[Mastoidectomy with reconstruction of the posterior canal wall and obliteration preventing postoperative morbidity].

INTRODUCTION: A cholesteatoma in the mastoid or in the middle ear presents a hazard to the well-being of patients. Commonly used surgical interventions are not an ideal solution as they bear with them postoperative morbidity such as the need for water precautions, a high rate of cholesteatoma recurrence and the inability to undergo hearing rehabilitation. METHODS: Forty-five patients underwent an innovative surgical procedure that enables complete removal of the cholesteatoma, preservation of ear anatomy and hearing restoration. Our series was divided into two groups. The first group comprised those in whom this innovative procedure was the first one and the posterior bony canal was preserved (primary surgery). The second group comprised those in whom the bony wall had been removed previously during surgery (secondary surgery). RESULTS: In the first group, which included 29 patients, the middle ear cavity was found to be aerated in 69% of the patients, the tympanic membrane was intact in 93% and the rate of cholesteatoma recurrence was 10.3%. In the second group, which included 16 patients, the middle ear cavity was found to be aerated in 56.2% of cases, the tympanic membrane was intact in 75% and the rate of cholesteatoma recurrence was 25%. DISCUSSION: Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO) was found to be an effective approach for completely removing a choLesteatoma and preventing cholesteatoma recurrence. It is water-safe and provides an excellent basis for hearing restoration. The use of the original posterior bony canal for middle ear reconstruction was found to be beneficial. The authors advise an MRI study 18 months after surgery for cholesteatoma detection.

A congenital tympanic membrane cholesteatoma (CTMC) in the adult: a case report.

OBJECTIVE: We present an additional very rare case of a congenital tympanic membrane cholesteatoma (CTMC) in the adult. METHOD: Case report and literature review of CTMC. CASE REPORT: A 54-year old man was referred to us by his primary care physician who noted a white mass on the right tympanic membrane without prior history of otorrhea, tympanic perforations or previous otologic procedures. The pearl was about 5 mm diameter, centered on the umbo of a normal tympanic membrane (TM). The audiogram and the tympanogram was absolutely normal. CT confirmed a soft round shape tissue mass, located in the centre of the TM near umbo. The mass protruded both in the auditory canal and in the middle ear space, touching the malleus extremity, without any relationship with medial wall of the cavum tympani. A surgical excision was performed using a "minimal" retroauricolar transcanalar approach: the CTMC was located into the thickness of the TM, between epidermic and mucous layers. The ossicular chain was preserved intact. A partial myringoplasty (underlay technique) using a temporalis fascia graft was necessary. Histopathology confirmed a cystic cholesteatoma. After two months and one year follow-up, otoendoscopy showed a well-healed TM with a preserved normal audiogram and tympanogram. DISCUSSION: This exceptional (probably the first reported) case showed the possible localization of the CC in the TM, also in the adult. Criteria for classification of a TM cholesteatoma as congenital and possible pathogenetic mechanisms are discussed.

[Clinical study of secondary cholesteatoma].

Acquired middle ear cholesteatoma is considered to be formed by retraction of the tympanic membrane. There are rare cases in which the tympanic membrane epidermis extends into the medial surface of the tympanic membrane from the margin of its perforation, namely so-called secondary cholesteatoma. We studied the cases of secondary cholesteatoma clinically. These cases were found in 13 of 419 ears (3.1%) with acquired middle ear cholesteatoma operated on in our hospital from March 2001 to October 2010. The average age of all the cases was 51.5 years old, with a range of 11-65 years. We adopted the canal wall down tympanoplasty procedure with canal reconstruction in all cases. The postoperative hearing improvement rate was 84.6%. There were no cases of recurrence of the cholesteatoma.

Efficacy of diluted vinegar in treating granular myringitis: a randomised controlled trial.

