A clinical conundrum: Temporal bone metastases from lung adenocarcinoma.

BACKGROUND: Metastatic disease to the temporal bone is rare. Even more uncommonly, it can be the first manifestation of an underlying malignancy. Patients typically present late in the disease process with non-specific symptoms of hearing loss, facial nerve palsy and otorrhea. CASE: A 62-year-old Chinese female presented with right facial weakness, which had near-complete improvement in response to pulse prednisolone. On examination, she had a right temporal swelling and right mild-severe conductive hearing loss. A computed tomography scan showed a destructive lesion centred in the squamous temporal bone, with an associated soft tissue component. Positron emission tomography scan revealed bony and lung metastases, but no distinct hypermetabolic primary site. An incisional biopsy unexpectedly returned as metastatic lung adenocarcinoma. CONCLUSION: Although rare, it is important for otolaryngologists to be aware of the insidious nature of temporal bone metastases and possible atypical clinical and radiological features, to facilitate timely workup and initiation of treatment.

Novel use of precipitating hydrophobic injectable liquid (PHIL) in pre-operative angioembolisation of a large posterior auricular arteriovenous malformation.

BACKGROUND: Large arteriovenous malformations are often managed via endovascular embolisation followed by surgical resection. We describe the use of a new liquid embolic agent (LEA) - precipitating hydrophobic injectable liquid (PHIL) and its advantages over existing LEAs. CASE: A 60-year-old male presented with a progressively enlarging right post-auricular arteriovenous malformation. He underwent successive angioembolisation with PHIL and subsequent surgical resection on post-embolisation day 1. CONCLUSION: To our knowledge, this is the first reported case of PHIL being used in pre-operative embolization of a large extra-cranial head and neck AVM. Its excellent penetration into small calibre vessels, decreased glare artefact on imaging and decreased skin pigmentation render it a compelling alternative to existing LEAs.

Post-operative healing and long-term stability after mastoid cavity reconstruction using the middle temporal artery and inferior musculoperiosteal flaps.

PURPOSE: This study aims to evaluate the surgical outcomes with the use of a combination of the middle temporal artery (MTA) flap and the inferior musculoperiosteal (IMP) flap for mastoid obliteration after canal wall down mastoidectomy. METHODS: Seventy-five patients who have undergone canal wall down mastoidectomy and mastoid obliteration with the MTA and the IMP flaps at a single tertiary hospital were included. Surgical outcomes measured included the creation of a dry mastoid cavity as measured by a previously developed semi-quantitative scale, mastoid cavity epithelization time, rate of revision surgery needed, and rate of recurrent cholesteatoma. RESULTS: Patients were followed up for a median of 29 months. The median time to epithelization of the mastoid cavity was 2 months. At 1 and 3 months, 36.0% and 76.0% of patients had grade 0 and grade 1 cavities, respectively, with either a dry cavity or one or less episodes of mild otorrhea or sensation of wetness. Hundred percent of the patients achieved a grade 2 (more than one episode of otorrhea or the presence of granulation tissue that promptly resolved with simple treatment) or better cavity at 3 months. One patient re-presented with a grade 3 cavity with uncontrolled infection and daily otorrhea secondary to an attic perforation that manifested at 6 months, requiring revision surgery. There were no recurrent cholesteatomas during the follow-up period. CONCLUSIONS: The use of the MTA and the IMP flaps for mastoid obliteration may be considered as an adjunct to achieving a safe, dry ear after canal wall down mastoidectomy.

TORP ossiculoplasty in the presence of an intact stapes superstructure.

