Pilot study of dogs with suppurative and non-suppurative Malassezia otitis: A case series.

BACKGROUND: Rarely, Malassezia otitis presents as a painful, erosive otitis with an otic discharge containing Malassezia and neutrophils on cytology. There are no published reports of this type of suppurative Malassezia otitis (SMO). The role of Malassezia hypersensitivity in otitis is still unknown, and no association has been demonstrated with SMO. We compared Malassezia IgE levels, intradermal test and histology changes in SMO dogs with the more conventional Malassezia otitis (MO) presentation. RESULTS: Three dogs (case 1, case 2 and case 3) were diagnosed with SMO, one dog (case 4) was diagnosed with unilateral MO and unilateral SMO, and one dog (case 5) was diagnosed with MO. Only one case (case 4) with SMO/MO had a positive Intradermal Allergy Test (IDAT) and elevated IgE levels for Malassezia. Histopathology findings from SMO revealed: interface dermatitis (case 1 and 3), lymphocytic dermatitis (case 2) and chronic hyperplastic eosinophilic and lymphoplasmacytic dermatitis (case 4). Histopathology findings from MO showed perivascular dermatitis (case 4 and 5). All the cases were treated successfully. CONCLUSIONS: SMO presents with a distinct clinical phenotype in comparison with conventional MO. No consistent aetiology could be isolated. In these clinical cases it is possible that previous treatments could have influenced the results. More research is needed to understand the possible aetiologies and the pathogenesis of SMO.

Comparison of Tympanic Membrane Perforation With and Without Calcification of Anterior Mallear Ligament Under Transcanal Endoscopic Type I Tympanoplasty.

OBJECTIVES: Chronic suppurative otitis media (CSOM) induced tympanic membrane perforation (TMP) can be accompanied by anterior mallear ligament (AML) calcification. So far, comparative evaluations of TMP with and without AML calcification have rarely been reported. The aim of the current study is to compare the hearing outcomes of TMP with and without calcification of AML under transcanal endoscopic type I tympanoplasty. METHODS: Records of 67 patients diagnosed with CSOM and receiving transcanal endoscopic type I tympanoplasty were divided into the AML calcification group (Cal group, n = 31) and the non-AML calcification group (non-Cal group, n = 36). The 31 patients in the Cal group were divided into subgroup A and B according to the severity of calcification. The operation time, closure rate, and pre- and postoperative audiometric results were retrospectively collected and analyzed. RESULTS: Preoperatively, the Cal group had higher mean air-bone gap (ABG; P = .022), and ABGs at 250 Hz (P = .017) and 500 Hz (P = .008) compared with the non-Cal groups. The Cal group showed higher improvements of ABGs at 250 Hz (P = .039) and 500 Hz (P = .021) compared with the non-Cal groups postoperatively. CONCLUSIONS: The TMP with AML calcification leads to higher ABGs at low frequencies. The hearing outcomes are similar for TMP both with and without AML calcification after surgery. Our results suggest that transcanal endoscopic type I tympanoplasty is an appropriate surgical method for TMP with AML calcification, if the lesion can be detected and completely eliminated.

Unsolved problems and new medical approaches to otitis media.

INTRODUCTION: Otitis media (OM) is a spectrum of infectious and inflammatory diseases that involve the middle ear. It includes acute otitis media (AOM), otitis media with effusion (OME) and chronic suppurative otitis media (CSOM). AREAS COVERED: This manuscript discusses some of the emerging and unsolved problems regarding OM, and some of the newly developed prophylactic and therapeutic medical measures. EXPERT OPINION: In recent years, considerable progress in the knowledge of OM physiopathology has been made. However, although extremely common, diseases included under OM have not been adequately studied, and many areas of development, evolution and possible treatments of these pathologies are not defined. It is necessary that these deficiencies be quickly overcome if we want to reduce the total burden of a group of diseases that still have extremely high medical, social and economic relevance.

[Evaluation of structural changes of bone in chronic purulent otitis media]. / Klassifikatsiia strukturnykh izmenenii kostnoi tkani pri khronicheskom gnoinom srednem otite.

