A Proof-of-Concept Computer Vision Approach for Measurement of Tympanic Membrane Perforations

OBJECTIVE

Size, an important characteristic of a tympanic membrane perforation (TMP), is commonly assessed with gross estimation via visual inspection, a practice which is prone to inaccuracy. Herein, we demonstrate feasibility of a proof-of-concept computer vision model for estimating TMP size in a small set of perforations.

METHODS

An open-source deep learning architecture was used to train a model to segment and calculate the area of a perforation and the visualized tympanic membrane (TM) in a set of endoscopic images of mostly anterior and relatively small TMPs. The model then computed relative TMP size by calculating the ratio of perforation area to TM area. Model performance on the test dataset was compared to ground-truth manual annotations. In a validation survey, otolaryngologists were tasked with estimating the size of TMPs from the test dataset. The primary outcome was the average absolute error of model size predictions and clinician estimates compared to sizes determined by ground-truth manual annotations.

RESULTS

The model's average absolute error for size predictions was a 0.8% overestimation for all test perforations. Conversely, among the 38 survey respondents, the average clinician error was a 11.0% overestimation (95% CI, 5.2-16.7%, p = 0.003).

CONCLUSIONS

In a small sample of TMPs, we demonstrated a computer vision approach for estimating TMP size is feasible. Further validation studies must be done with significantly larger and more heterogenous datasets.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2906-2911, 2024.

Tympanic membrane perforations cannot be reliably detected using computed tomography based on 15 cadaver dogs

The integrity of the tympanic membrane is an important factor when deciding treatment and therapeutic recommendations for dogs with ear disease; however, otoscopic examination may be difficult to perform due to features of external ear canal disease or patient compliance. CT is useful for the evaluation of middle ear disease, including cases in which middle ear disease is detected incidentally. The tympanic membrane is detectable using CT, but anecdotally, apparent focal defects or discontinuities of the tympanic membrane are often seen in patients with and without ear disease. The purpose of this prospective, observer agreement study was to determine if perforations of the tympanic membrane are reliably detectable on CT. Fifteen cadaver dogs underwent CT and video otoscopy to verify the integrity of each tympanic membrane. Cadavers were randomly assigned to have the tympanic membranes left intact or to undergo a myringotomy on either the left, the right, or both sides. CT was performed immediately following the myringotomies. Four blinded evaluators evaluated the pre- and post-myringotomy scans for a total of 30 scans (60 tympanic membranes). Average accuracy was low (44%), and interobserver agreement for all four evaluators was fair. Although the tympanic membrane is visible on CT, perforations of the tympanic membrane are unlikely to be accurately detected or excluded. The appearance of an intact tympanic membrane or defect in the membrane on CT should not be used as criteria to guide clinical treatment recommendations based on this cadaver model.

Tracking cell layer contribution during repair of the tympanic membrane

The tympanic membrane (i.e. eardrum) sits at the interface between the middle and external ear. The tympanic membrane is composed of three layers: an outer ectoderm-derived layer, a middle neural crest-derived fibroblast layer with contribution from the mesoderm-derived vasculature, and an inner endoderm-derived mucosal layer. These layers form a thin sandwich that is often perforated following trauma, pressure changes or middle ear inflammation. During healing, cells need to bridge the perforation in the absence of an initial scaffold. Here, we assessed the contribution, timing and interaction of the different layers during membrane repair by using markers and reporter mice. We showed that the ectodermal layer is retracted after perforation, before proliferating away from the wound edge, with keratin 5 basal cells migrating over the hole to bridge the gap. The mesenchymal and mucosal layers then used this scaffold to complete the repair, followed by advancement of the vasculature. Finally, differentiation of the epithelium led to formation of a scab. Our results reveal the dynamics and interconnections between the embryonic germ layers during repair and highlight how defects might occur.

[The technique and application of individualized tympanic membrane flap in the repair of tympanic membrane under endoscopy ear surgery]

Objective:To investigate the technique of personalized flap making under otoscopy and its clinical application. Methods:The clinical data of patients who underwent 301 Military Hospital myringoplasty in the Department of otoendoscopic surgery, Department of Otorhinolaryngology, head and neck surgery, Department of Otorhinolaryngology, from October 2022 to 2023 August were analyzed retrospectively, all enrolled patients were performed independently by the same skilled otoendoscopic surgeon. The patients' general condition, medical history, tympanic membrane perforation scope, perforation size, need for tympanic cavity exploration, thickness of skin flap, tympanic cavity lesion scope, skin flap making method and postoperative rehabilitation were collected. Results:Many factors such as the location of tympanic membrane perforation, the thickness of the skin flap, the degree of curvature or stricture of the ear canal and the extent of the lesion in the tympanic cavity should be considered in the manufacture of the individualized tympanic membrane skin flap, the way of skin flap making does not affect the long-term postoperative rehabilitation, but it can effectively avoid unnecessary ear canal skin flap injury and improve the operation efficiency. Conclusion:Scientific flap fabrication is important for improving surgical efficiency and enhancing surgical confidence.