INTRODUCTION: In this series, we describe ossicular reconstruction using routine TORP in the presence of the stapes superstructure using a tympanic-membrane-to-footplate configuration. MATERIALS AND METHODS: This is a case series of 12 patients who underwent TORP ossiculoplasties from 1st January 2010 to 31st October 2017. Data collected included demographics, indication for surgery, status of the middle ear and pre-operative and post-operative audiometric data (including pure tone average (PTA) and air-bone gap (ABG)). RESULTS: The mean pre-operative PTA was 56.5 dB and ABG was 39.8 dB. Surgical success (ABG ≤ 20 dB) was achieved in 83.3%, with an average improvement in PTA of 24.3 dB and closure of ABG of 27.1 dB. The mean post-operative ABG was 12.7 dB. CONCLUSION: TORP ossiculoplasty with tympanic-membrane-to-footplate configuration is a feasible means of ossicular reconstruction, independent of the status or spatial arrangement of the remnant ossicles. Using this technique, it is possible to achieve a consistently good outcome for improvement in hearing and closure of ABG.

Atypical thyroglossal duct cyst with intra-laryngeal and para-glottic extension.

Thyroglossal duct cysts (TDC) are the most common congenital neck masses. Although they are anatomically closely related to the larynx, intra-laryngeal extension is very rare. We present a case, review the literature and discuss the challenges of intra-laryngeal TDC. A 55-year-old man presented with a neck mass associated with dysphagia. Computer Tomography neck scan showed a midline cyst extending to the pre-epiglottic space with partial obliteration of the right pyriform sinus and narrowing of the larynx. The cyst was excised en-bloc via Sistrunk procedure. Intra-laryngeal TDC are surgically challenging due to risk of perforation into the aerodigestive tract.

PEAK PlasmaBlade versus monopolar electrocautery tonsillectomy in adults: A prospective double-blinded randomized controlled trial.

OBJECTIVE: To evaluate the efficacy and compare postoperative pain and recovery following PEAK PlasmaBlade and monopolar electrocautery tonsillectomy in adults. STUDY DESIGN: Prospective double-blinded randomized controlled trial. METHODS: Fifty-eight patients were recruited and randomized into 2 groups: PEAK PlasmaBlade (n = 29) or monopolar electrocautery (n = 29) tonsillectomy. Postoperative pain, complications, patient satisfaction, number of tablets of analgesia taken and days taken to return to soft diet, normal diet, normal activities and achieve pain-free swallowing were compared and analysed, with the aid of a pain diary given to patients. Statistical analysis was performed with SPSS 13.0 with statistical significance set at P < 0.05. RESULTS: Patients in the PEAK PlasmaBlade group were able to achieve pain-free swallowing in a shorter time compared to the electrocautery group (13.28 versus 15.76 days, P = 0.035). Patients were also more satisfied with PEAK PlasmaBlade tonsillectomy (P = 0.046). No significant differences in the incidence of postoperative haemorrhage, daily visual analog score for pain, number of tablets of analgesia taken and time taken to return to soft diet, normal diet and activities were seen for both groups. CONCLUSIONS: This study showed that PEAK PlasmaBlade tonsillectomy has a faster recovery period in terms of time taken to achieve pain-free swallowing and may offer advantages when compared to monopolar electrocautery tonsillectomy. LEVEL OF EVIDENCE: 1b.

An unusual case of temporal bone encephalomeningocele occurring together with normal pressure hydrocephalus.

Temporal bone encephalomeningoceles are uncommon clinical entities that can be challenging to diagnose and treat. Common presenting complaints include symptoms of aural fullness, hearing loss, clear otorrhea and meningitis. Common etiologies are chronic middle ear disease and trauma. A significant proportion of cases are spontaneous, which occurs in relation to benign intracranial hypertension. Normal pressure hydrocephalus associated with temporal bone encepahomeningoceles has not been previously described. The authors present an unusual case of spontaneous right sided temporal bone encephalomeningocele associated with symptomatic normal pressure hydrocephalus. Surgical repair of the defect was successful. The diagnostic and management approach to this unique case are discussed.

Neuroendocrine adenoma of middle ear with new bone formation and review of literature.

Neuroendocrine adenoma of the middle ear has been described in literature as middle ear adenoma with neuroendocrine differentiation or carcinoid tumor. While there have been several case reports describing imaging features of carcinoid tumors of the ear and middle ear adenomas, in our literature review, we have not found a single case where bone formation is described as a prominent radiological feature. We report a first documented case of middle ear carcinoid tumor with new bone formation demonstrated on CT imaging and performed a review literature regarding the tumor. A differential diagnosis of neuroendocrine adenoma of the middle ear should be considered when there is prominent bone formation with a soft tissue mass in the middle ear on CT imaging.