Fragments of bone tissue of the temporal bone, obtained during reconstructive-sanitizing operations in patients with chronic purulent otitis media, were studied by light and electron microscopy. An analysis was made of the degree of structural changes in bone tissue in chronic inflammation at the cellular and tissue levels after a histomorphological study in microwave decalcification. The method of diagnosis reliably allowed to differentiate the diseases characterized by the rarefaction of bone tissue, due to chronic inflammation, and also to determine the processes of transformation of bone tissue. The method of diagnosis reliably allows to differentiate diseases characterized by the rarefaction of bone tissue due to chronic inflammation, as well as to determine the processes of bone tissue transformation, however, the study is time-consuming, long-lasting and expensive.

Does The Type of Ossicular Chain Lesion Affect Outcomes in Chronic Suppurative Otitis Media Without Cholesteatoma?

OBJECTIVES: We evaluated the pattern of ossicular chain (OC) lesion in chronic suppurative otitis media (CSOM) without cholesteatoma and its impact on outcomes in primary and revision surgeries. MATERIALS AND METHODS: This was a retrospective chart review. Patients who underwent tympanoplasty due to CSOM with OC defect between 2010 and 2015 were included in the study. RESULTS: OC lesions were found during 40 of 147 tympanoplasties performed due to CSOM. The preoperative air-bone gap (ABG) was greater in both discontinuity and fixation cases than in cases with CSOM with an intact OC (p<0.001). Twenty-nine patients were followed up postoperatively, after excluding four patients with stapes footplate fixation, in whom stapedotomy was not performed simultaneously. Among the 29 patients, the audiological results were similar in cases of discontinuity and fixation regarding gap change, residual ABG, and the rate of successful ossiculoplasty. Primary tympanoplasties provided better results according to postoperative ABG and the rate of successful ossiculoplasty than revision surgeries (p<0.05); however, similar patterns of OC lesions were found during primary and revision surgeries. CONCLUSION: Both OC discontinuity and fixation occur in CSOM in a similar distribution in primary tympanoplasties and revision surgeries. The type of OC lesion does not affect outcomes. Primary surgeries provide better results, but that is not due to a difference in the character of the OC lesion.

Fungal Suppurative Otitis Media (Histopathology) Among Patients in North India.

Chronic suppurative otitis media (CSOM) has a substantial worldwide prevalence and is a major cause of hearing impairment. In cases of CSOM unresponsive to local antibiotics, superimposed fungal infection should be suspected. The aim of the present study was to study the spectrum of cases with fungal otitis media. The study was conducted over a period of 12 years (2006-2017). Fifteen cases of CSOM clinically not suspected to be of fungal etiology that underwent surgery with identification of fungal organisms on histopathology were included in the study. Age of the patients ranged from 12 to 75 years (mean age: 37.1 ± 22.7 years). Of 15 cases, 9 (60.0%) were males and 6 (40.0%) were females. It was a unilateral presentation in all. The complaints observed were ear discharge in all followed by itching (86.7%), pain (46.7%), decreased hearing (26.7%) and blocking sensation (13.3%). Histomorphologic typing of fungus was possible in 13/15 patients. Isolated aspergillus was identified in eight patients while mucor alone was seen in three patients. Mixed infection with Aspergillus + Candida and Aspergillus + Mucor was seen in one patient each. Categorization of fungus could not be done in rest of the two patients due to paucity of fungal profiles. Histopathological identification of fungal organisms in otomycosis provides a quick and fairly reliable diagnosis. Culture is considered the gold standard but it may not always be available or fruitful. Less turnaround time and accurate diagnosis facilitates prompt and optimal therapy in fungal otitis media thus preventing adverse outcomes.

Functional and Anatomical Outcome of Inside Out Technique For Cholesteatoma Surgery.

BACKGROUND: To study the efficacy of inside-out technique in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing & and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations. MATERIAL AND METHODS: Non-randomized, prospective, observational study performed at the Department of ENT in our hospital. In the study we included 100 patients presenting with chronic suppurative otitis media with cholesteatoma, they underwent inside out mastoidectomy and were followed up till the end of the study to evaluate the efficacy of inside out mastoidectomy in eradicating the disease from the middle ear cleft. To assess preservation of hearing and to assess cavity problems. RESULTS: Of the 100 patients, 98 patients had a total clearance of disease by the inside out approach, and 2 patients, had doubtful clearance. All patients came for regular follow up and none of them had residual disease at the end of the study period. Thus, the overall success rate was 100% in our study. A significant improvement in the mean air conduction (p < 0.01) and the mean air bone gap (p < 0.01) was seen in all postoperatively at 3rd month PTA. Only one patient had conductive hearing loss one and a half years postoperatively after initial improvement. A dry self-cleansing cavity was achieved in 95% of the patients and only 5% required regular cleaning of wax the cavities. CONCLUSION: Inside out mastoidectomy is a better alternative in canal wall down procedures as it not only clears the disease from the middle ear cleft, but also leaves behind a small postoperative cavity, which will preserve the hearing, decrease the cavity problems and increase the quality of life of such patients.