Prophylactic antibiotics has no benefit for outcome in clean myringoplasty-A register-based cohort study from SwedEar

OBJECTIVES

To investigate if prophylactic antibiotics (PA) in conjunction with myringoplasty of clean and uninfected ears entails a reduction of postoperative infections within 6 weeks after surgery, and whether it affects the healing rate of the tympanic membrane (TM) at follow-up, 6-24 months after surgery.

DESIGN

A retrospective cohort study of prospectively collected data.

SETTING

Data extracted from The Swedish Quality Register for Ear Surgery (SwedEar), the years 2013-2019.

PARTICIPANTS

All patients in SwedEar with a registered clean conventional myringoplasty (tympanoplasty type I) including a follow-up visit.

MAIN OUTCOME MEASURES

The effect of PA use on TM healing rate at follow-up and postoperative infection within 6 weeks of surgery.

RESULTS

In the study group (n = 1665) 86.2% had a healed TM at follow-up. There was no significant difference between the groups that had PA administered (87.2%) or not (86.1%). A total of 8.0% had a postoperative infection within 6 weeks. Postoperative infection occurred in 10.2% of the group that received PA (n = 187) compared with 7.7% of the group that did not receive PA. However, this difference was not statistically significant. Postoperative infection within 6 weeks significantly lowered the frequency of healed TMs.

CONCLUSION

PA administered during clean conventional myringoplasty does not improve the chance of having a healed TM at follow up, nor decrease the risk of having a postoperative infection within 6 weeks after surgery.

Necessities, opportunities, and challenges for tympanic membrane perforation scaffolding-based bioengineering

Tympanic membrane (TM) perforation is a global clinical dilemma. It occurs as a consequence of object penetration, blast trauma, barotrauma, and middle ear diseases. TM perforation may lead to otitis media, retraction pockets, cholesteatoma, and conductive deafness. Molecular therapies may not be suitable to treat perforation because there is no underlying tissue matrix to support epithelium bridging. Chronic perforations are usually reconstructed with autologous grafts via surgical myringoplasty. Surgical treatment is uncomfortable for the patients. The grafting materials are not perfect because they produce an opaque membrane, fail in up to 20% of cases, and are suboptimal to restore acoustic function. Millions of patients from developing parts of the world have not got access to surgical grafting due to operational complexities, lack of surgical resources, and high cost. These shortcomings emphasize bioengineering to improve placement options, healing rate, hearing outcomes, and minimize surgical procedures. This review highlights cellular, structural, pathophysiological, and perforation specific determinants that affect healing, acoustic and surgical outcomes; and integrates necessities relevant to bioengineered scaffolds. This study further summarizes scaffolding components, progress in scaffolding strategies and design, and engenders limitations and challenges for optimal bioengineering of chronic perforation.

Repair of subtotal tympanic membrane perforations: A temporal bone study of several tympanoplasty materials

The aim of this project was to investigate the effects of different types of graft material, and different remaining segments of the native TM on its motion. In twelve human temporal bones, controlled TM perforations were made to simulate three different conditions. (1) Central perforation leaving both annular and umbo rims of native TM. (2) Central perforation leaving only a malleal rim of native TM. (3) Central perforation leaving only an annular rim of native TM. Five different graft materials (1) perichondrium (2) silastic (3) thin cartilage (4) thick cartilage (5) Lotriderm^® cream were used to reconstruct each perforation condition. Umbo and stapes vibrations to acoustic stimuli from 250 to 6349 Hz were measured using a scanning laser Doppler vibrometer. Results showed that at low frequencies: in the Two Rims condition, all grafting materials except thick cartilage and Lotriderm cream showed no significant difference in umbo velocity from the Normal TM, while only Lotriderm cream showed a significant decrease in stapes velocity; in the Malleal Rim condition, all materials showed a significant decrease in both umbo and stapes velocities; in the Annular Rim condition, all grafting materials except Lotriderm and perichondrium showed no significant difference from the Normal TM in stapes velocity. Umbo data might not be reliable in some conditions because of coverage by the graft. At middle and high frequencies: all materials showed a significant difference from the Normal TM in both umbo and stapes velocities for all perforation conditions except in the Annular Rim condition, in which silastic and perichondrium showed no significant difference from the Normal TM at umbo velocity in the middle frequencies. In the low frequencies, the choice of repair material does not seem to have a large effect on sound transfer. Our data also suggests that the annular rim could be important for low frequency sound transfer.

Effects of an enrofloxacin-silver sulfadiazine emulsion in the ears of rabbits with perforated tympanic membranes

OBJECTIVE

To determine whether an enrofloxacin-silver sulfadiazine emulsion (ESS) labeled for treatment of otitis externa in dogs has ototoxic effects in rabbits following myringotomy.

ANIMALS

6 healthy adult New Zealand White rabbits.

PROCEDURES

Rabbits were anesthetized for brainstem auditory-evoked response (BAER) tests on day 0. Myringotomy was performed, and BAER testing was repeated. Saline (0.9% NaCl) solution and ESS were then instilled in the left and right middle ears, respectively, and BAER testing was repeated prior to recovery of rabbits from anesthesia. Application of assigned treatments was continued every 12 hours for 7 days, and rabbits were anesthetized for BAER testing on day 8. Rabbits were euthanized, and samples were collected for histologic (6 ears/treatment) and scanning electron microscopic (1 ear/treatment) examination.

