[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.

Cochlear implantation in elderly patients: surgical and audiological outcome.

BACKGROUND: Deteriorated hearing affects speech perception and speech production, and negatively impacts on social interaction, employment, income, and, as a result, the quality of life of the elderly population. Lack of satisfaction with conventional hearing aids motivated part of them to turn to more sophisticated cochlear device systems. OBJECTIVE: To investigate the outcome of cochlear implantation (CI) among elderly cochlear implant recipients. METHODS: The medical records of 20 postlingual patients aged >65 years at the time of CI, who were followed up for a period of at least 12 months were retrospectively reviewed for age at the time of CI, the cause and duration of deafness, hearing aid experience, comorbidities, complications of the procedure and audiological outcome. Pre- and post-CI speech perception performance was tested using a battery of speech perception tests. RESULTS: In addition to bilateral severe to profound hearing loss, all 20 patients had some comorbidities and 13 had more than 2 pathologies that are associated with hearing impairment. Major complications such as facial nerve paralysis and foreign body reaction were rare (n = 2). Minor complications such as disequilibrium (n = 5) and wound problems (n = 5) resolved spontaneously or were successfully managed conservatively. There were no complications associated with general anesthesia used during the CI procedure. Statistical analysis using the Wilcoxon Signed Rank Test showed significant differences (p < 0.01) between the pre- and postspeech perception categories. No significant correlations were found between the background data: unaided thresholds, aided thresholds, duration of profound deafness, duration of hearing aid use prior to CI, speech perception before CI and speech perception performance after CI using Pearson correlations. CONCLUSION: CI was found to be associated with significant hearing benefit in elderly candidates. However, every CI candidate must be informed about possible complications associated with the procedure, especially related to the vestibular system. At the same time, it should be made clear that life-threatening conditions are rare and that the surgery is usually safe.

Integration of cochlear-implanted children into the general Israeli community.

BACKGROUND: Severe hearing impairment can have devastating effects on social integration and vocational opportunities. OBJECTIVES: To investigate how well--or poorly--individuals who underwent cochlear implantation as children integrated into the general Israeli hearing community. METHOD: We sent a questionnaire to the 30 subjects > or = 18 years old who underwent cochlear implants in our department from 1990 to 2004 when they were < 18 years of age and had used their device for at least 3 years before replying. RESULTS: Eighteen implant users responded (14 males), yielding a 60% response rate. Their mean age was 13.3 +/- 7.0 years (range 6-17) at implantation and 21.1 +/- 3.6 years (range 18-34) when they filled in the questionnaire. Five were attending rabbinical school (yeshiva students), four were in regular military service, five were university students (three also held jobs), two were attending high school, one was employed (and had a university degree), and one had left the yeshiva and was unemployed when he returned the questionnaire. Fourteen respondents use the oral communication mode for conversation and the other 4 use both oral and sign languages. Longer daily implant use was significantly associated with coping with the difficulties in the setting in which they were currently active, with a higher level of satisfaction with their current lifestyle and with recognition of the implant's contribution to this satisfaction (P = 0.037, P = 0.019 and P = 0.001, respectively). CONCLUSIONS: Advances in cochlear implant technologies enable profoundly deaf implanted children to integrate well into the Israeli hearing society, albeit with a large intersubject variability.

Parotid mass as presenting symptom of lymphoma.