High-frequency conductive hearing loss as a diagnostic test for incomplete ossicular discontinuity in non-cholesteatomatous chronic suppurative otitis media.

Chronic suppurative otitis media, with or without cholesteatoma, may lead to erosion of the ossicles and discontinuity of the ossicular chain. In incomplete ossicular discontinuity (IOD), partial erosion of the ossicles occurs, but some sound transmission is noted throughout the ossicular chain. High-frequency conductive hearing loss (HfCHL) has been considered a hallmark of incomplete ossicular discontinuity. This study aims to evaluate the use of HfCHL as a preoperative predictor of IOD in patients with non-cholesteatomatous chronic suppurative otitis media. The HfCHL test was defined as the preoperative air-bone gap (ABG) at 4 kHz minus the average of the ABG at 0.25 and 0.5 kHz. The test was applied in 328 patients before surgery and compared to intraoperative findings as the gold standard. At surgery, 201 (61.3%) patients had an intact ossicular chain, 44 (13.4%) had a complete ossicular discontinuity, and 83 (25.3%) exhibited an IOD. The best cutoff level was calculated as 10 dB. The HfCHL test to diagnose IOD had a sensitivity of 83% and a specificity of 92% with a post-test probability of 78% and a likelihood ratio of 10.2. We concluded that the HfCHL test is highly effective in predicting IOD in patients with non-cholesteatomatous chronic suppurative otitis media and that it should be used routinely as a screening test prior to surgery.

Progression of changes in the sensorial elements of the cochlear and peripheral vestibular systems: The otitis media continuum.

Our study aimed to evaluate pathologic changes in the cochlear (inner and outer hair cells and stria vascularis) and vestibular (vestibular hair cells, dark, and transitional cells) sensorial elements in temporal bones from donors who had otitis media. We studied 40 temporal bones from such donors, which were categorized in serous otitis media (SOM), serous-purulent otitis media (SPOM), mucoid/mucoid-purulent otitis media (MOM/MPOM), and chronic otitis media (COM); control group comprised 10 nondiseased temporal bones. We found significant loss of inner and outer cochlear hair cells in the basal turn of the SPOM, MOM/MPOM and COM groups; significant loss of vestibular hair cells was observed in the MOM/MPOM and COM groups. All otitis media groups had smaller mean area of the stria vascularis in the basal turn of the cochlea when compared to controls. In conclusion, our study demonstrated more severe pathologic changes in the later stages of the continuum of otitis media (MOM/MPOM and COM). Those changes seem to progress from the basal turn of the cochlea (stria vascularis, then inner and outer hair cells) to the middle turn of the cochlea and to the saccule and utricle in the MOM/MPOM and COM stages.

Patho-bacteriological investigation of an outbreak of Mycoplasma bovis infection in calves - Emerging stealth assault.

Mycoplasma bovis (M. bovis) is an important bacterium, causing severe respiratory infection, and arthritis in dairy animals worldwide. This study is based on 50 suckling calves among which 15 showed respiratory distress, lameness and swollen joints and died later. M. bovis was isolated and identified from all dead (n = 15) and live (17.14%; 06 out of 35) calves on the basis of bacteriological examination. In morbid calves, the carpus and stifle joints were severely affected, while necropsy revealed multiple well-circumscribed calcified abscesses and caseous exudates in cranio-ventral and diaphragmatic lobes of lungs. Suppurative polyarthritis, fibrino-suppurative, teno-synovitis and otitis media were the common and striking lesion observed at postmortem examination. Histopathological examination revealed broncho-interstitial pneumonia and necrotic fibrino-purulent broncho-pneumonia in lungs. Similarly, synovial membranes and joints revealed presence of multiple foci of liquefactive necrosis surrounded by lymphocytes, plasma cells, macrophages and peripheral fibroplasia. In the bacteriological investigations, the characteristic fried egg colonies of M. bovis further confirmed this infection in all suspected cases. In conclusion, the current clinico-histo-pathological features are the depictive picture, and is the first report of M. bovis infection in calves in Pakistan.