RESULTS

Most hearing thresholds (11/12 ears) were subjectively increased after myringotomy, with BAER measurements ranging from 30 to 85 dB in both ears. All day 8 hearing thresholds exceeded baseline (premyringotomy) values; results ranged from 30 to 85 dB and 80 to > 95 dB (the upper test limit) in saline solution-treated and ESS-treated ears, respectively. All ESS-treated ears had heterophilic otitis externa, epithelial hyperplasia of the external ear canal, various degrees of mucoperiosteal edema, and periosteal new bone formation on histologic examination. Scanning electron microscopy revealed that most outer hair cells in the ESS-treated ear lacked stereocilia or were absent.

CONCLUSIONS AND CLINICAL RELEVANCE

Results supported that ESS has ototoxic effects in the middle ear of rabbits. Further research is needed to confirm these findings. Myringotomized laboratory rabbits may be useful to study ototoxicity of drugs used in human medicine.

Retrospective Analysis of 24 Cases of Forensic Medical Identification on Traumatic Tympanic Membrane Perforations

OBJECTIVES

To study the case characteristics of forensic medical identification of traumatic tympanic membrane perforations, and to discuss the key points of forensic medical identification and evaluations methods for tympanic membrane perforations.

METHODS

Twenty-four cases of traumatic tympanic membrane perforations accepted by the Academy of Forensic Science during 2017 were retrospectively analysed. The data of perforation size, form, predilection site, healing time and healing mode were evaluated.

RESULTS

For the traumatic tympanic membrane perforations, the study showed that the small size of perforation （<1/2 quadrant） with irregular shape was common. The location of perforations was almost on the anterior and inferior quadrant, and centripetal migration healing was common. The healing rate within 6 weeks was up to 90%.

CONCLUSIONS

In the identification cases of traumatic tympanic membrane perforations, the key is to determine whether it is traumatic and whether it will heal spontaneously within 6 weeks. It is suggested to check the tympanic membrane weekly by an otic endoscope combined with acoustic impedance measurement at the sixth week, which can improve the accuracy, objectivity and scientificity of the identification.

Incidence of middle ear barotrauma in staged versus linear chamber compression during hyperbaric oxygen therapy: a double blinded, randomized controlled trial

CONTEXT

Middle ear barotrauma (MEB) is common during chamber compression in hyperbaric oxygen therapy. However, little evidence exists on an optimal compression protocol to minimize the incidence and severity of MEB.

OBJECTIVE

To compare the incidence of MEB during hyperbaric oxygen therapy using two different chamber compression protocols.

DESIGN

Double-blinded, randomized controlled trial.

SETTING

Hyperbaric Medicine Unit, The Townsville Hospital, Queensland, Australia, September 2012 to December 2014.

PATIENTS

100 participants undergoing their first hyperbaric oxygen therapy session.

INTERVENTION

Random assignment to a staged (n=50) or a linear (n=50) compression protocols. Photographs of tympanic membranes were taken pre- and post-treatment and then graded. Middle ear barotrauma was defined as an increase of at least one grade on a modified TEED scale.

RESULTS

The observed MEB incidence under the staged protocol was 48% compared to 62% using the linear protocol (P=0.12, exact one-sided binomial test), and thus the staged protocol did not show a significant improvement in MEB. However, the staged protocol resulted in significantly less severe deteriorations in MEB grades when compared to the linear protocol (P=0.028, exact one-sided Mann-Whitney type test).

CONCLUSION

The use of the assessed staged compression protocol for the first hyperbaric oxygen treatment showed no significant effect on the overall incidence of MEB when compared to the gold standard linear protocol but resulted in a significant improvement in the severity of the experienced MEBs. Further studies are needed to elucidate an optimal compression protocol to minimize middle ear barotrauma.

Hearing Loss in Young Adults Who Had Ventilation Tube Insertion in Childhood

It is known that insertion of ventilation tubes can cause damage to the tympanic membrane and hearing deterioration in the long term. To investigate long-term effects of recurrent otitis media and of ventilation tube insertion, we used a study group (n = 358 subjects), with or without a history of otitis media and/or ventilation tube insertion, derived from a birth cohort that had been followed for 16 years. At 18 years of age, a standardized audiometric and otoscopic examination was performed. We found that ventilation tube insertion in childhood was associated with a mean persistent hearing loss in young adults of about 5 to 10 dB at the group level with a sensorineural component of 3 to 4 dB. This hearing loss could not be explained by the disease load of otitis media in childhood. Repeated insertions of ventilation tubes caused a greater deterioration of hearing than did a single insertion. Structural changes of the tympanic membrane were a mediating factor in the causal relationship between ventilation tube insertion and hearing loss. We conclude that ventilation tube insertion in childhood may induce hearing deterioration in the long term.

Tympanic membrane bleeding complications during hyperbaric oxygen treatment in patients with or without antiplatelet and anticoagulant drug treatment

INTRODUCTION

Middle ear barotrauma (MEBt) is a frequently occurring complication of hyperbaric oxygen treatment (HBOT). High-grade MEBt may involve tympanic membrane (TM) haemorrhaging. Although many patients undergoing HBOT use antiplatelet or anticoagulant drugs, it is unknown whether these drugs increase the risk of MEBt and particularly TM bleeding complications.

