Effects of tympanic membrane perforation, middle ear cavity volume, and mastoid aeration on hearing impairment.

AIMS: To investigate the effects of the location and size of tympanic membrane (TM) perforation and middle ear cavity volume on conductive hearing loss in patients with TM perforation. METHODS: Data were collected via a retrospective medical chart review. RESULTS: We enrolled 128 patients with a mean age of 45.6 ± 10.1 years. The mean perforation size was 21.2 ± 8.6% of the TM area, and the mean air-bone gap (ABG) was 20.2 ± 8.6 dB HL on pure tone audiometry. Patients were divided into two groups based on mean ABG. Patients with a large ABG had a significantly larger TM perforation area and smaller mastoid volume. The TM perforation was most commonly located in the central section. However, regression analyses showed that the proportion of the perforated TM area was the only independent predictor of a large ABG (odds ratio, 1.053; 95% confidence interval, 1.022-1.085; p = 0.001). When we analyzed the frequencies in which hearing loss occurred due to TM perforation, we confirmed that hearing loss occurred mainly in the low-frequency range. CONCLUSION: In patients with TM perforation, conductive hearing loss occurs mainly at low frequencies and in proportion to the size of the TM perforation.

Endoscopic Assessment of the Isthmus Tympanicum and Tensor Tympani Fold and their Relationship with Mastoid Pneumatization in Chronic Otitis Media.

OBJECTIVES: To endoscopically evaluate the patency of the isthmus tympanicum and integrity of the tensor tympani fold as routes of ventilation of the attic and mastoid in chronic otitis media (COM) and to assess their effects on mastoid pneumatization. MATERIALS AND METHODS: Sixty patients with COM were categorized into two groups: (1) Group A: 36 patients with tympanic membrane perforation (2) Group B: 24 patients with limited attic disease of whom 14 patients had attic retraction pockets and 10 with limited attic cholesteatoma. A multislice computed tomography scan of the temporal bone was performed for each patient to assess the degree of mastoid pneumatization. Notably, either myringoplasty or tympanomastoid surgery was performed in all patients. An endoscope was inserted into the middle ear for evaluation of the isthmus tympanicum and tensor fold area. RESULTS: The isthmus tympanicum was patent in most ears (83.3%) of group A, whereas it was blocked in most ears (83.3%) of group B. The tensor fold was complete in 77.8% of ears in group A and 83.3% of ears in group B. It was observed that 94.1% of ears with patent isthmus in both groups had normal mastoid pneumatization and 5.9% of ears had poorly pneumatized mastoid. By contrast, 7.7% of ears with blocked isthmus tympanicum had normal mastoid pneumatization and 92.3% had poor mastoid pneumatization. Normal mastoid pneumatization was observed in 50% of ears in both groups with complete tensor fold, and 83.3% of ears with an incomplete tensor fold. CONCLUSION: A significant correlation was observed between COM with limited attic disease and obstruction of the isthmus tympanicum. Obstruction of isthmus tympanicum was associated with poor mastoid pneumatization. Furthermore, an incomplete tensor fold was associated with well pneumatized mastoid.

The potential protective effects of temporal bone pneumatization: A shock absorber in temporal bone fracture.

OBJECTIVES: We hypothesize that when temporal bone fractures occur, the pneumatic cells in the temporal bone are able to absorb most of the impact force during a traumatic event. This study aims to correlate the degree of pneumatization of the temporal bone with the severity of temporal bone fracture (TBF). METHODS: Charts and computed tomography scans representing 54 TBFs, diagnosed from 2012 to 2017 at a single tertiary hospital, were retrospectively reviewed. Temporal bone pneumatization (TBP) in the petrous apex and mastoid region was evaluated using previously published classification systems. TBP classifications and fracture types were correlated with TBF complications such as sensorineural hearing loss (SNHL), facial nerve palsy (FNP), and vestibular dysfunction. RESULTS: Patients with increased pneumatization of the temporal bone had significantly fewer and less severe SNHL. SNHL more strongly correlated with the degree of pneumatization in the mastoid (P = 0.005) than that in the petrous apex (P = 0.024). On the other hand, the degree of TBP correlated poorly with FNP and vestibular dysfunction. However, the mastoid hypopneumatization demonstrated significant correlation with otic-capsule violations (P = 0.002). Fractures with otic-capsule violation were 4 times more likely to have vestibular dysfunction (P = 0.043) and 3 times more likely to have SNHL (P = 0.006). FNP was not associated with otic-capsule violating fractures but was 3.5 times more common in comminuted fractures (P = 0.025). CONCLUSIONS: The degree of temporal bone pneumatization was negatively correlated to the incidence of otic-capsule violation and the severity of hearing impairment in patients with temporal bone fracture. This study substantiated the potential protective effect of temporal bone pneumatization in TBFs.