Postinflammatory medial canal fibrosis: An institutional review and meta-analysis of short- and long-term outcomes.

OBJECTIVE: Few studies report outcomes of surgical management of postinflammatory medial canal fibrosis (PIMCF). The objectives were to compare short- and long-term outcomes after surgical repair of PIMCF at our institution and systematically aggregate published data for meta-analysis. DATA SOURCES: Medical records for the case series; PubMed, Scopus, and OVID/Medline for the systematic review/meta-analysis. METHODS: Patients undergoing surgical treatment of PIMCF were identified. Short-term (<2 years) and long-term (>2 years) postoperative outcomes were evaluated for the case series and aggregated for the meta-analysis. RESULTS: At our institution, 16 patients (21 ears) were identified. Compared to the preoperative air-bone gap (ABG) (27.7 ± 7.5 dB), mean postoperative short-term ABG (8.2 ± 7.5 dB) and long-term ABG (15.3 ± 11.3 dB) were significantly improved (P < 0.001 for both). Although short-term restenosis rate was low (0%) among long-term follow-up patients, 64% (9 of 14) experienced some degree of recurrent canal narrowing, including one case of complete restenosis (7%). Similarly, meta-analysis pooled preoperative ABG (29.3 ± 9.7 dB, 95% confidence interval [CI] 27.0-31.6) improved significantly during short-term (11.4 ± 8.0 dB, 95% CI 8.3-4.5, P < 0.0001) and long-term (14.3 ± 9.6 dB, 95% CI 11.6-16.9, P = 0.0004) follow-ups, with partial deterioration in hearing over time. Long-term complete restenosis rate (13.8%) was worse than short-term (8.0%), with no significant difference over time (P = 0.85). CONCLUSION: Postinflammatory medial canal fibrosis is a rare condition that can successfully be treated with surgery to restore patency of the external auditory canal. Patients who experience improved hearing early on, however, are at significant risk of restenosis and recurrence of their conductive hearing loss with time. LEVEL OF EVIDENCE: N/A. Laryngoscope, 2016 127:488-495, 2017.

Comparison of results of graft uptake using tragal cartilage perichondrium composite graft versus temporalis fascia in patients undergoing surgery for chronic otitis media - squamous type.

BACKGROUND: To assess, analyze and compare the results of graft uptake using Tragal Cartilage-Perichondrium Composite (TCPC) graft with Temporalis Fascia (TF) graft in patients who undergoing surgery for chronic otitis media - squamous type. METHODS: Patients aged 13 years and above with diagnosis of chronic otitis media - squamous type undergoing modified radical mastoidectomy, either primary or revision surgery with grafting of tympanic membrane (TM) and patients undergoing excision of postero-superior retraction pocket (PSRP) were included in this study. Patients were divided in two groups: Group A-patients undergoing TCPC graft and Group B -patients undergoing TF graft. Graft uptake results were assessed between 8-12 weeks of surgery. RESULTS: In both Groups there were 30 patients each. In Group A successful graft uptake was seen in 27 patients (90 %) and failure of graft uptake was seen in 3 patients(10 %). In Group B successful graft uptake was seen in 28 patients (93.3 %) and failure in 2 patients (6.67 %).Out of the total 60 patients, 11 patients had PSRP. All 6 patients with PSRP in Group A had successful graft uptake and no retraction. Among the 5 patients with PSRP in Group B all patients had sucessful graft uptake, however, in 2 patients retraction of the tympanic membrane was seen similar to the preoperative findings. CONCLUSIONS: There was no statistical difference (p = 0.433) between the use of temporalis fascia or tragal cartilage perichondrium in patients undergoing surgery for chronic otitis media - squamous type.

[The comparative analysis of the clinical and morphological picture of the various forms of chronic suppurative otitis media].