OBJECTIVE: This study aimed to evaluate the outcome of granular myringitis treatment of 1 per cent diluted vinegar ear drops or 1 per cent chloramphenicol ear drops and to assess the side effects of 1 per cent diluted vinegar. METHOD: Twenty-four patients aged over 18 years and diagnosed with granular myringitis grade I or II within 90 days of symptom onset were included. Patients were equally randomised into either the 1 per cent diluted vinegar group or the 1 per cent chloramphenicol group. Outcome of treatment and side effects were compared between groups. The main outcome measure was completely epithelialised tympanic membrane at the eight-week period. RESULTS: Eleven of 12 patients treated with 1 per cent diluted vinegar had complete recovery. In the 1 per cent chloramphenicol group, 8 of 12 patients recovered. The difference between groups was not statistically significant (p = 0.156). The observed side effects of diluted vinegar included dizziness and mild external auditory canal irritation. CONCLUSION: One per cent diluted vinegar is an interesting option for granular myringitis. Other comparative advantages of 1 per cent diluted vinegar include its low price and no induction of antimicrobial resistance.

Middle-ear or mastoid granulation pathology associated with retraction of the pars flaccida and low-pitched tinnitus.

OBJECTIVE: This study aimed to evaluate the clinical features and outcomes of patients with middle-ear granulation pathologies associated with attic retractions. METHOD: The clinical records of adult patients with middle-ear granulation pathologies and attic retractions confirmed via computed tomography and surgical exploration between January 2012 and January 2019 were retrospectively reviewed. RESULTS: A total of 59 patients were included. Endoscopic examination showed a normal pars tensa but retraction of the pars flaccida in all patients. No granulation tissue or debris were observed. Low-pitched tinnitus was the principal complaint of 55 patients (100 per cent), followed by ear fullness (14 patients, 23.7 per cent). Of the 59 patients, 52 patients (88.1 per cent) underwent canal wall up mastoidectomy and 7 patients (11.9 per cent) underwent endoscopic endaural atticoantrotomy. No ossicular chain destruction was evident. All patients were followed up for 12 months. Tinnitus disappeared completely in 48 patients (81.4 per cent), improved significantly in 9 patients (15.3 per cent) and improved mildly in 2 patients (3.3 per cent). CONCLUSION: A granulation tissue pathology should be considered when a patient complains of low-pitched tinnitus and exhibits retraction of the pars flaccida. Computed tomography and surgical exploration should be scheduled.

Cartilage tympanoplasty with island technique for reconstruction of tympanic membrane perforation: anatomic and audiologic results.

OBJECTIVES: The aim of this study was to evaluate anatomic/audiologic outcomes of cartilage tympanoplasty with island technique and compare the results with the results of temporalis fascia tympanoplasty. PATIENTS AND METHODS: The charts of 40 patients who underwent surgery for primary type 1 tympanoplasty either with perichondrium-cartilage (12 males, 11 females; mean age 29.7 years; range 12 to 58 years) or fascia graft (9 males, 8 females; mean age 32.4 years; range 13 to 61 years) between January 2006 and January 2008 were retrospectively reviewed. Patients in whom the only pathology was subtotal tympanic membrane perforation with intact ossicular chain were included in the study. Pre- and postoperative audiograms, postoperative otoscopy findings and follow-up time were obtained from the patient's chart in both groups. Reviewed parameters were the complete closure rates of the tympanic membrane perforation and the change in air bone gap at each of four frequencies (0.5, 1, 2, 4 kHz). Audiologic evaluation was made among the patients in whom complete ear drum closure was achieved in both groups. RESULTS: Anatomic closure rates of the tympanic membrane perforation for perichondrium-cartilage and fascia group were 91.3% and 88.2%, respectively. Pre- and postoperative pure tone average air bone gap obtained at four frequencies for the perichondrium-cartilage and fascia group were 21.3+/-6.7 dB, 9.0+/-3.9 dB, and 21.2+/-6.9 dB, 8.5+/-4.4 dB, respectively. These findings revealed the overall gains of 12.3 dB for the cartilage-perichondrium group and 12.7 dB for the fascia group (p>0.05). CONCLUSION: The anatomic and audiologic results after cartilage tympanoplasty with island technique are comparable to those after temporalis fascia tympanoplasty. Furthermore, the cartilage is more resistant than the fascia to the anatomic deformation and necrosis. Therefore, we advise its use as a routine tympanic membrane reconstruction material without concern about effecting audiometric resuls.