Síndrome de Eagle: relato de caso / Eagle Syndrome: a case report

A síndrome de Eagle é uma condição rara e com etiologia ainda não bem estabelecida, a qual se deve ter bastante suspeição para seu correto tratamento. Seu tratamento deve ser definido em conjunto com o paciente, seja ele conservador ou cirúrgico, sempre levando em consideração as expectativas do paciente, além da maior expertise do profissional na modalidade escolhida para o tratamento. Neste artigo, apresentamos uma paciente de 35 anos atendida no Hospital Felício Rocho, discutindo os diversos aspectos da doença, inclusive a modalidade de tratamento escolhida para o caso.

Eagle syndrome is a rare condition, and its etiology has not yet been well established and its correct treatment is uncertain. Its treatment must be defined together with the patient, be it conservative or surgical, always taking into consideration the patient's expectations, in addition to a solid professional expertise in the modality chosen for the treatment. In this article, we present the case of a 35-year-old patient who was admitted to the Felício Rocho Hospital and discuss the various aspects of the disease, including the treatment modality chosen for the case.

Differentiating among conductive hearing loss conditions with wideband tympanometry.

OBJECTIVE: This study was aimed to investigate whether wideband tympanometry (WBT) can distinguish among various kinds of conductive hearing loss and provide additional information. METHODS: We recruited normal subjects and patients with conductive hearing loss due to the following reasons: tympanic membrane perforation only, ossicular chain problem only, and one or other of those conditions combined with mastoid problems. Wideband absorbance at ambient pressure, peak pressure, resonance frequency, and averaged tympanogram data were measured by WBT and compared between the normal, tympanic membrane perforation only, ossicular chain problem only, and combined with mastoid problems groups. RESULTS: The normal subjects showed an average peak pressure of -19.51daPa and an average resonance frequency of 965.94Hz. Tympanic membrane perforation only patients showed a very low peak pressure (-124.93daPa) and resonance frequency (73.12Hz). When patients have ossicular chain problems, they showed slightly low peak pressures (43.08daPa) without changes in the resonance frequency (1024.8Hz). Mastoid problem subjects showed slightly decreased resonance frequencies (787.71Hz). Tympanic membrane perforation subjects showed decreased absorbance at low frequencies and ossicular chain problem subjects showed decreases at high frequencies. When comparing the perforation only and ossicular chain subjects by absorbance at 707Hz, the area under the ROC curve was 0.719 (P<0.022). Mastoid problems subjects showed decreased absorbance at all frequencies. CONCLUSION: WBT can help to distinguish tympanic membrane perforation only and ossicular chain problem patients. WBT may provide additional information on "combined with mastoid problems" patients.

Actinomycosis of the Middle Ear and Mastoid.

INTRODUCTION: Actinomycosis is a saprophytic infection caused by actinomycetes. Actinomycetes is a gram positive, anaerobic, non acid-fast, filamentous bacterium. Although actinomyce is considered as a part of the normal flora, it is rarely seen in middle ear and mastoid cavity. AIM: is to report a rare case of Actinomycosis infection of the middle ear and mastoid cavity. CASE REPORT: We presented A 24 years old male arrived to our outpatient department complaining of right-sided otalgia and hearing loss for 8 years, no history of otorreah, vertigo or dizziness. He had a history of right-sided chronic suppurative otitis media with a history of two operations at the same side. This report suggests that actinomycosis , although it is rare, it could occurs in middle ear. It should be considered as one of the differential for chronic suppurative otitis media patients with no improvement on medical treatment. CONCLUSION: Combined medical and surgical treatment is the recommended management for Actinomycosis infection of the middle ear and mastoid cavity.