METHODS

This multicentre, prospective cohort study investigates the prevalence of MEBt and TM bleeding during HBOT in patients using antiplatelet/anticoagulant drugs, compared with control patients not on such medications. MEBt was assessed by video otoscopy of the TM pre and post HBOT and scored according to the modified Teed score. Any complications from previous HBOT sessions were retrospectively documented.

RESULTS

Of 73 patients receiving HBOT, 34 used antiplatelet/anticoagulant drugs. Mild MEBt (Teed score 1 or 2) occurred in 23 of these 34 patients and in 31 of the 39 controls. Teed score 3 MEBt occurred in only two of the control-group patients and none of the patients using antiplatelet/anticoagulant drugs. Two patients using anticoagulant drugs reported epistaxis during a previous HBOT session, epistaxis was not reported by any control patients.

CONCLUSION

Low-grade MEBt is common during HBOT, however, high-grade barotrauma is rare with current chamber operating procedures. Patients using antiplatelet/anticoagulant drugs potentially may be prone to MEBt-associated haemorrhagic complications, but we did not observe any such increase in this cohort. Only mild epistaxis occurred in patients using anticoagulant drugs.

[Comparative study of the clinical observation on traumatic perforation of tympanic membrane]

OBJECTIVE

To explore the clinical treatment effects of sea buckthorn oil for in different size traumatic perforation of tympanic membrane in different size.

METHOD

Prospective, randomized study of 199 outpatients with traumatic perforation of tympanic membrane who were enrolled between December 2012 and December 2014 after informed consent. The patients were divided into treatment group (101 cases) and control group (98 cases). According to the size of the perforations, patients in each group were divided into large perforation group, middle perforation groups and small perforation group. The cases in large perforation group, middle perforation groups and small perforation group were 36, 34, 31 in treatment group and 35, 33, 30 in control group. The patients in treatment group were treated with sea buckthorn oil once a week, while the patient in control group were self-healing and checked once a week. All the patients were followed-up in two months. The healing rate of two groups was applied for the evaluation indicator of clinical effect. We compared the healing rate, average healing time and phological change of tympanic membrane of patients at the first and second month.

RESULT

The total healing ratio of patients in treatment group is 62.4% and 79.2% compared with 29.6% and 57.1% in control group at the first and second month (P < 0.05). There is statistical significance between the healing ratios of middle, large perforation groups in treatment group and control group (P < 0.05). There is no statistical significance between the healing ratios of small perforation group in treatment group and control group (P > 0.05). The average healing time of large, middle and small perforation group at the second month are significantly shorter than the control group.

CONCLUSION

It is better to apply observation method and let it self-healed for small traumatic tympanic membrane perforation according to its higher healing ratio. While, it is better to apply sea buckthorn oil method for middle and large traumatic tympanic membrane perforation according to its lower healing ratios. Sea buckthorn oil treatment is benefitial for increasing the ratio of perforation healing, shorten the healing time, resumpting of the middle ear function earlier, helping most of the patients to avoid operation and the reduce medical expense. Therefore, it is valuable to promote the method in clinical treatment.

The O'Neill grading system for evaluation of the tympanic membrane: A practical approach for clinical hyperbaric patients

Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the two most common complications of clinical hyperbaric oxygen (HBO2) treatment. The current grading system, the Teed's Classification, was first described in 1944 with modifications to this system over the years, but none are specific for the evaluation and treatment of patients undergoing clinical HBO2 therapy. Currently, the standard of care is a baseline otoscopic examination performed prior to starting HBO2 therapy. Repeat otoscopy is required for patients having ETD, pain or other symptoms during the compression and/or decompression phase of the treatment. Results from these examinations are used to determine the proper course of treatment for the ETD or MEB. The Teed's classification was not intended to correlate with the consistency of diagnosis, the clinical approach to relieving symptoms or the treatment of the inflicted trauma. It is not a practical tool for the modern hyperbaric team. We describe a newer grading system, the O'Neill Grading System (OGS), which allows simple, practical and consistent classification of ETD and MEB by all members of the clinical hyperbaric medicine team. Based on the O'Neill Grade assigned, evidence supported suggestions for appropriate actions and medical interventions are offered.

Risk factors affecting human traumatic tympanic membrane perforation regeneration therapy using fibroblast growth factor-2

OBJECTIVE

The use of growth factors to achieve closure of human traumatic tympanic membrane perforations (TMPs) has recently been demonstrated. However, pretreatment factors affecting healing outcomes have seldom been discussed. The objective of this study was to evaluate pretreatment factors contributing to the success or failure of healing of TMPs using fibroblast growth factor-2 (FGF-2).

DESIGN AND PARTICIPANTS

A retrospective cohort study of 99 patients (43 males, 56 females) with traumatic TMPs who were observed for at least 6 months after FGF-2 treatment between March 2011 and December 2012. Eleven factors considered likely to affect the outcome of perforation closure were evaluated statistically using univariate and multivariate logistic regression analysis.

INTERVENTIONS

Each traumatic TMP was treated by direct application of FGF-2.

MAIN OUTCOME MEASURES

Complete closure versus failure to close.