Congenital cholesteatoma associated with blue eardrum.

The classic presentation of congenital cholesteatoma is a pearl behind the anterior-superior quadrant of an intact tympanic membrane. Idiopathic hemotympanum is characterized by a dark blue eardrum, the most prominent feature of which is the presence of cholesterol granulomas. Blue eardrum is associated with eustachian tube dysfunction. Despite the well-established relationship between eustachian tube dysfunction and the development of pediatric cholesteatoma, little has been written concerning the appropriate timing of tympanostomy tube placement. To date, there are no reports of congenital cholesteatoma associated with blue eardrum. A recent case of advanced congenital cholesteatoma (stage IV) associated with blue eardrum was treated using preoperative tympanostomy tube insertion. Tympanostomy tubes were helpful in preventing recurrence of the cholesteatoma after surgery. The case is presented along with a review of the literature.

Analysis of surgical treatment for middle-ear cholesterol granuloma.

Cholesterol granuloma is an intractable ear disease. Many studies of this condition have been published since the initial report by Manasse. However, the pathogenesis of this condition is unclear. This study reviewed the treatment of middle-ear cholesterol granuloma in 16 patients undergoing surgical treatment at Kurume University Hospital.The relationship between patients' pre-operative tympanic membrane findings and post-operative course was analysed. Patients with swollen tympanic membranes had significantly poorer outcomes. Patients with retracted tympanic membranes and those undergoing ossicular chain reconstruction had significantly better outcomes. The patients' overall hearing success rate at approximately two weeks post-operatively was 75 per cent. However, by six months post-operatively, the overall hearing success rate had declined to 62.5 per cent. Patients with poor hearing two weeks post-operatively did not acquire better hearing.

Acquired medial external auditory canal stenosis, anterior tympanomeatal angle blunting, and lateralized tympanic membrane: Nosology, diagnosis, and treatment.

OBJECTIVES: To analyze the etiologies, auditory consequences, diagnostic tools and therapeutic results of three often confused pathologies: acquired fibrous stenosis of the medial part of the external auditory canal (EAC), fibrous anterior tympanomeatal angle blunting, and lateralized tympanic membrane. MATERIAL AND METHODS: Retrospective study of 18 cases operated on over a 16-year period (14 patients: 7 female, 7 male; aged 11-64 years): 8 cases of medial EAC stenosis, 3 of blunting, and 7 of tympanic membrane lateralization. RESULTS: In all 3 pathologies, otoscopic and radiologic diagnosis was easily established, so that they could not be confused. All 3 induced>33dB conductive hearing loss. Medial EAC stenosis was secondary to chronic inflammation of the EAC, aggravated by surgery in 5 cases. Blunting was secondary to surgery altering the anterior tympanic annulus. Tympanic membrane lateralization was secondary to prior surgery without inflammatory process. Underlying EAC cholesteatoma was found in 3 cases of medial stenosis and in 1 case of blunting. Surgical results were disappointing in medial stenosis, with 62.5% recurrence and mean functional gain of 9dB, and in blunting, with 66.7% recurrence and mean functional gain of 6dB; auditory results were, however, good in these 2 pathologies when there was no recurrence of fibrosis. Results were significantly better in lateralized tympanic membrane, with 28.6% recurrence and mean functional gain of 16dB. CONCLUSION: The good results obtained in tympanic membrane lateralization seem to justify surgery in patients bothered by their hearing loss. The indication is more questionable in cases of medial fibrous stenosis and blunting, although significant auditory improvement is achieved in case of surgical success.

Lateral attic reconstruction technique: preventive surgery for epitympanic retraction pockets.