Tubotympanic system functioning.

The Eustachian (auditory) tube and tympanomastoid cavities form an anatomic and functional whole that cannot easily be divided, and is therefore known as the "tubotympanic system". The system has been the focus of several studies, with complex and sometimes contradictory results, making an overview of its functioning difficult to obtain. The objective of the present article is to review the current state of knowledge, as an indispensable preliminary to understanding tubotympanic system dysfunction, and notably the development of chronic otitis. The system as a whole is covered by mucosa, which provides continuity, although with certain particularities from one area to another, and plays a primordial role. Thus, under physiological conditions, gas diffusion across the tympanomastoid mucosa largely ensures the equilibrium of pressure between the middle ear and outside environment, the tube orifice being very little involved. Under large rapid change in atmospheric pressure, the aeration function of the Eustachian tube comes into play, governed by a reflex mechanism. The system also has other functions that are essential to good middle-ear functioning: protection against nasopharyngeal secretions and pathogens and against certain physiological noises; middle-ear cavity clearance by mucociliary transport of pathogens, partly related to submucosal gland secretion; and immune defense.

Upbeat nystagmus after bilateral superior canal plugging: A peripheral cause of vertical nystagmus.

Vertical nystagmus without a torsional component is generally considered a finding indicative of central nervous system pathology. We report two cases of purely upbeat nystagmus elicited with mastoid vibration after bilateral superior canal plugging, to highlight the vestibular pathophysiology involved in this unusual peripheral cause for upbeat nystagmus. Laryngoscope, 127:1698-1700, 2017.

Assessment of Mastoid Function with Magnetic Resonance Imaging after Canal Wall Up Cholesteatoma Surgery.

OBJECTIVE: To use magnetic resonance imaging (MRI) to assess the extent of mastoid opacification after canal wall up (CWU) cholesteatoma surgery. MATERIALS AND METHODS: Thirty-five children in whom post-operative MRI had been obtained after CWU surgery. Cholesteatoma confined to the meso- and/or epi-tympanum was removed using a transcanal approach (n=18). More extensive disease required a combined approach tympanomastoidectomy (CAT, n=17). Mastoid opacification was assessed in both ears by a neuroradiologist blind to surgical details using an ordinal scale from 0 (no opacification) to 6 (completely opacified). The primary outcome measure was presence of normal mastoid ventilation, defined by evaluation of non-operative ears as a score ≤2. The presence of normal ventilation, as well as the raw opacification scores, were compared according to type of cholesteatoma surgery: 1) transcanal, with no mastoidectomy and 2) CAT. RESULTS: Mastoid ventilation was normal in 18 post-operative ears (51%). There was no significant difference in the proportion of normally ventilated mastoids in the CAT (n=17) and transcanal (n=18) groups (p=0.318; Fisher's exact). However, mastoid opacification scores were significantly higher in the CAT group than in the transcanal group (p=0.036; Mann-Whitney U). CONCLUSION: The mastoid frequently fails to become normally ventilated after cholesteatoma surgery. Subgroup analysis suggests cortical mastoidectomy does not increase the likelihood of normal mastoid ventilation after CWU cholesteatoma surgery. MRI provides a non-invasive tool to assess mastoid function, which contributes to the current debate on optimum surgical strategies for management of the mastoid in cholesteatoma surgery. Further research will determine whether this measure of mastoid health correlates with risk of recurrent cholesteatoma.

Middle ear ventilation status postoperatively after translabyrinthine resection of vestibular schwannoma with mastoid obliteration and Eustachian tube occlusion: is the Eustachian tube enough to ventilate the middle ear without the mastoid air cell system?