Intratympanic steroids as a salvage treatment for sudden sensorineural hearing loss? A meta-analysis.

Sudden sensorineural hearing loss is typically treated with systemic steroids. The aim of this meta-analysis was to evaluate the efficacy of salvage intratympanic steroid treatment in patients who have initial treatment failure with systemic steroids. A MEDLINE literature search was performed, supported by searches of Web of Science, Biosis, and Science Direct. Articles of all languages were included. Selection of relevant publications was conducted independently by three authors. Only randomized controlled trials were considered. In one arm of the studies, the patients received salvage intratympanic steroids. In the other arm, patients did not receive further treatment. The standard difference in mean (SDM) amount of improvement in hearing threshold between patients who did and did not receive salvage intratympanic steroids was calculated. From an initial 184 studies found via the search strategy, 5 studies met inclusion criteria and were included. There was a statistically significant greater reduction in hearing threshold on pure-tone audiometry in patients who received salvage intratympanic steroids than in those who did not (SDM = -0.401, p = 0.005). Subgroup analysis showed that administration by intratympanic injection (SDM = -0.375, p = 0.013) rather than a round window catheter (SDM = -0.629, p = 0.160) yielded significant improvement in outcome. The usage of dexamethasone yielded better outcomes (SDM = -0.379, p = 0.039) than the use of methylprednisolone (SDM = -0.459, p = 0.187). No serious side effect of treatment was reported. In patients who have failed initial treatment with systemic steroids, additional treatment with salvage intratympanic dexamethasone injections demonstrate a statistically significant reduction in the hearing thresholds as compared to controls.

Effects of tonsillectomy on sleep study parameters in adult patients with obstructive sleep apnea--a prospective study.

OBJECTIVE: The objective of this study is to evaluate the efficacy of tonsillectomy in reduction of respiratory disturbance index (RDI) and other sleep study parameters in patients with obstructive sleep apnea (OSA). METHODS: This study involves 34 adults with OSA and Friedman grade 3 or 4 tonsils. All 34 patients were treated with tonsillectomy, as the only surgical treatment for OSA from 2007 to 2011. Pre- and postoperative polysomnography were performed in all these patients. RESULTS: Prior to tonsillectomy, 21 patients had severe, 9 had moderate, and 4 had mild OSA. Surgical response rate (defined as 50% or more reduction in apnea-hypopnea index (AHI) and a postoperative AHI of less than 20) was 71.4% among patients with severe OSA, 77.7% among patients with moderate, and 75% among patients with mild. Among all the 34 patients, there was a reduction of 24.6 (p = 0.000) in the RDI postoperatively. In our sub-analysis, we arbitrarily divided the patients into three groups: patients with RDI less than 30, patients with RDI between 30 and 60, and patients with RDI above 60. It showed that, in the group with RDI >60, an average reduction of RDI by 57.6 (p = 0.000) was achieved and was the greatest reduction in RDI. CONCLUSIONS: Tonsillectomy alone may be considered as an effective first line surgical procedure in the treatment of OSA in selected patients. Patients with Friedman grade 3 or 4 tonsils may be considered for tonsillectomy as the initial surgical procedure, reserving other upper airway procedures at a later stage if necessary.

Pre-operative high resolution computed tomography scans for cholesteatoma: has anything changed?