RESULTS

In total, 99 patients were analyzed. The total closure rate was 92/99 (92.9%) at 6 months; the mean closure time was 10.59 ±  6.81 days. The closure rate did not significantly differ between perforations with or without inverted edges (100.0% vs. 91.4%, p = 0.087), among different size groups (p = 0.768), or among different periods of exposure to injury (p = 0.051). However, the closure rate was significantly different between the high- and low-dose FGF-2 groups (85.0% vs. 98.3%, p = 0.010) and between perforations where the umbo or malleus was or was not involved in perforation (85.4% vs. 98.3%, p = 0.012). Additionally, univariate logistic regression analysis tests showed that it was difficult to achieve healing of these perforations with a history of chronic otitis media or residual TM calcification (p = 0.006), the umbo or malleus was involved in perforation (p = 0.038), and with a high dose of FGF-2 (p = 0.035) compared with control groups. Multivariate logistic regression analysis showed that only a history of chronic otitis media and residual TM calcification and perforation close to the umbo or malleus were associated with non-healing of the TM perforation (p = 0.03 and p = 0.017, respectively) with relative risk factors.

CONCLUSIONS

Direct application of FGF-2 can be used in all traumatic TMPs, the size of the perforation and inverted edges did not affect the closure rate, and the most beneficial dose was sufficient to keep the residual eardrum environment moist, but without adding liquid. Additionally, multivariate logistic regression analysis revealed that a large perforation was not a major risk factor for nonhealing of TM perforations. However, a history of chronic otitis media, residual TM calcification and involvement of the umbo or malleus in perforation were significant risk factors.

A new patch material for tympanic membrane perforation by trauma: the membrane of a hen egg shell

CONCLUSION

The egg shell membrane (ESM) patch may promote tympanic membrane (TM) healing in acute traumatic TM perforation.

OBJECTIVE

To evaluate the use of ESM for treating acute traumatic TM perforation.

METHODS

We reviewed charts of patients with traumatic TM injury from 2008 to 2011. Treatments were an ESM patch or a perforation edge approximation. We divided patients into two groups according to the treatment used. Each patient was matched by treatment onset and perforation size. We compared healing ratio, healing time, and frequency of otorrhea between the perforation edge approximation group and the ESM patch group. Matched t tests were used for analysis.

RESULTS

The healing ratio of the TM showed no significant difference between the two groups, but the time to heal was significantly shorter in the ESM patch group than in the perforation edge approximation group.

[The emergency plastic reconstruction of the tympanic membrane defects of post-traumatic and iatrogenic etiology with the application of the nanostructured bioplastic material]

The objective of the present study was to estimate the effectiveness of the application of the nanostructured bioplastic material for the plastic reconstruction of tympanic defects of post-traumatic and iatrogenic etiology. The authors report the results of the emergency plastic reconstruction of tympanic defects of post-traumatic and iatrogenic nature with the application of the nanostructured bioplastic material (giamatrix). The analysis of the results of the study prfovidd definitive evidence of the effectiveness of plastic reconstruction of tympanic defects with the application of the nanostructured bioplastic material.

Mechanisms of hearing loss after blast injury to the ear

Given the frequent use of improvised explosive devices (IEDs) around the world, the study of traumatic blast injuries is of increasing interest. The ear is the most common organ affected by blast injury because it is the body's most sensitive pressure transducer. We fabricated a blast chamber to re-create blast profiles similar to that of IEDs and used it to develop a reproducible mouse model to study blast-induced hearing loss. The tympanic membrane was perforated in all mice after blast exposure and found to heal spontaneously. Micro-computed tomography demonstrated no evidence for middle ear or otic capsule injuries; however, the healed tympanic membrane was thickened. Auditory brainstem response and distortion product otoacoustic emission threshold shifts were found to be correlated with blast intensity. As well, these threshold shifts were larger than those found in control mice that underwent surgical perforation of their tympanic membranes, indicating cochlear trauma. Histological studies one week and three months after the blast demonstrated no disruption or damage to the intra-cochlear membranes. However, there was loss of outer hair cells (OHCs) within the basal turn of the cochlea and decreased spiral ganglion neurons (SGNs) and afferent nerve synapses. Using our mouse model that recapitulates human IED exposure, our results identify that the mechanisms underlying blast-induced hearing loss does not include gross membranous rupture as is commonly believed. Instead, there is both OHC and SGN loss that produce auditory dysfunction.

Natural evolution of an eardrum bridge in patients with a traumatic eardrum perforation

Although the "eardrum bridge" of traumatic tympanic membrane perforations (TMPs) is very little seen, the underlying natural evolution during the healing process are still unknown.The aim of this retrospective study was to evaluate the natural evolution of the "eardrum bridge" of TMPs. The data for 36 patients with barotrauma-associated traumatic TMPs with an "eardrum bridge" between January 2006 and December 2007 were retrieved. The eardrum bridge was completely liquefied due to infection in one patient. The bridge gradually became necrotic and incorporated into the new eardrum in four patients, and the healed eardrum formed a retraction pocket. In nine patients, epithelial hyperplasia occurred on both sides of the eardrum bridge at the edges, and the bridge became incorporated into the new eardrum, which became very thin over time. However, in 22 patients, the eardrum bridge gradually became necrotic, finally forming a yellow crust-like substance and migrating to the external auditory canal (EAC); it was not incorporated into the new eardrum. The closure of the perforation depended on stratified epithelial migration at the perforation edges near the eardrum bridge, resulting in a normal morphology of the healed eardrum. The present study shows that the eardrum bridge has a different natural evolution during the healing process in patients with a TMP. Most eardrum bridges gradually became necrotic and migrated toward the EAC, and stratified epithelial migration occurred at the perforation edges near the eardrum bridge and closed the perforation. However, a few eardrum bridges gradually became necrotic or developed epithelial hyperplasia, then became incorporated into the new eardrum, resulting in the formation of a retraction pocket and the development of atrophy. Thus, long-term follow-up and histological examination of a larger sample is necessary.