BACKGROUND: Gas pressure balance is essential for maintaining normal middle ear function. The mucosal surfaces of the middle ear, the mastoid air cell system (MACS), and the Eustachian tube (ET) play a critical role in this process; however, the extent that each of these factors contributes to overall middle ear ventilation is unknown. The objective of this study was to determine if the ET alone can maintain normal middle ear pressure without the MACS. To do this, we reviewed subjects who had their MACS completely removed with translabyrinthine (TL) surgery for vestibular schwannoma. METHODS: A retrospective chart review was done to collect pre and postoperative tympanometry data from patients who underwent resection of vestibular schwannoma. Data from the operative side was compared to the non-operative side at 2 years post-op. RESULTS: Twenty-four patients were included in this study. Of these, 63 % achieved a type A tympanogram at 2 years post-op in the TL resection group, implying an ability to maintain middle ear pressure in the absence of a mastoid cavity. Because some had negative pressures post TL resection, the average change in pre and postoperative pressure was -37.5 daPa for the operative side and 7.8 daPa for the non-operative side. This was significantly different. DISCUSSION: The difference for change in pre and postoperative pressure and compliance between operative and non-operative side might be expected from the ET plugging during TL resection. However, more interesting are those patients in whom the ET presumably reopens, and in these subjects, despite having no mastoid compartment at all, and the space obliterated with fat, they were still able to maintain normal ventilation of the middle ear space. CONCLUSION: Our findings imply that the ET alone is adequate to ventilate at least the reduced middle ear space following TL surgery in most subjects, and perhaps in 100 % if the ET hadn't been plugged during surgery. Hence, the mastoid air cell system, even when healthy, is not needed to maintain air in the middle year cleft.

Etiopathogenesis of acquired cholesteatoma: prominent theories and recent advances in biomolecular research.

OBJECTIVE: To review recent biomolecular advances in etiopathogenesis of acquired cholesteatoma. DATA SOURCES: MEDLINE via OVID (to March 2014) and PubMed (to March 2014). REVIEW METHODS: All articles referring to etiopathogenesis of acquired cholesteatoma were identified in the above databases, from which 89 articles were included in this review. RESULTS: The mechanisms underlying the etiopathogenesis of acquired cholesteatoma remain a subject of competing hypotheses. Four theories dominate the debate, including theories of invagination, immigration, squamous metaplasia, and basal cell hyperplasia. However, no single theory has been able to explain the clinical characteristics of all cholesteatoma types: uncoordinated hyperproliferation, invasion, migration, altered differentiation, aggressiveness, and recidivism. Modern technologies have prompted a number of researchers to seek explanations at the molecular level. First, cholesteatomas could be considered an example of uncontrolled cell growth, capable of altering the balance toward cellular hyperproliferation and enhancing the capacity for invasion and osteolysis. Second, the dysregulation of cell growth control involves internal genomic or epigenetic alterations and external stimuli, which induce excessive host immune response to inflammatory and infectious processes. This comprises several complex and dynamic pathophysiologic changes that involve extracellular and intracellular signal transduction cascades. CONCLUSIONS: This article summarizes the existing theories and provides conceptual insights into the etiopathogenesis of acquired cholesteatoma, with the aim of stimulating continued efforts to develop a nonsurgical means of treating the disorder.

[Blood flow measurement and clinical usefulness of the temporal fascial scar tissue flap and the periosteal scar tissue flap in posterior canal wall reconstructed tympanoplasty for the mastoid cavity problem in the postoperative ear].

In the postoperative ear, following reconstructive tympanoplasty for a mastoid cavity problem, a very important key is to maintain a stable reconstructed posterior canal wall with the bone plate and cartilage in the posterior canal wall. The authors manage reconstruction of the posterior canal wall with the temporal fascial scar tissue flap (TFSF) and the temporal periosteal scar tissue flap (TPSF) to ensure obtaining a stable posterior canal wall and a tympanic membrane graft. Well-vascularized TFSF and TPSF enable us to acquire a solid reconstructed posterior canal wall because of the secure blood supplies to the flaps. In order to investigate the blood supplies of TFSF and TPSF, we employed laser Doppler blood flowmeters and measured blood flow in the flaps in 20 cases of posyoperative ears treated for a mastoid cavity problem. The blood supplies to both flaps were good, with the blood supply to the TFSF being statistically better than in the case of the TPSF. These findings suggested that the TFSF and TPSF were a reliable source of local well-vascularized tissue which were pliable and could facilitate the creation of a stable posterior canal wall. Furthermore it seems the good blood supply was linked to the prompt postoperative healing, the avoidance of postoperative infection, and good hearing improvement postoperatively.