OBJECTIVE: To provide an estimate of the reliability of a preventive surgical approach named lateral attic reconstruction (LAR) technique for the treatment of Type II epitympanic retraction pockets. STUDY DESIGN: From a cohort of 25 adult patients presenting with a Type II epitympanic retraction pocket, 2 groups were randomly formed: a first one, with 15 patients who underwent LAR technique, and a second one, in whom (10 patients) only observation was planned and was therefore used as control. SETTING: University hospital as tertiary referral center. PATIENTS: Selection criteria for composing the 2 groups of study were the presence of a Type II epitympanic retraction pocket and a normal audiogram. INTERVENTION(S): The surgical procedure (LAR) consisted of a retroauricular approach, removal of a small piece of tragal cartilage, cleansing of the epitympanic pocket until denudation of the ossicular components, and placement of the cartilage graft to reconstruct the lateral epitympanic wall. MAIN OUTCOME MEASURE(S): All the patients were controlled at different postoperative or postobservation times (1, 3, 6, and 12 mo) via otomicroscopic examination, pure-tone audiometry, and tympanometry. RESULTS: All operated patients showed a normal anatomic pattern starting from the first postoperative control (1 mo) with a normal or near-normal hearing threshold and a Type A or As tympanogram in most cases. CONCLUSION: Lateral attic reconstruction technique has proved to be a reliable preventive technique for impeding a Type II epitympanic retraction pocket to worsen because it was observed in a percentage, although small (33.3%), of patients in whom a wait-and-scope policy was applied.

Recognition of paediatric otopathology by General Practitioners.

OBJECTIVE: General Practitioners (GPs) are required to diagnose a number of common ear pathologies on a regular basis. In particular, otitis media with effusion (OME) can be well managed in primary care if a reliable diagnosis can be made. We set out to assess the confidence and ability of GPs to diagnose otopathology, as well as the access that they had to tympanometry and pneumatic otoscopy to assist in making their diagnoses. METHODS: Twenty GPs were shown a series of forty slides, half with OME and half with normal tympanic membranes; they were then asked to state whether each image represented an ear with OME or not. The same GPs were then shown 20 slides, half of which were ears with a common pathology and half were normal; the participants were asked to state whether the slide was of a normal ear or make a diagnosis of the pathology. Access to equipment and previous training were assessed via a short questionnaire. RESULTS: The median score for the correct diagnosis of OME was 53% (range 30-67.5%), only slightly higher than chance. The participants correctly identified that an ear was abnormal for a mean of 80% of the time (range 65-95%), but were only able to make a correct diagnosis of the pathology for a mean of 41% of the ears (range 20-80%). No participant had access to pneumatic otoscopy or tympanometry in their practices. CONCLUSIONS: GPs have difficulty in correctly diagnosing OME from otoscopy alone, but are able to determine the presence of other otopathology. They were less able to diagnose specific abnormalities.

Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear--evaluation of image quality and agreement between examiners.

OBJECTIVE: To evaluate digital imaging of the tympanic membrane by telemedicine technology and study interpersonal agreement in assessing image quality. METHODS: In an open consecutive study, 64 children aged 2-16 years who attended three rural health care centres in Northern Sweden with otalgia were examined with video endoscopic photography of their tympanic membrane in a telemedical environment. One hundred and twenty-four images were stored in a central database and later assessed independently regarding image quality by an ENT specialist, a general practitioner and a registrar in general practice. The overall image quality was graded (0-2) regarding assessment of signs of tympanic membrane inflammation. All images were also assessed regarding 8 different components, four image-related components and four anatomically related components. RESULTS: Overall image quality was good, with 82.3% of acceptable or excellent quality. The position and thickness of the TM were found to be the most important factors of the images to be able to assess inflammatory disease. Image quality tended to be higher later in the study as a sign of improved skills of examiners. Interpersonal agreement between examiners was acceptable. Overall grade showed kappa 0.56, 0.49 and 0.66 respectively, and focus, light and existence of obscuring objects were the components with the highest agreement. CONCLUSIONS: The image quality of video endoscopy of the tympanic membrane was good overall. Interpersonal agreement in evaluating image quality was acceptable but not excellent. The use of digital imaging of good quality in clinical studies can offer an objective clinical evaluation of the TM in retrospect by independent reviewers using strict criteria.