BACKGROUND: Lymphomas arising from the parotid gland are an uncommon entity, said to account for only 0.6-5% of tumors or tumor-like lesions of the parotid, and are therefore commonly overlooked. This misdiagnosis often leads to unnecessary diagnostic procedures, delaying the initiation of proper treatment. OBJECTIVES: To examine the clinical, diagnostic, therapeutic and survival data of patients with this disease. METHODS: We retrospectively reviewed our experience with patients diagnosed and treated for parotid lymphoma in our medical center during the period 1998-2008. RESULTS: The 13 patients in the series were aged 42-83. Twelve had non-Hodgkin's lymphoma and 1 had Hodgkin's lymphoma. In eight, parotid mass was the first manifestation of the disease, while in five who were in clinical remission its reoccurrence was first manifested in the parotid gland. Mean survival was 6.3 years CONCLUSIONS: Since parotid lymphoma is uncommon, it is often overlooked in the differential diagnosis. Methods of diagnosing and treating parotid lymphoma are different from those of other parotid pathologies. A high index of suspicion is warranted in order to provide a quick and efficient diagnosis and treatment without subjecting the patient to unnecessary tests and procedures.

[Bilateral cochlear implantation].

Cochlear implant surgery became the standard of care in hearing rehabilitation of patients with severe to profound sensorineural hearing loss. This procedure may alter the lives of children and adults enabling them to integrate with the hearing population. In the past, implantation was performed only in one ear, despite the fact that binaural hearing is superior to unilateral, especially in noisy conditions. Cochlear implantation may be performed sequentially or simultaneously. The "sensitive period" of time between hearing loss and implantation and between the two implantations, when performed sequentially, significantly influences the results. Shorter time spans between implantations improve the hearing results after implantation. Hearing success after implantation is highly dependent on the rehabilitation process which includes mapping, implant adjustments and hearing training. Bilateral cochlear implantation in children is recommended as the proposed procedure in spite of the additional financial burden.

Petromastoid canal and cochlear aqueduct in cochlear implant candidates.

OBJECTIVE: To present temporal bone fine channels in cochlear implantation candidates. METHODS: Review of the axial sections of 108 temporal bone CTs. In type I, the petromastoid canal (PMC) was invisible but appeared as channels in type II and type III, <0.5 and 0.5-1 mm wide, respectively, and in type IV was >1 mm wide. The cochlear aqueduct (CA) was visualized up to the vestibule in type 1, the medial two thirds in type 2, the external aperture and/or the medial third in type 3, and was undetectable in type 4. RESULTS: The PMC size and shape differed significantly between the young (aged <5 years) and older (aged 5-16 years) children and between the young children and adults. A wide PMC (>2 mm) was found in only children younger than 2 years. Children up to 2 years of age and those aged 2 to 5 years demonstrated similar findings. The CA types differed among the pediatric and adult CI candidates, with the main difference appearing after the age of 16 years. There was no correlation between CA and PMC types. CONCLUSIONS: It is likely that the age-related changes in CA and PMC are attributable to the developmental or age-related changes in skull base growth.

Self-reported listening habits and enjoyment of music among adult cochlear implant recipients.

OBJECTIVES: We sought to assess the associations between self-reported listening habits and enjoyment of music, and the following variables: age at implantation, gender, prelingual versus postlingual deafness, duration of deafness, duration of cochlear implant (CI) use, type of CI, speech coding strategy, and speech perception abilities. METHODS: A questionnaire on listening habits and enjoyment of music before the onset of deafness and after implantation was sent to 85 adult CI recipients who had been using the devices for at least 6 months. RESULTS: Of the 53 responders, 39 (73.6%) listened to music after implantation. Listening to music was not significantly related to age at implantation, gender, duration of deafness, duration of CI use, type of CI device, speech coding strategy, or open-set speech perception abilities. The 14 nonlisteners were postlingually deafened. The ratings of enjoyment were the same for 22.6% of patients, improved for 26.4%, and worse for 50.9%. Only 2 of 13 patients who played a musical instrument and 14 of 24 patients who sang before the onset of deafness resumed their musical activities. CONCLUSIONS: Despite the decline in listening habits and in the enjoyment of music after cochlear implantation, most patients do listen to music. The changes in listening habits and enjoyment were not related to the selected background variables.

Cholesteatoma invasion into the internal auditory canal.

