RESUMO
OBJECTIVE: To demonstrate the important role of the anterior epitympanic recess (AER) in the surgery of noncholesteatomateous chronic inflammatory middle ear disorders. To establish selective criteria as to the indication of surgical intervention on the AER, aiming to create a permanent anterior aeration pathway for the attic. In addition, to point out the mandatory role of preoperative temporal bone computed tomography (CT) demonstrating whether the AER is involved and thus contributing, within the clinical context, to the indication for this surgery and its appropriate approach. STUDY DESIGN: Prospective study on patients with persistent or recurring chronic inflammatory middle ear disease for at least 3 years, after failure of conventional medical or surgical treatments. SETTING: Tertiary referral university centre. PATIENTS: Between November 2002 and July 2003, every patient presenting with clinical findings suggestive of an AER pathology was included in this study. SURGERY: Surgical approach of the AER during a mastoatticotomy and tympanoplasty with excision of the Cog and the tensor tympani fold, preserving the ossicular chain in almost all cases. OUTCOME MEASURES: Absence of postoperative otorrhea, satisfactory otoscopic examination, and improvement in the air-bone gap postoperatively in case the presurgery hearing level was abnormal and not due to an ossicular chain abnormality. RESULTS: Eight patients were included in the study. The preoperative CT scan showed AER opacities in all patients that were either isolated or associated with a diseased meso- or hypotympanum or the mastoid cavity. The measurement of the relevant transverse diameter of the AER is proposed to evaluate preoperatively the distance between the Cog laterally and the facial nerve canal medially to minimize the risk of a perioperative injury. During the operation, we found granulation tissue and adhesions in the AER in all cases A clinical follow-up 3 months after the intervention showed good local control in all patients, absence of otorrhea, and almost complete closure of the air-bone gap at audiometric evaluation. The last clinical follow-up in August 2004, a mean of 18 months after our intervention, did not reveal any relapse of symptoms in any case. CT control could be obtained in five of eight cases, within 13 to 21 months after the intervention, showing a reaerated tympanic cavity and AER. CONCLUSION: The AER plays a major role in sustaining some noncholesteatomateous chronic or recurrent inflammatory middle ear disorders that do not respond to conventional medical treatment. Definitive control of this pathology will be obtained by approaching the AER through an excision of the Cog and the tensor tympani fold, exenterating the inflammatory tissues, and creating a sufficient and permanent anterior atticomesotympanic communication. The indication for such a surgical approach is highly dependent on clinical findings correlated to temporal bone CT. Familiarity with the AER and its critical role should become part of every resident's training program in otology.