Ear injuries caused by parts of hearing aid

This paper presents two cases of ear injuries caused by parts of hearing aids -a five-year old girl whose tympanic membrane was ruptured by a metal part of the earmold, and a patient with injury and inflammation of outer auditory channel caused by parts of a channel hearing aid. Aid amplifier could serve its purpose only if it is applied and handled with direct coordination with an ORL specialist.

Measurement of conductive hearing loss in mice

In order to discriminate conductive hearing loss from sensorineural impairment, quantitative measurements were used to evaluate the effect of artificial conductive pathology on distortion-product otoacoustic emissions (DPOAEs), auditory brainstem responses (ABRs) and laser-Doppler vibrometry (LDV) in mice. The conductive manipulations were created by perforating the pars flaccida of the tympanic membrane, filling or partially filling the middle-ear cavity with saline, fixing the ossicular chain, and interrupting the incudo-stapedial joint. In the saline-filled and ossicular-fixation groups, averaged DPOAE thresholds increased relative to the control state by 20-36 and 25-39 dB, respectively with the largest threshold shifts occurring at frequencies less than 20kHz, while averaged ABR thresholds increased 12-19 and 12-25 dB, respectively without the predominant low-frequency effect. Both DPOAE and ABR thresholds were elevated by less than 10 dB in the half-filled saline condition; no significant change was observed after pars flaccida perforation. Conductive pathology generally produced a change in DPOAE threshold in dB that was 1.5-2.5 times larger than the ABR threshold change at frequencies less than 30 kHz; the changes in the two thresholds were nearly equal at the highest frequencies. While mild conductive pathology (ABR threshold shifts of <10 dB) produced parallel shifts in DPOAE growth with level functions, manipulations that produced larger conductive hearing losses (ABR threshold shifts >10 dB) were associated with significant deceases in DPOAE growth rate. Our LDV measurements are consistent with others and suggest that measurements of umbo velocity are not an accurate indicator of conductive hearing loss produced by ossicular lesions in mice.

Ear syringing: minimising the risks

The patient, 61 years of age, saw the general practitioner for a repeat prescription for her blood pressure medication. During the consultation, the patient mentioned that she had some discomfort in her left ear. The GP examined the patient's ears and noted that both external auditory canals were blocked by wax. He recommended that the patient have her ears syringed and arranged for the practice nurse to perform the procedure. The GP did not see the patient again.

Blast injury of the ears: the experience from Yala Hospital, Southern Thailand

OBJECTIVE

To report acute and subacute consequences of blast injury to the ear from terrorists' bombings experienced from Yala Provincial Hospital, Southern Thailand

STUDY DESIGN

Retrospective chart review was done on 54 patients who suffered otologic injuries from bombing attacks in Yala Province from January to May 2005. Only 33 patients who had complete otologic and audiologic examination with a 3-month follow-up were studied.

MATERIAL AND METHOD

The ear symptoms, the size of tympanic membrane perforation, degree of hearing loss at first examination within 30 days after injuries were recorded. After a 3-month follow-up, the rate of spontaneous healing, rate of operation needed and long-term complications including hearing loss were analyzed.

RESULTS

The two most common initial symptoms were hearing loss (72.73%) and tinnitus (66.67%). Tympanic membrane perforations were encountered in 31 ears of 22 out of 33 patients. Spontaneous healing occurred in 23 ears (74.19%) with the highest incidence in small perforations (size < 50%). All healings occurred within 8 weeks. Tympanoplasty was done on the rest, except one patient. Eight patients (24.24%) had sensorineural hearing loss without tympanic membrane perforation. They still have sensorineural hearing loss, which is rather mild and typically affects in high tone with five of this group having normal hearing in speech range. Eleven patients from the tympanic membrane perforation group still have mixed hearing loss, which were also mostly mild.

CONCLUSION

Patients with aural symptoms after a blast injury need thorough otologic and audiological examination. The spontaneous healing of tympanic membrane perforation from explosive injury was relatively high (74.19%) after an 8-week follow-up, only 8/31 ears required surgical repair. At 3-months follow-up, more than two-thirds of the patients still had residual hearing loss, which was rather mild and affected mainly in high tone.

Lightning strike: a rare cause of bilateral ossicular disruption

Otologic injury associated with fatal and nonfatal lightning strikes has been sporadically reported in the literature. The most common acoustic insult is a conductive hearing loss secondary to rupture of the tympanic membrane. Although conjecture has been made of the theoretic possibility of ossicular injury from lightning strike, to our knowledge, none has been demonstrated intraoperatively or postmortem. We report the first documented case of ossicular disruption in a lightning-strike victim.

