of complications, particularly intracranial infection. Mucosal disease, on the other hand, is considered 'safe' because complications are thought to be rare. Surgery in the form of a modified radical mastoidectomy is considered to make active chronic otitis media 'safe'. A retrospective review of 26 consecutive brain abscesses considered secondary to active chronic otitis media revealed that a cholesteatoma was present in 12 (46 per cent), mucosal disease in 10 (38 per cent) and a modified radical mastoidectomy had been performed in four (15 per cent). Mucosal disease and a modified radical mastoidectomy should no longer be considered 'safe'. However, the risk of developing an intracranial abscess from any type of active chronic otitis media is low, in the region of one in 3,500.