Cholesteatoma invasion into the internal auditory canal (IAC) is rare and usually results in irreversible, complete hearing loss and facial paralysis on the affected side. This retrospective study examines the clinical characteristics of seven patients with cholesteatoma invading the IAC, analyzes possible routes of the cholesteatoma's extension and describes the surgical approaches used and patient outcome. Extension to the IAC was via the supralabyrinthine route in most patients. A subtotal petrosectomy, a translabyrinthine approach or a middle cranial fossa approach combined with radical mastoidectomy were required for the complete removal of the cholesteatoma. All seven patients presented with some preoperative facial nerve palsy. The facial nerve was decompressed in four patients and facial nerve repair was performed in three others, two by hypoglossal-facial anastomosis and one by a greater auricular nerve interposition grafting. All patients ended up with total deafness in the operate ear. At 1 year following surgery, the facial nerve function was House-Brackmann grade III in six cases and grade II in one. In conclusion, cholesteatoma invading the IAC is a separate entity with characteristic clinical presentations, require a unique surgical approach, and result in significant morbidity, such as total deafness in the operated ear and impaired facial movement.

Taste changes in patients who underwent cochlear implantation by the nonmastoidectomy approach.

OBJECTIVES: To describe taste changes following a nonmastoidectomy approach to cochlear implantation (CI). STUDY DESIGN: Retrospective. METHOD: Ninety-four adult patients (63 females) who underwent CI using the suprameatal approach (SMA) were studied. They responded to a questionnaire on post-CI taste changes, duration of these changes and their influence on eating habits, weight and quality of life. RESULTS: Fourteen patients (14.9%, all females) reported taste dysfunction (13 ranked as being mild). In 1 patient, the symptoms lasted >24 months, and dysgeusia was counted as permanent in this case. One patient changed her eating habits: she now prefers vegetarian food. The patients with early (<1 month) recovery of taste function were younger than those with delayed recovery. CONCLUSIONS: The SMA is a favorable technique for the preservation of taste sensation in CI patients. Manipulation on the chorda tympani nerve during the SMA did not much disturb the patients' eating habits and their quality of life.

MRI, not CT, to rule out recurrent cholesteatoma and avoid unnecessary second-look mastoidectomy.

BACKGROUND: Aural cholesteatoma is an epidermal cyst of the middle ear or mastoid that can be eradicated only by surgical resection. It is usually managed with radical or modified radical mastoidectomy. Clinical diagnosis of recurrent cholesteatoma in a closed postoperative cavity is difficult. Thus, the accepted protocol in most otologic centers for suspected recurrence consists of second-look procedures performed approximately 1 year after the initial surgery. Brain herniation into a post-mastoidectomy cavity is not rare and can be radiologically confused with cholesteatoma on the high resolution computed tomographic images of temporal bones that are carried out before second-look surgery. OBJECTIVES: To present our experience with meningoceles that were confused with recurrent disease in patients who had undergone primary mastoidectomy for cholesteatoma and to support the use of magnetic resonance imaging as more suitable than CT in postoperative follow-up protocols for cholesteatoma. METHODS: We conducted a retrospective chart review of four patients. RESULTS: Axial CT sections demonstrated a soft tissue mass in the middle ear and mastoid in all four patients. Coronal reconstructions of CT scans showed a tympanic tegmen defect in two patients. CT failed to exclude cholesteatoma in any patient. Each underwent a second-look mastoidectomy and the only finding at surgery was meningocele in all four patients. CONCLUSIONS: Echo-planar diffusion-weighted MRI can differentiate between brain tissue and cholesteatoma more accurately than CT. We recommend that otolaryngologists avoid unnecessary revision procedures by using the newest imaging modalities for more precise diagnosis of patients who had undergone mastoidectomy for cholesteatoma in the past.

Is there a right cochlear implant advantage?