[Traumatic luxation of the stapes: radiology and surgical outcome]

OBJECTIVES

To describe the value of high resolution computed tomography scan (HRCT scan) in post traumatic hearing loss.

METHOD

HRCT scan of the temporal bone in millimetric cut with axial and coronal views was performed.

RESULTS

CT scan confirmed pneumolabyrinth with intact stapes depressed deeply into the vestibule. Surgical exploration was performed and the stapes was gently removed from the vestibule.

CONCLUSION

CT scan confirmed the diagnosis and studied the stapes integrity. Hearing deteriorated postoperatively is increased in case of stapes fracture. When a luxation of the stapes into the vestibule is suspected, it is important to determine how deeply and whether it is fractured. When such a case is encountered, high resolution CT scan of the temporal bone must be performed to confirm the diagnosis and to confirm integrity of the stapes.

Myringoplasty

There is marked diversity in the reported success rates for achieving an intact tympanic membrane following myringoplasty. Controversy exists about the factors thought to influence surgical outcome. Both of these facts have important implications for obtaining informed consent prior to surgery. This study reviews the factors thought to determine the likelihood of achieving complete closure of the tympanic membrane following surgical closure.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. Myringotomy in traumatic haemotympanum

A short-cut review was carried out to establish whether myringotomy is of value in cases of haemotympanum. In all, 205 papers were found in Medline and 105 in Cochrane using the reported searches. None presented any evidence to answer the clinical question. Hence, it is concluded that there is no evidence available to guide this decision and that local expert advice should be followed.

Comparative observation of protective effects of earplug and barrel on auditory organs of guinea pigs exposed to experimental blast underpressure

OBJECTIVE

To explore the protective effects of earplug and barrel on auditory organs of guinea pigs exposed to experimental blast underpressure (BUP).

METHODS

The hearing thresholds of the guinea pigs were assessed with auditory brainstem responses (ABR). The traumatic levels of tympanic membrane and ossicular chain were observed under stereo-microscope. The rate of outer hair cells (OHCs) loss was analyzed using a light microscope. The changes of guinea pigs protected with barrel and earplug were compared with those of the control group without any protection.

RESULTS

An important ABR threshold shift of the guinea pigs without any protection was detected from 8h to 14d after being exposed to BUP with a peak ranging from -64.5 kPa to -69.3 kPa ( P<0.01). The rate of perforation of tympanic membrane reached 87.5% and that of total OHCs loss was 19.46% +/- 5.38% at 14d after exposure. The guinea pigs protected with barrel and earplug had lower ABR threshold and total OHCs loss rate compared with the animals without any protection (P<0.01). All of the tympanic membrane and ossicular chain of the protected animals maintained their integrities. Meanwhile, the guinea pigs protected with the barrel had lower ABR threshold and total OHCs loss rate than those with earplug (P<0.01).

CONCLUSIONS

The earplug and barrel have protective effects against BUP-induced trauma on auditory organs of the guinea pigs and the protective effects of barrel are better than those of earplug.

Unusual middle-ear mischief: trans-tympanic trauma from a hair grip resulting in ossicular, facial nerve and oval window disruption

A case of piercing of the tympanic membrane, resulting in unusual consequences, is described. This is the first reported case of the long process of a dislocated incus resulting in trauma to the horizontal portion of a dehiscent facial nerve. Simultaneous depression of the stapes footplate resulted in a perilymph leak, but with delayed presentation.

Trommelfellrekonstruktion mit Knorpel

Autogenous cartilage-perichondrium-composite-grafts have become essential and well established transplant materials in reconstructive middle ear surgery. They have proven to be particularly appropriate for surgical situations which benefit from the bradytrophy and stiffness of the cartilage (adhesive otitis, retraction pockets, subtotal tympanic membrane defects, revision tympanoplasty). Of the numerous techniques available, the perichondrium-island technique and the palisade-cartilage technique are described in detail in this review, also regarding modifications and comments in the literature. Both methods show good functional and morphological results and should be chosen according to individual surgical requirements. The data of experimental investigations are involved in the decision which technique should be favored.

Penetrating middle ear trauma: a report of 2 cases

Penetrating middle ear injury can result in hearing loss, vertigo, and facial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disruption; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a perforation in the posterosuperior quadrant of the tympanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other. Both children underwent middle ear exploration and reduction of a subluxed stapes. We discuss the diagnosis, causes, and management of penetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeons should act promptly and be versatile in choosing methods of repairing ossicular chain injuries.

Experienced scuba divers in Australia and the United States suffer considerable injury and morbidity

OBJECTIVE

Scuba diving-specific injuries have been well described. However, the injury experiences of individual divers over long diving careers have rarely been investigated. Our objective was to study the acute and chronic injuries of experienced, recreational scuba divers.

METHODS

This was an international, cross-sectional, descriptive postal survey of experienced, recreational scuba divers belonging to diving clubs in Australia and the United States.