We present the results of the surgical treatment of 300 patients presenting with chronic suppurative otitis media. The changes in the mucous membrane of the tympanic cavity were revealed in 61% of the patients with mesotympanitis while spreading cholesteatoma occurred in 48% of the cases of «dry¼ perforations. The cholesteatomic process was documented in 64% of the patients with epitympanitis, the remaining patients presented with the pyo-carious process. The efficiency of the surgical intervention on the «dry¼ ear of the patients with the tubotympanic form of chronic suppurative otitis media (CSOM) amounted to 91.4% compared with 85% in the case of the altered mucous membrane of the tympanic cavity, 85.5% and 92.9% in the patients with the pyo-carious and cholesteatomic forms of the tympano-antral lesions, respectively. Residual cholesteatomas were found in 7.8% of the patients suffering from epitympanitis during the three year follow-up period. It is concluded that the results of clinical and morphological observations taken together with intraoperative findings give reason to consider mesotympanitis to be a prognosticallyunfavourable form of chronic suppurative otitis media.

A 43-year-old woman presenting with subacute, bilateral, sequential facial nerve palsies, then developing pseudotumour cerebri.

A patient presented elsewhere with what appeared to be a simple, unilateral, chronic suppurative otitis media and then developed an ipsilateral facial palsy. She soon developed the same problem on the other side. At the time, a brain MRI had been ordered but the clinician did not review it with a radiologist. The surgical specimens were not sent for histopathology. When transferred to our institution 3 months later, the patient had severe bilateral papilloedema due to intracranial hypertension due to missed cerebral venous sinus thrombosis. Further surgery revealed that the pathology in the temporal bone was B-cell lymphoma, which, fortunately, responded to chemoradiotherapy. There was good resolution of the facial palsies, but the patient has severe permanent visual loss due to optic atrophy.

Current concepts in the pathogenesis and treatment of chronic suppurative otitis media.

Otitis media (OM) is an inflammation of the middle ear associated with infection. Despite appropriate therapy, acute OM (AOM) can progress to chronic suppurative OM (CSOM) associated with ear drum perforation and purulent discharge. The effusion prevents the middle ear ossicles from properly relaying sound vibrations from the ear drum to the oval window of the inner ear, causing conductive hearing loss. In addition, the inflammatory mediators generated during CSOM can penetrate into the inner ear through the round window. This can cause the loss of hair cells in the cochlea, leading to sensorineural hearing loss. Pseudomonas aeruginosa and Staphylococcus aureus are the most predominant pathogens that cause CSOM. Although the pathogenesis of AOM is well studied, very limited research is available in relation to CSOM. With the emergence of antibiotic resistance as well as the ototoxicity of antibiotics and the potential risks of surgery, there is an urgent need to develop effective therapeutic strategies against CSOM. This warrants understanding the role of host immunity in CSOM and how the bacteria evade these potent immune responses. Understanding the molecular mechanisms leading to CSOM will help in designing novel treatment modalities against the disease and hence preventing the hearing loss.

[Comparative evaluation of mastoidoplasty results in application of various plastic materials].

The results of surgical treatment of 62 patients, suffering chronic purulent middle otitis, were analyzed. The structure of mastoid processus and attic constitutes a base for choice of middle ear surgical sanation. Sanation operation with preservation or reconstruction of external acoustical meatus posterior wall was finished with combined mastoidoplasty using autobone, spongioid bone bioimplant Tutoplast or bioceramic material "Sintekost". Achievement of a steady sanating effect have promoted in late postoperative period a trustworthy lowering of the perception threshold of the bone--conducted sounds as on vocal, and also on high frequencies, while of the air--conducted sounds--on vocal frequencies. This permits in perspective to perform a hearing--improving operations with good functional result.

Heparin binding-epidermal growth factor-like growth factor for the regeneration of chronic tympanic membrane perforations in mice.