OBJECTIVE: CT temporal bone scans are often performed to aid in surgical planning and management of cholesteatomas. With improvements in the resolution of CT scans today, it is now possible to obtain more information from these scans than before. The aim of this study is to compare findings on high resolution CT (HRCT) temporal bone scans to intra-operative findings, so as to determine how well various middle ear structures are assessed by HRCT scanning. STUDY DESIGN: Retrospective study. SETTING: Otology clinic of a tertiary otolaryngology centre. SUBJECTS AND METHODS: 32 mastoidectomies performed by a single otologist for clinically confirmed cholesteatoma were included. Correlation of CT and intra-operative findings on the status of structures including the ossicles, semicircular canals, facial canal and tegmen was analysed using kappa and AC1 statistics. RESULTS: In all patients, a soft tissue mass with bony erosion in keeping with a cholesteatoma was seen on CT. Radiosurgical agreement was excellent for the presence of semicircular canal erosion (k=0.89, AC1=0.96), facial canal dehiscence (k=0.74, AC1=0.76), tegmen erosion (k=0.76, AC1=0.92) and malleus erosion (k=0.76, AC1=0.85). It was good for incus erosion (k=0.71, AC1=0.92) and stapes erosion (k=0.63, AC1=0.73). CONCLUSION: There was good to excellent radiosurgical agreement in the assessment of the status of various middle ear structures. Improvement in radiosurgical agreement from existing studies in the literature was noted. This was especially true for features such as facial canal dehiscence. With technological advancements, CT temporal bone scans appear even more valuable for evaluation of patients prior to cholesteatoma surgery.

Bilateral enlarged vestibular aqueduct with associated bilateral Mondini's dysplasia.

Enlarged Vestibular Aqueduct (EVA) and Mondini's dysplasia (incomplete partitioning type II) are entitites that have been fairly well described in the literature as potential causes of hearing loss in the young. However, it is uncommon for this condition to be detected bilaterally, especially so for both conditions to coexist bilaterally in the same patient. This is a brief description of a patient with the above bilateral condition with attached high resolution CT scan images of the temporal bone to illustrate the case.

The prevalence of isolated otolith dysfunction in a local tertiary hospital.

OBJECTIVE: Patients with dizziness may present with symptoms of tilting, swaying, rocking, floating or with disequilibrium. This may be suggestive of an isolated otolithic dysfunction yet, there is little emphasis on this emerging clinical entity. To characterize and describe the prevalence of isolated otolith dysfunction in a local tertiary hospital and correlate them with clinical diagnosis. METHODOLOGY: Retrospective medical chart review of patients who presented with dizziness to the specialist outpatient Otolaryngology clinic, who required vestibular laboratory investigation. RESULTS: Of the 206 patients, more than half of them (52.4%) fulfilled the criteria for either probable or definite isolated otolith dysfunction. When there are clinical symptoms of otolith dysfunction reported, there is a 1.62 odds of a remarkable laboratory otolith finding. The most common clinical finding was "no clear diagnosis" (65.5%) followed by Vestibular Migraine (13.6%). CONCLUSION: The prevalence of isolated otolith dysfunction is quite high. Laboratory tests of otolith function should be performed more routinely. This can be done in a sequential way to optimize cost effectiveness in countries with no insurance reimbursement. Prospective cohort studies on isolated otolith dysfunction, will lay the groundwork for achieving diagnostic consensus and formulating rehabilitation plans to aid this group of patients.

Respiratory droplet generation and dispersal during nasoendoscopy and upper respiratory swab testing.

Respiratory particle generation and dispersal during nasoendoscopy and swab testing is studied with high-speed video and laser light illumination. Video analysis reveals droplet formation in three manoeuvres during nasoendoscopy - sneezing, vocalization, and nasal decongestion spray. A capillary bridge of mucus can be seen when a nasoendoscope exits wet nares. No droplet formation is seen during oral and nasopharyngeal swab testing. We outline the following recommendations: pull the face mask down partially and keep the mouth covered, only allowing nasal access during nasoendoscopy; avoid nasal sprays if possible; if nasal sprays are used, procedurists should be in full personal protective equipment prior to using the spray; withdrawal of swabs and scopes should be performed in a slow and controlled fashion to reduce potential dispersion of droplets when the capillary bridge of mucus breaks up.

Management of single-sided deafness with the bone-anchored hearing aid.