Otopathologic evaluation of temporalis fascia grafts following successful tympanoplasty in humans.

OBJECTIVE: Temporalis fascia is a commonly used graft material in tympanoplasty; however, little is known about how the histological structure of fascia remodels postimplantation. Herein, we aim to quantify the pre- and postoperative microstructure of temporalis fascia and compare histological findings to the native tympanic membrane (TM). METHODS: Temporal bone specimens having undergone successful subtotal or total drum replacement using temporalis fascia were identified (n = 3). Surgically prepared preimplantation temporalis fascia (PreTF, n = 4) and normal TMs (n = 5) were used as controls. Multiple measurements of thickness of PreTF and of normal and fascia reconstructed TMs at the mesotympanum and hypotympanum were obtained. Collagen fiber patterns of normal and reconstructed TMs were histologically described. RESULTS: In cases of fascia tympanoplasty, the mean time of surgery to death was 16 years (range 8-28 years). All cases contained an aerated middle ear without residual perforation. There was no significant difference between the thickness of PreTF and fascia of reconstructed TMs (234.9 ± 144.9 µm vs. 162.9 ± 71.9 µm, P = 0.1). The lamina propria and total thicknesses of controls (59.8 ± 39.3 µm and 83.7 ± 42.4 µm, respectively) were thinner than the PreTF and fascia-reconstructed TMs, respectively, in all cases (P ≤ 0.001, P ≤ 0.001). Reconstructed TMs contained a thick, longitudinal fiber structure that was qualitatively similar to PreTF. CONCLUSION: Based on human temporal bone specimens, temporalis fascia does not significantly remodel, change thickness, or change fibrous structure following successful tympanoplasty. Results have implications for selection and surgical preparation of graft materials in TM reconstruction. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:E351-E358, 2018.

Dehiscent high-riding jugular bulb presenting as conductive hearing loss: A case report.

RATIONALE: Jugular bulb anomalies are asymptomatic lesions commonly seen in routine practice. However, some patients with jugular bulb anomalies may present with symptoms such as tinnitus or conductive hearing loss (CHL). PATIENT CONCERNS: A 9 year old boy complained right sided hearing disturbance without any vestibular symptoms. Pure tone audiometry (PTA) revealed a mild right sided conductive hearing loss. Otoscopy showed a red-purplish mass like lesion in his right middle ear cavity, which was regarded as hypervascular tumor. DIAGNOSIS: Based on otoscopic findings, preliminary differential diagnoses included jugular bulb anomaly, hemotympanum, cholesterol granuloma and paraganglioma. INTERVENTIONS: We performed contrast enhanced computed tomography of the temporal bone (TBCT). OUTCOMES: CT scan showed and enhancing lesion which was bulging from his right jugular foramen to the middle ear with dehiscent jugular bulb. The lesion showed the same degree of contrast enhancement with the venous vasculature. This lesion contacted with the tympanic membrane, incudostapedial joint and round window, which might be attributable to interruption of sound transmission mechanics. Otherwise there was no evidence of mass or trauma related lesions in the temporal bone. LESSONS: Although most of jugular bulb anomalies are asymptomatic, patients may present with conductive hearing loss due to the interference of sound transmission mechanics.

Assessment and management of retraction pockets.