OBJECTIVE: To compare behavioral speech perception performance of children with right versus left cochlear implants (CIs). STUDY DESIGN: A retrospective cohort study. SETTING: Academic university medical center. SUBJECTS: Seventy-one prelingually deafened children that obtained a CI device at 48 months or younger. INTERVENTION: Cochlear implantation with Cochlear, Advanced Bionics, and Med-El devices. MAIN OUTCOME MEASUREMENTS: Patients were divided into 2 groups according to ear of implant (right, n = 30; left, n = 41) and matched in age at implantation and preoperative audiologic results. Multivariate analysis of variance was used to evaluate the effects of 1) side of CI, 2) age at implantation, 3) time with CI (T1, 18-24 mo; T2, 36-42 mo), and 4) dominance (i.e., compatibility between CI side and handedness) on performance in a monosyllabic open-set test scored for words and phonemes. RESULTS: A small yet significant "right CI advantage" was evident throughout the study follow-up and was independent of age at implantation. The performance of children implanted at 24 months or younger was significantly higher than that of children implanted between 25 and 48 months. Regardless of CI side and age at implantation, all children exhibited improvement in speech perception with continuous use. CONCLUSION: The present study provides first-time evidence for a right CI advantage for speech perception in prelingually deafened children that can be taken into account when selecting side of CI in candidates with similar residual hearing in both ears and no anatomic constraints. The present data lend further support to the notions that greater gains in speech perception are associated with earlier age at implantation and continuous use.

[Our experience with bilateral cochlear implantation].

Cochlear implantation is a standard method of hearing rehabilitation among patients with severe to profound bilateral sensorineural hearing loss. In recent years there have been an increasing number of studies showing superior hearing with bilateral cochlear implantation in comparison with a unilateral procedure. In this study we present our experience with 15 patients, children and adults, who had bilateral cochlear implant surgery. Speech perception test results demonstrated a hearing benefit in bilateral cochlear implantation in comparison with a unilateral device, mainly by improvement in the identification of speech in noise tests.

The clinical behavior of isolated sphenoid sinusitis.

OBJECTIVE: We sought to study the clinical behavior and treatment outcome of isolated sphenoid sinusitis (ISS). STUDY DESIGN AND SETTING: We conducted a retrospective study of patients diagnosed with ISS in a tertiary medical center over 20 years. RESULTS: Of 72 patients with ISS, 79 percent had acute symptoms, 15 percent had chronic symptoms, and 6 percent had incidental radiological findings. Fifteen percent were children. Most patients were diagnosed between January and April (P < 0.01), and increasing incidence was noted over the years (P < 0.001). Headache was the most common presenting symptom (85%). Chronic patients complained also of nasal symptoms (82%). Six patients had a major complication of sinusitis (none of them were children), and two patients died. Immunocompromised patients had more major complications (P

Posterior glottic stenosis in adults.

BACKGROUND: Posterior glottic stenosis is a complication of prolonged intubation, manifesting as airway stenosis that may mimic bilateral vocal cord paralysis. It presents a variety of features that mandate specific surgical interventions. OBJECTIVES: To summarize our experience with PSG and its working diagnosis. METHODS: We conducted a retrospective review of a cohort of adult patients with PGS operated at the Sheba Medical Center between 1994 and 2006. RESULTS: Ten patients were diagnosed with PGS, 6 of whom also had stenosis at other sites of the larynx and trachea. Since 2000, all patients underwent laryngeal electromyographic studies and direct laryngoscopy prior to surgery. Surgical interventions included endoscopic laser procedures (in 2 patients), laryngofissure and scar incision (in 1), laryngofissure with buccal mucosa grafting (in 3) or with costal cartilage grafting (in 1) and laryngofissure with posterior cricoid split and stenting (in 1); one patient was not suitable for surgery. Postoperative follow-up included periodic fiberoptic endoscopies. Voice analysis was evaluated by the GRBAS grading. Seven patients were successfully decannulated within one to three procedures. Voice quality was defined as good in 7 patients, serviceable in 2 and aphonic in 1. CONCLUSIONS: Posterior glottic stenosis may be isolated or part of complex laryngotracheal pathologies. Electromyographic studies and direct laryngoscopy must be included in the diagnostic workup. Costal cartilage or buccal mucosa grafts are reliable, safe and successful with respect to graft incorporation and subglottic remodeling.