Middle ear gas pressure regulation: the relevance of mastoid obliteration.

OBJECTIVES: To establish a mathematical model of middle ear gas pressure regulation and to discuss potential implications for pathophysiology-oriented theoretical approach to middle ear surgery, with particular attention to mastoid obliteration. BACKGROUND: Numerous studies support that small mastoid volume is associated with cholesteatoma. Latest studies show that mastoid obliteration is an effective technique to lower the recurrence rate in these ears. METHODS: A mathematical model was used to predict the development of gas pressure balance in the function of different middle ear volumes (VME), considering normal and dysfunctional Eustachian tube. Published data as gas pressure input values and our 3D CT reconstruction data in healthy and pathologic middle ears of children were applied. RESULTS: The model predicted ≤6.66 daPa pressure fluctuations in VME ≥3 ml, compared to ≥16 daPa of a VME ≤1 ml at perfect ET function, because of the different pressure change rate and pressure buffer effect of the MEs. Substantially larger fluctuations can be expected in a VME <3 ml with malfunctioning ET. Modeling mastoid obliteration predicts similar pressure fluctuations to a VME ≥3 ml resulting from elimination of gas exchange surface. CONCLUSION: Pressure change is faster in smaller MEs than in larger ones. Healthy MEs between 3 and 6 ml are very sensitive to the duration of a potential ET dysfunction to develop ME pathology. In MEs with poor mastoid pneumatization and dysfunctional ET, typical in cholesteatoma cases, mastoid obliteration as surgical reduction of mucosal surface for gas exchange can improve ME gas pressure balance resulting in better long-term outcome.

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?

OBJECTIVES: To identify whether the scratch test can be used as an alternative to the Weber's test after tympanomastoid surgery. METHODS: This twin-center prospective study assessed major tympanomastoid surgery patients over a 6-month period. Patients were assessed postoperatively on Day 0 or Day 1 of surgery using a standardized proforma. A Weber's test was performed using a 512-Hz tuning fork, placed midline on the forehead to assess the direction of sound localization. This was directly compared with a scratch test, by asking the patient the following while scratching the head bandage in the midline: "Can you hear this? And which side is loudest?" RESULTS: Fifty-six patients were assessed in total. Sixteen mastoid explorations, 14 tympanoplasties, 18 combined approach tympanoplasties, and 8 other procedures were included, all of which had standard external auditory canal packing and head bandage. Assessment with Weber's test found 41 patients to have sound lateralizing to the operated ear. In comparison, 50 patients lateralized sound to the operated ear with the scratch test. Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the "Scratch Test." No patients had a dead ear after surgery. CONCLUSION: The scratch test proved to be more accurate than traditional postoperative tuning fork assessment and provides a quick, accurate, and simple solution for when such equipment is unavailable.

Prescriptive proprioceptive insoles and dental orthotics change the frontal plane position of the atlas (C1), mastoid, malar, temporal, and sphenoid bones: a preliminary study.

The purpose of this series of case studies was to determine if the frontal plane position of the cranial bones and atlas could be altered using dental orthotics, prescriptive insoles, or both concurrently. The cranial radiographs of four patients were reviewed for the study. Three of the patients were diagnosed as having a temporomandibular joint (TMJ) dysfunction and a preclinical clubfoot deformity. The fourth patient was diagnosed as having a TMJ dysfunction, a preclinical clubfoot deformity and a Catetgory II sacral occipital subluxation, as designated in the chiropractic's Sacro Occipital Technique (SOT). Each patient had a series of four cranial radiographs taken using a modified orthogonal protocol. In two patients, improvement towards orthogonal was achieved when using both prescriptive dental orthotics and prescriptive insoles concurrently. Improvement towards orthogonal was less apparent when using only the prescriptive dental orthotic. No improvement or a negative frontal plane shift was noted when using only the prescriptive proprioceptive insoles. In the third patient, the frontal plane position of the cranial bones and atlas increased (away from orthogonal) when using the generic proprioceptive insoles alone or in combination with a prescriptive dental orthotic. In the fourth patient, the frontal plane position of the cranial bones improved using the dental orthotic. However, the proprioceptive insoles, when used alone or in combination with the dental orthotic, increased the frontal plane position of the cranial bones and atlas. This study demonstrates that changes in the frontal plane position of the cranial and atlas bones can occur when using proprioceptive insoles and/or dental orthotics.