RESULTS

Seven hundred nine divers were enrolled (346 Australian divers and 363 US divers). Most participants were experienced (mean number of dives, 262) male divers (488; 68.8%) aged 31 to 50 years (425; 59.9%). Mild barotrauma was common. Ear, sinus, and tooth "squeeze" had been experienced on > or = 1 occasion by 369 (52.1%), 245 (34.6%), and 66 (9.2%) divers, respectively. Tympanic membrane (TM) rupture, round/oval window rupture, and subcutaneous emphysema had been experienced by 38 (5.4%), 8 (1.1%), and 5 (0.7%) divers, respectively. No diver reported pneumothorax or arterial gas embolism (AGE); however, 31 divers (4.4%) had suffered decompression sickness (DCS). A wide range of other injuries were reported. Sixteen divers (2.3%) reported permanent disabilities, which largely consisted of hearing loss, tinnitus, and balance disorder.

CONCLUSIONS

The majority of experienced divers who responded to the survey had suffered diving-related injuries, mainly barotrauma. Further research and diver education are needed to better document injury rates and minimize serious diving-related injuries and permanent disabilities.

[The effect of vitamin E on histopathologic healing and lipid peroxidation levels in experimentally induced traumatic tympanic membrane perforations]

OBJECTIVES

To examine the favorable effects of vitamin E on tympanic membrane perforations induced mechanically in guinea pigs.

STUDY DESIGN

Bilateral tympanic membrane perforations of 1.8 mm were induced in 40 guinea pigs. The animals were randomly divided into two groups equal in number. One group remained untreated, while the other was administered vitamin E (100 mg/kg/day) through intramuscular injections. On days 1, 3, 5, and 7, five animals in each group were randomly sacrificed. Histopathologic changes in the tympanic membranes were evaluated and malondialdehyde levels were determined.

RESULTS

Significant increases were observed in epithelial thickness, fibroblastic proliferation, and neovascularization in the study group (p<0.05). Epithelial thickness was found to be increased in both groups beginning from the first day; however, this increase was more rapid in the study group. Although malondialdehyde levels showed significant increases on days 3 and 5 in both groups (p<0.05), they returned to the first day values in vitamin E-treated animals on day 7, whereas controls still maintained high malondialdehyde levels.

CONCLUSION

Vitamin E hastens the healing process of traumatic tympanic membrane perforations.

Perilymphatic fistula following trans-tympanic trauma: a clinical case presentation and review of the literature

The perilymphatic fistula is constituted by an anomalous connection between the perilymphatic space and the middle ear. The principal accuses are to be sought in the intracranial pressure increasement, cranial traumas, barotraumas, congenital anomalies, trans-tympanic traumas, etc. Stapes's dislocation in the vestibule and the fracture of the platina are the most frequent pathogenic mechanisms. In clinical practice, the diagnosis remains a problem rather debated, even if the clinical pattern, the laboratory investigations, the diagnostic images and the tympanic exploration, all together can confirm, in the majority of the cases, the diagnostic suspect. This article presents a clinical case of a transtympanic trauma with perilymphatic fistula caused by a foreign body. The peculiarity of this case must be set in relation with both the aetiopathogenesis of the labyrinthine lesion and the severity of the symptomatology caused by it.

Rate of recovery of taste function after preservation of chorda tympani nerve in middle ear surgery with special reference to type of disease

To study the recovery of function of the chorda tympani nerve, we examined by electrogustometry 79 patients (83 ears) with both preoperative normal function of the nerve and operative preservation of the nerve, every 2 days during hospitalization and at 6 months after surgery. For symptoms such as tongue numbness and taste disturbance, patients with noninflammmatory (NI) diseases (13/20 or 65.0%) showed a significantly higher rate of symptoms than did patients with chronic otitis media (COM; 13/35 or 37.1%) at 2 weeks after surgery (p = .032). The patients with NI diseases (5/20 or 25.0%) tended to show a higher rate of symptoms than did the COM patients (2/35 or 5.7%) or cholesteatoma patients (2/28 or 7.1%) at 6 months after surgery. The rate of recovery of the EGM threshold to normal at 2 weeks after surgery was significantly lower in NI disease patients (6/20 or 30.0%) than in COM patients (23/ 35 or 62.9%) or cholesteatoma patients (19/28 or 67.9%; p = .015 and .008, respectively). Thus, the patients with NI diseases had postoperative symptoms and elevation of EGM threshold more frequently than did the patients with inflammatory diseases.

Ear injury caused by a sticky-tipped applicator

We here report a relatively rare case of traumatic injury of the tympanic membrane caused by a sticky-tipped applicator as well as some characteristics of this sticky-tipped applicator that were examined experimentally. This rare case was very unusual in that the injury was caused by external force applied from the medial to lateral direction during very careful cleaning (no unexpected force). Although removal of cerumen by a sticky substance seems to be an excellent idea, the present case shows that the stickiness that facilitates removal of the cerumen may be dangerous for thin, dry skin such as the tympanic membrane. Actually, the experimental considerations indicated that the stickiness was affected by the surface condition of the objective: soft, dry conditions increase it, while on the contrary, moist, dusty and oily conditions reduce it. The stickiness of the applicator, which was adjusted to use in the ear canal with an oily surface, appeared to be too large for a dry tympanic membrane. It is recommended that the sticky substance should be removed from the tip area or reduced by application of oil or powder before use.