[Cochlear implantation in children].

The pediatric cochlear implant program was launched in our department in 1990. A year earlier, we began the cochlear implant program in our center. Cochlear implant surgery changed the life of implanted children by enabling integration into the regular education program. The experience of the Sheba Medical Center is presented in 286 children who were operated on between the years 1990-2005. Hearing results were examined using questionnaires and designated audiology tests. Improvement in the hearing ability of implanted children was noted, especially in those who underwent implantations in their first years of life and in those who had previous experience using hearing aids. Post-operative complications were scanty and similar to those reported in the literature. The incidence of device failure is decreasing over the years due to production improvement. The frequency of electronic failure was found to be similar to those described in the literature.

[Recurrent pleomorphic adenomas of the parotid gland--treatment and outcome].

Epithelial tumors of the parotid gland comprise 3% of head and neck tumors, and 70%-80% of those are benign. Pleomorphic adenoma is the most common tumor of the parotid gland. Recurrence rate of pleomorphic adenomas (RPAs) following superficial parotidectomy was reported to be as high as 4%, sometimes associated with inadequate surgical treatment of the primary tumor. These tumors have a very slow growth rate, and a ten-year follow-up period is mandatory. RPAs are usually located in the superficial lobe (75%) and are often multinodular. Treatment of RPAs is challenging due to a high risk of facial nerve paresis (7%-50%) and of re-recurrence. Occasionally, post-operative radiotherapy is indicated, but this treatment must be balanced with potential long term risks of secondary malignancy. Medical records of 16 patients with first recurrence and 4 patients with more than one recurrence who were treated in our institution during the past 5 years were reviewed. Five patients were treated by post-operative radiotherapy. Residual or recurrence rate following a second procedure was 15%. Two patients (10%) had permanent paresis of a single branch of the facial nerve. Seventeen out of 20 patients (85%) treated were disease-free after a follow-up period of 5 years. In conclusion, surgical treatment of RPAs is a complex procedure which should be managed by a trained surgical team and can be performed with success and minimal morbidity.

Connexin-associated deafness and speech perception outcome of cochlear implantation.

OBJECTIVE: To compare performance after cochlear implantation in children with mutations in connexin (Cx) 26 (GJB2) or Cx30 (GJB6) and children with deafness of unknown etiology. DESIGN: Genetic analysis and speech perception evaluation was performed in the children with and without Cx mutations who had undergone cochlear implantation. Speech perception performance was retrospectively analyzed 6, 12, 24, 36, and 48 months after implantation. Test material was selected according to the child's age and cognitive and language abilities. SETTING: The study took place at speech and hearing and genetic centers of a hospital in the central part of Israel and the genetics departments of 3 additional centrally located hospitals. PATIENTS: A total of 30 children who had undergone cochlear implantation were selected for the study, with control patients matched according to age at implantation, duration of implant use, and mode of communication. There was no evidence for additional disabilities or handicaps in either group. MAIN OUTCOME MEASURES: Speech perception measurements included a questionnaire, as well as closed and open-set tests. RESULTS: Overall, the 2 groups showed significant improvement in speech perception results after implantation. Four years after implantation, both groups achieved mean open-set speech perception scores of approximately 60%, 75%, and 90% for monosyllabic, 2 syllables, and words in sentences tests, respectively. CONCLUSIONS: There were no apparent differences in speech perception performance after implantation between the children with Cx mutations and children with deafness of unknown etiology. These data have important implications as a prognostic indicator when counseling candidates for cochlear implantation.

Olfactory function in oncologic hospice patients.