The possible associations of septal deviation on mastoid pneumatization and chronic otitis.

OBJECTIVES: The purpose of this study was to determine the role of nasal septal deviation on volume of mastoid air cells and possible relationship to chronic otitis. MATERIALS AND METHODS: Between May 2010 and September 2012, paranasal sinus computed tomographic findings of 825 patients (470 male and 355 female subjects) who were treated in Ear Nose and Throat Department of Bozok University Medical Faculty were retrospectively analyzed. By excluding the other coexistent sinonasal pathologies, 100 patients (45 male and 55 female subjects; mean age, 37.7 ± 10.4 yr; range, 18-70 yr) with nasal septal deviations were recruited for the study. The convex side of the septal curvature was accepted as the direction of deviation. The findings were grouped according to the radiologically measured angle of nasal septal deviations. The deviation angle of the nasal septum was described as follows: mild (<9 degrees), moderate (9-15 degrees), or severe (≥ 15 degrees). The volume of each mastoid air cells was also calculated using the computer program. Chronic otitis was defined a abnormality criteria of the normal temporal scan. Criteria for a normal temporal bone were as follows: 1) absence of bony destruction or sclerosis; 2) absence of fluid or mass in any of the temporal bone air spaces; and 3) the presence of "normal" air cells. RESULTS: There were 45 male and 55 female subjects (mean age, 37.7 ± 10.4 yr; range, 18-70 yr). Nasal septal deviation angles were found to range between 5 and 28.1 degrees (mean, 14 ± 1.2 degrees). The left-sided deviations included 16 mild (<9 degrees, Group I), 15 moderate (9-15 degrees, Group II), and 17 severe (≥ 15 degrees, Group III) subjects. The right-sided deviations included 18 mild (<9 degrees, Group I), 16 moderate (9-15 degrees, Group II), and 18 severe (≥ 15 degrees, Group III) cases. We could not demonstrate a statistically significant difference between the right mastoid cell volumes of the Group I and Group II in left-sided deviation cases (p = 0.51). In the same side comparison of Group I to Group III and Group II to Group III, the mastoid cell volume differences were found to be significantly meaningful (p = 0.00 and p = 0.00, respectively). Identical results were yielded in the right-sided septal deviation group related to the mastoid cell volumes of Group I and Group II and Group I to Group III and Group II to Group III comparisons (p = 0.55, p = 0.00, and p = 0.011, respectively). In both right and left deviation groups, ipsilateral and contralateral mastoid cell volume comparisons produced statistically significant results (p = 0.04 and p = 0.003, respectively). The presence of chronic otitis findings were significantly increased in both groups (p = 0.00). Statistical significance was set at p < 0.05. CONCLUSION: Our findings suggest that mastoid cell volumes tend to be larger at the contralateral side of the severe septum deviations.

Successful behavioral interventions, international comparisons, and a wonderful variety of topics for clinical practice.

This is the issue of successful behavioral interventions and international comparisons that support the need for better primary health care in the United States. Men's preconception care is considered, and the issue rounds out with articles about the radiologic findings of fluid in the mastoid bone, sex of physicians and mortality rates, a diabetes drug review, and, as usual, some informative brief case reports.

Panel 2: Eustachian tube, middle ear, and mastoid--anatomy, physiology, pathophysiology, and pathogenesis.