This manuscript intends to review types, pathogenesis, associated risk factors, and potential methods of prevention and treatment of the retraction pockets in adults and children. The importance of retraction pockets (RP) lies in loss of original histological and anatomical structure which is associated with development of ossicular chain erosion, cho¬lesteatoma formation and potentially life threatening complications of cholesteatoma. The trans-mucosal exchange each gas in the middle ear (ME) is towards equalizing its partial pressures with the partial pressure in the environ¬ment. MEs that have abnormalities in the volume and ventilation pathways in the epitympanic may be more suscep¬tible to retraction pockets. Sustained pressure differences and/or inflammation leads to destruction of collagen fibers in the lamina propria. Inflammatory mediators and cytokines lead to release of collagenases result in viscoelastic properties of the lamina propria. The process of changes in the tympanic membrane structure may evolve to the cho¬lesteatoma formation. There are many different staging systems that clinicians prioritize in their decision making in the management of RP. The authors discuss the management possibilities in different clinical situations: RP without and with ongoing or intermittent evidence of Eustachian Tube Dysfunction (ETD), presence of adenoid hypertrophy or re-growth of adenoids, presence or absence of effusion, invisible depth of RP without effusion. invisible depth of RP with effusion, ongoing RP after VT insertion, and finally suspicion of cholesteatoma in a deep RP with ME effusion. A decision algorithm regarding the management of TM retraction and retraction pockets is provided.

Repair of Tegmen Tympani Defect Presenting with Spontaneous Cerebrospinal Fluid Otorrhea Using the Middle Cranial Fossa Approach.

Spontaneous cerebrospinal fluid (CSF) otorrhea frequently occurs without temporal bone trauma, fracture, surgery, or any identifiable causes. It is usually associated with tegmen tympani defects of the temporal bone in adults. The congenital origin theory and the arachnoid granulation theory have been accepted to explain the tegmen tympani defect. Magnetic resonance imaging (MRI) and computed tomography (CT) are used to show the defects, brain tissue, and the meninges. We recently encountered three cases of spontaneous CSF otorrhea with a defect on the tegmental plate of the temporal bone. High-resolution CT (HRCT) scan of the temporal bones showed the tegmen tympani defects. The defects were successfully repaired with temporal muscle fascia or fascia lata graft and fibrin glue using the middle cranial fossa approach via craniotomy.

What not to do in acute otitis media: the top five recommendations proposed by the Italian Society of Preventive and Social Pediatrics.

INTRODUCTION: With the aim to reduce inappropriate procedures and antibiotic therapy in the management of acute otitis media (AOM) in children, the Italian Society of Preventive and Social Pediatrics (SIPPS) proposed a top five list of recommendations for clinical practice. Areas covered: AOM is one of the most frequent reasons for antibiotic prescription in pediatric age. The over-estimation of AOM is associated with inappropriate treatment, increased costs, adverse events and spread of antibiotic resistance. Thus, the most recent guidelines provided stringent diagnostic criteria and considered the 'watchful waiting' approach, limiting the immediate antibiotic therapy to a well-characterized subgroup of children. Expert commentary: The five recommendations proposed are: 1) Do not diagnose AOM without having documented the presence of middle ear effusion 2) Do not diagnose AOM without examining the entire tympanic membrane; 3) Do not treat immediately all cases of AOM with antibiotics; 4) Do not administer ear analgesic drops until examining the whole tympanic membrane 5) Do not use macrolides in the AOM therapy. This list of top five recommendations could be a novel tool to spread the key messages on the guidelines and to promote the correct diagnostic procedures as well as a rational use of antibiotics in children.

Malleus head fixation: histopathology revisited.

CONCLUSIONS: Malleus head fixation is a rare but not exceptional pathology. It may be apparently congenital or acquired, and can be associated with stapes fixation. In the acquired secondary process two histological types of malleus head fixation were found: the first corresponded to non-tympanosclerotic bone remodeling and the second to localized tympanosclerosis. OBJECTIVE: To describe the histopathologic features of malleus head fixation and to correlate them with its clinical appearance. MATERIAL AND METHODS: Ten patients with surgically proven malleus head fixation were included in this series. A fixed malleus head was resected via a transcanal approach in six patients, and attic bony fragments fixing the malleus head were removed via a mastoidectomy without disruption of the ossicular chain in four. Histopathologic studies were performed for both types of malleus head fixation. RESULTS: Three types of acquired malleus head fixation were defined in accordance with the surgical and histopathological findings. Histologically, the first type presented with normal bone tissue, the second was characterized by non-tympanosclerotic bone remodeling and the third presented with a localized tympanosclerotic focus in the tympanic cavity.