INTRODUCTION: Normal sense of smell is important for well being. Although cancer is reported to be associated with impaired olfactory function, very few studies have directly evaluated this effect. PATIENTS AND METHODS: We performed a quantitative analysis of olfactory status in 42 hospice patients in a hospital-based hospice facility. Olfaction was assessed using the "Sniffin' Sticks" (Burghart Medical Technology, Tinsdaler, Germany) kit. RESULTS: Twenty-five patients (60%) were found to be hyposmic. CONCLUSION: Study results indicate the high incidence of decreased olfactory function among hospice patients.

Radiology of the petromastoid canal.

OBJECTIVE: The petromastoid canal is a thin structure that connects the mastoid antrum with the posterior cranial fossa and houses subarcuate blood vessels and prolongation of the dura. The current retrospective study was designed to investigate radiology of the petromastoid canal in different age groups and to determine whether increasing the scanner's resolution could enhance the detection capability of this structure. METHODS: Axial sections of 504 high-resolution computed tomographic images obtained with 0.6-, 1.1-, or 1.3-mm-thick slices through the petrous bones were reviewed. Sixteen asymmetric images were excluded from the statistical analysis. Type I petromastoid canal was invisible; Type II and Type III appeared as thin channels less than 0.5 and 0.5 to 1 mm in width, respectively, and Type IV was greater than 1 mm wide. RESULTS: The petromastoid canal Type II was detected more frequently in patients older than 5 years (p<0.0001) and Type IV was demonstrated more often in children up to age 5 years (p<0.0001). The occurrence of a Type I petromastoid canal was not dependent on the age of the patients or the resolution of the images (p=0.82). Increasing the resolution failed to improve the visibility of the petromastoid canal or the ability to detect it. A wide petromastoid canal (>2 mm) was significantly more common in younger patients (22.2% versus 2.4% in the older group) (p<0.0001). A petromastoid canal beginning medially directly from the internal auditory canal was detected in 4 of 488 (0.8%) images. The lateral opening of the petromastoid canal can be found posteriorly to the medial orifice, anteriorly to it, or at the same level. The posterior lateral opening was demonstrated to be more common than the other two types in patients younger than 5 years, and the anterior opening was detected more frequently in older patients (p=0.0006). CONCLUSION: The shape and width of the petromastoid canal differ radiologically between populations younger and older than 5 years of age. The findings of the current study may be important for otolaryngologists engaged in cochlear implantation or involved in treating otogenic intracranial complications, especially in young children.

Granular myringitis: Incidence and clinical characteristics.

OBJECTIVE: To examine the incidence and the clinical features of granular myringitis (GM). STUDY DESIGN: A 2-year prospective cohort study. SETTING: A primary otolaryngology clinic affiliated with a tertiary academic referral center. PATIENTS: All-aged patients diagnosed with GM who had no apparent middle ear disease or did not undergo ear surgery. INTERVENTION: Otoscopy and bacteriologic and histopathologic studies. MAIN OUTCOME MEASURES: Granular myringitis was noted in 0.41% of patient's population presenting different forms. RESULTS: Granular myringitis was detected in 26 patients. Recurrent infection occurred in seven (26.9%) and bilateral GM in five patients (19.2%). Perforation of the tympanic membrane (TM) was noted in eight patients (30.7%), six of which closed spontaneously. Otoscopic findings could be classified into three grades: focal de-epithelization (in 10), focal polypoid granulations (in 13), and diffuse polypoid formation over the entire TM (in 3). Histopathologic examination disclosed tiny fragments of granulation tissue infiltrated by nonspecific chronic and acute inflammatory reaction. CONCLUSION: Granular myringitis is encountered not infrequently in primary otolaryngology practice and presented different forms, recurrent episodes, and bilateral involvement. Topical application of antibiotics or caustic agents was successful in all cases. Perforation of the TM may develop and resolve spontaneously during the course of the disease.