We aim to explore the role of epidermal growth factor (EGF) ligand shedding in tympanic membrane wound healing and to investigate the translation of its modulation in tissue engineering of chronic tympanic membrane perforations. Chronic suppurative otitis media (CSOM) is an infected chronic tympanic membrane perforation. Up to 200 million suffer from its associated hearing loss and it is the most common cause of pediatric hearing loss in developing countries. There is a need for nonsurgical treatment due to a worldwide lack of resources. In this study, we show that EGF ligand shedding is essential for tympanic membrane healing as it's inhibition, with KB-R7785, leads to chronic perforation in 87.9% (n=58) compared with 0% (n=20) of controls. We then show that heparin binding-EGF-like growth factor (5 µg/mL), which acts to shed EGF ligands, can regenerate chronic perforations in mouse models with 92% (22 of 24) compared with 38% (10 of 26), also with eustachian tube occlusion with 94% (18 of 19) compared with 9% (2 of 23) and with CSOM 100% (16 of 16) compared with 41% (7 of 17). We also show the nonototoxicity of this treatment and its hydrogel delivery vehicle. This provides preliminary data for a clinical trial where it could be delivered by nonspecialist trained healthcare workers and fulfill the clinical need for a nonsurgical treatment for chronic tympanic membrane perforation and CSOM.

Bilateral nontuberculous mycobacterial middle ear infection: a rare case.

Nontuberculous Mycobacterium (NTM) middle ear infection is a rare cause of chronic bilateral intermittent otorrhea. We report a rare case of bilateral NTM middle ear infection in which a 55-year-old woman presented with intermittent otorrhea of 40 years' duration. The patient was treated medically with success. We conclude that NTM is a rare but probably under-recognized cause of chronic otitis media. A high index of suspicion is needed for the diagnosis to avoid prolonged morbidity. Treatment includes surgical clearance of infected tissue with appropriate antimycobacterial drugs, which are selected based on culture and sensitivity.

Attenuated TLRs in middle ear mucosa contributes to susceptibility of chronic suppurative otitis media.

The variability in the recovery of otitis media (OM) is not well understood. Recent data have shown a critical role for toll-like receptors (TLRs) in inflammatory responses to bacteria. It remains unclear whether TLRs-mediated mucosal immunity plays a role in the OM recovery. The etiology, pathological profile, expression levels of TLR2, TLR4, TLR5, TLR9 and proinflammatory cytokines were measured in human middle-ear mucosae sampled from three subject groups: non-OM group, chronic otitis-media (COM) group, and chronic suppurative otitis-media (CSOM) group. Of the 72 ears, 86.11% CSOM patients were positive for bacteria. The cellular makeup of the middle ear mucosa differs among the three groups. Mucosae from the CSOM group presented chronic inflammation or suppurative inflammation in the rudimentary stroma, mainly with infiltration of monocytes and macrophages. The mRNA and protein levels of TLR2, TLR4, and TLR5 exhibited no difference between the non-OM and COM groups but were significantly lower in the CSOM group. Conversely, there was no significant difference in the TLR9 level among the three groups. Furthermore, proinflammatory cytokines TNF-α, IL-1ß, IFN-γ, IL-6 were up-regulated in the CSOM group. This study provides evidence that the variability in clinical otitis media recovery might be associated with the variability in the expression of mucosal TLRs. Reduced TLR levels in the middle-ear mucosa might cause weak host response to bacteria, persistent inflammation and susceptibility to CSOM.

Postinflammatory medial meatal fibrosis: early and late surgical outcomes.

OBJECTIVES: To evaluate the primary and long-term surgical outcomes of patients with postinflammatory medial meatal fibrosis. METHODS: A retrospective study was conducted of 14 ears (in 12 patients) with postinflammatory medial meatal fibrosis managed surgically. Outcome measures were primary (i.e. less than six months) and long-term (i.e. greater than five years) closure of the air-bone gap, and the incidence of otorrhoea and restenosis. RESULTS: At primary review, the mean air-bone gap ± standard deviation had decreased from 29.9 ± 11.6 dB to 12 ± 8.4 dB (p < 0.0006). Seven (50 per cent) ears had closure of the air-bone gap to within 10 dB. However, for the 9 ears receiving long-term review, the mean air-bone gap ± standard deviation increased to 19.3 ± 15.2 dB; there was no significant difference between this result and pre-operative values (p = 0.06). Of the 9 long-term review ears, 3 (33 per cent) showed closure of the air-bone gap to within 10 dB. Recurrent otorrhoea was the most common complication, occurring in 5 of the 9 long-term review ears (56 per cent); in addition, 3 (33 per cent) of these 9 ears developed restenosis. CONCLUSION: Over time, the success of surgery for postinflammatory medial meatal fibrosis diminishes. This was demonstrated in the present study by progressive post-operative hearing decline and a high prevalence of otorrhoea and restenosis.