OBJECTIVES: The benefits of the bone-anchored hearing aid (BAHA) for rehabilitation of conductive and mixed hearing loss are well established. Recently, the BAHA was used to rehabilitate patients with single-sided deafness (SSD). In this study, the benefits of the BAHA in SSD are presented. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Twenty-one consecutive adult patients with SSD underwent single-stage BAHA implantation on the side of deafness. Testing in sound field was performed using the hearing-in-noise test (HINT) in both unaided and aided conditions. Speech and noise signals were delivered through two speakers oriented in two test paradigms. The outcomes were expressed as signal-to-noise (S/N) ratios. Subjective benefit analyses were determined through two questionnaires: the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Glasgow Hearing Aid Benefit Profile (GHABP). RESULTS: All subjects demonstrated significant improvement in speech reception thresholds with the HINT using the BAHA, especially with the 90/270 speaker paradigm, in which the mean improvement over the unaided condition was 5.5 dB SPL (range, 2.0-11.0 dB; P=0.00001). Qualitative subjective outcome measures demonstrated additional benefits. CONCLUSION: In SSD patients, the BAHA provides significant subjective benefits and improves speech understanding in noise.

Otosclerosis in a nonendemic population: Utility of CT scan and correlation with audiometry and surgical outcome.

The incidence of otosclerosis in nonendemic patients is low, and preoperative diagnosis can be challenging. The aim of this study was to evaluate computed tomography (CT) findings in patients with otosclerosis and determine their correlation with audiometric findings and surgical outcome in a nonendemic population. We retrospectively reviewed 17 patients from August 2011 to August 2013 with surgically confirmed otosclerosis who underwent preoperative high-resolution CT scans and pre- and postoperative audiometry. Otosclerotic foci were identified on the scans. The density ratio of these foci was calculated and compared with pre- and postoperative audiometric parameters. One patient with Paget disease was excluded from the study. A total of 19 ears were operated on and included in the data analysis. CT scans were normal in 4 ears (21.1%). Hypodense lesions were detected in the remaining 15 (78.9%) ears and the region of interest mapped out. The density ratio was obtained between the hypodense area and adjacent normal labyrinthine bone. No statistically significant correlation was found between the density ratio and any of the audiometric parameters tested (p > 0.05). The diagnosis of otosclerosis in nonendemic areas is challenging. A preoperative CT scan can be useful when otosclerotic foci are present. However, the density ratio of the otosclerotic foci did not correlate with audiometric parameters or surgical outcome.

Classification of Temporal Bone Pneumatization on High-Resolution Computed Tomography: Prevalence Patterns and Implications.

Objective The degree of pneumatization of the temporal bone has implications in the pathophysiology and surgical considerations of many temporal bone disorders. This study aims to identify common pneumatization patterns in the petrous apex, mastoid, and infralabyrinthine compartments of the temporal bone. Variables associated with temporal bone pneumatization were also identified. Study Design Case series with chart review. Setting Single tertiary hospital. Subjects and Methods In total, 299 high-resolution computed tomography scans of the temporal bone performed on patients between 2013 and 2016 were reviewed. Only normal temporal bone scans in patients aged 13 years and older were included. Previously published grading systems were used to classify pneumatization patterns in the petrous apex, mastoid, and infralabyrinthine region. Results The most common pneumatization pattern in the petrous apex was group 2 (less than half of the petrous apex medial to the labyrinth is pneumatized), that in the mastoid was group 4 (hyperpneumatization), and that in the infralabyrinthine region was type B (limited pneumatization), at 54.8%, 55.4%, and 76.0% of patients, respectively. Patients with increased pneumatization of 1 temporal bone compartment tended to have increased pneumatization of the same compartment on the contralateral side and the other compartments on the ipsilateral side ( P < .05). Younger age ( P < .001) and male sex ( P = .001) were associated with increased pneumatization in the petrous apex and infralabyrinthine compartments. Conclusion The degree of temporal bone pneumatization varies among the different compartments. Age and sex have a significant association with the degree of pneumatization of the petrous apex and infralabyrinthine compartment.