OBJECTIVE: This report reviews the literature to identify the advances in our understanding of the middle ear (ME)-Eustachian tube (ET) system during the past 4 years and, on that basis, to determine whether the short-term goals elaborated in the last report were achieved and propose updated goals to guide future otitis media (OM) research. DATA SOURCES: Databases searched included PubMed, Web of Science (1945-present), Medline (1950 to present), Biosis Previews (1969-present), and the Zoological Record (1978 to present). The initial literature search covered the time interval from January 2007 to June 2011, with a supplementary search completed in February 2012. REVIEW METHODS: The panel topic was subdivided; each contributor performed a literature search and provided a preliminary report. Those reports were consolidated and discussed when the panel met on June 9, 2011. At that meeting, the progress was evaluated and new short-term goals proposed. CONCLUSIONS: Progress was made on 16 of the 19 short-term goals proposed in 2007. Significant advances were made in the characterization of ME gas exchange pathways, modeling ET function, and preliminary testing of treatments for ET dysfunction. IMPLICATIONS FOR PRACTICE: In the future, imaging technologies should be developed to noninvasively assess ME/ET structure and physiology with respect to their role in OM pathogenesis. The new data derived from form/function experiments should be integrated into the finite element models and used to develop specific hypotheses concerning OM pathogenesis and persistence. Finally, rigorous studies of treatments, medical or surgical, of ET dysfunction should be undertaken.

Panel 3: Recent advances in anatomy, pathology, and cell biology in relation to otitis media pathogenesis.

BACKGROUND AND OBJECTIVES: The pathogenesis of otitis media (OM) involves a number of factors related to the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx. Although some issues of pathogenesis are fairly well established, others are only marginally indicated by current knowledge, and yet others remain undisclosed. The objective of this article is to provide a state-of-the-art review on recent scientific achievements in the pathogenesis of OM, as related to anatomy, pathology, and cell biology. DATA SOURCES: PubMed, Ovid Medline, and Cochrane Library. REVIEW METHODS: Articles published on the pathogenesis of OM and the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx between January 2007 and June 2011 were identified. Among almost 1900 abstracts, the authors selected 130 articles for full article review and inclusion in this report. RESULTS: New knowledge on a number of issues emerged, including cell-specific expression and function of fluid transportation and innate immune system molecules, mucous cell metaplasia, mucin expression, bacterial adherence, and epithelial internalization, as well as the occurrence, composition, dynamics, and potential role of bacterial biofilm. In addition, the potential role of gastroesophageal reflux disease and cigarette smoke exposure has been explored further. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Over the past 4 years, considerable scientific progress has been made on the pathogenesis of OM, as related to issues of anatomy, pathology, and cell biology. Based on these new achievements and a sustained lack of essential knowledge, suggestions for future research are outlined.

Vestibular neuritis has selective effects on air- and bone-conducted cervical and ocular vestibular evoked myogenic potentials.

OBJECTIVE: To characterise the changes in cervical (cVEMP) and ocular (oVEMP) vestibular evoked myogenic potentials to different stimuli in patients with vestibular neuritis (VN). METHODS: cVEMPs and oVEMPs were recorded using air-conducted (AC; clicks and short tone bursts) and bone-conducted (BC; lateral impulses and taps) stimuli in VN patients (n=23) and normals (n=40). RESULTS: AC evoked cVEMPs revealed few abnormalities, significantly less than for AC evoked oVEMPs (cVEMP: 22% vs oVEMP: 68%, P<0.001). Lateral impulses showed high rates of abnormalities (74% vs 70%, P>0.05) for both reflexes. Although forehead taps produced low rates of abnormalities for both reflexes (33% vs 13%, P>0.05), response amplitudes were smaller from the affected ear (P<0.05). CONCLUSIONS: AC stimuli were associated with low abnormality rates of cVEMPs, consistent with sparing of inferior nerve function in VN, but frequent abnormalities of oVEMPs. The high rates of abnormalities shown for lateral impulses suggest a dependence on superior nerve (i.e. utricular) afferents for both oVEMPs and cVEMPs. SIGNIFICANCE: Lateral impulses behave as expected for utricular function and AC cVEMPs for saccular function. The AC evoked oVEMP seems to depend on the integrity of the superior vestibular nerve, possibly due to saccular afferents travelling in it.