A database system for the registration of complications and failures in cochlear implant surgery applied to over 1000 implantations performed in Nijmegen, The Netherlands.

OBJECTIVE: To create a system for the uniform registration and classification of complications and failures in cochlear implant surgery, and apply it to all the patients who underwent implantation in our clinic. METHOD: The definition of a medical complication was established, and data for all cochlear implantations performed between 1987 and 2012 were entered into a custom-made database system. RESULTS: One or more medical complications were registered in 19.0 per cent of 1003 cochlear implantations. The incidence of 'hard failure' was 2.3 per cent. Findings revealed a decrease in device failures over the years; the rate of medical complications remained constant. CONCLUSION: Our database system, which is available free of charge, enables fast and accurate data entry. There were a relatively high number of (minor) complications in our series, but comparison with the relevant literature is difficult. This emphasises the need for a uniform definition of 'complication' as it relates to cochlear implant surgery, and an appropriate classification system for such complications.

Treatment of age-related hearing loss in dogs with the vibrant soundbridge middle ear implant: short-term results in 3 dogs.

BACKGROUND: Age-related hearing loss (ARHL), or presbycusis, is the most common form of acquired hearing loss in dogs. Middle ear implants have been used successfully in people with ARHL who cannot benefit from conventional hearing aids. HYPOTHESIS: Audibility improves in dogs with ARHL after implantation of the Vibrant Soundbridge (VSB) middle ear implant. ANIMALS: Three Beagle dogs with ARHL, mean age 11.1 years. METHODS: The dogs were assessed pre- and postoperatively by brainstem-evoked response audiometry (BERA), otoscopy, and computed tomography scans of the ears. A VSB middle ear implant was implanted unilaterally. Three months later the functionality of the implants was assessed by auditory steady-state responses (ASSRs), after which the dogs were euthanized for histopathological examination. RESULTS: The VSB was implanted successfully in all dogs. Recovery from surgery was uneventful, except for transient facial nerve paralysis in 2 dogs. ASSRs showed that hearing improved after activation of the implants with a mean of 20.7, 13, and 16.3 dB at 1, 2, and 4 kHz, respectively. The implantation procedure did not affect residual hearing (with inactive implants) as measured by BERA. CONCLUSIONS AND CLINICAL IMPORTANCE: Implantation of the VSB resulted in lower ASSR thresholds, but only at the higher gain settings of the audioprocessor. As in humans, a more powerful audioprocessor is required to treat sensorineural hearing loss exceeding 20 dB in dogs. A substantial improvement in patient-owner communication will have to be demonstrated in future studies before the procedure can be recommended in clinical practice.

Long-term ventilation tubes: results of 726 insertions.

Patients with chronic or recurrent otitis media with effusion who do not respond to treatment with conventional ventilation tubes are often treated with long-term ventilation tubes. The aim of this retrospective study was to determine the extrusion and complication rates of long-term ventilation tubes. The median ventilation time of the tubes was 31.5 months. The most common complication was otorrhoea. One episode of otorrhoea occurred after 24% of all tube insertions, and recurrent otorrhoea occurred in 29%. A persisting perforation developed in 19% after extrusion or removal of the tube. Other, mostly minor, complications occurred in 36% with the tube in situ and in 3% after extrusion or removal of the tube. Long-term ventilation tubes provided prolonged ventilation of the middle ear, but also resulted in a considerable number of complications. For each individual case, one should therefore determine whether the advantages of long-term ventilation tubes outweigh the possible complications in view of the available alternatives for middle ear ventilation.

[Choice of ear drops in chronic otorrhea]. / De keuze van oordruppels voor chronische otorroe.

In chronic otitis, the use of ear drops has certain advantages over the use of systemic antibiotics. The choice of ear drop depends on the condition of the eardrum, microbial pathogens present and the efficacy of the components of the ear drop. Ototoxicity, contact allergy and the development of bacterial resistance have to be taken into account. Ototoxicity is a rare complication of the application of ear drops, most often described when aminoglycosides were applied. Contact allergy is also most often seen in aminoglycoside-containing eardrops. Evaluation of ear swabs demonstrated a 5% resistance of Pseudomonas aeruginosa to ciprofloxacin. The appearance of resistant strains may impede systemic use of fluoroquinolones. Therefore, this class of antibiotics should be considered as reserve medication only. The first choice in local application of antiseptics in case of an open eardrum is aluminium acetotartrate 1.2% and, of a combination preparation, bacitracin-colistin-hydrocortisone. In case of a closed eardrum (external otitis) aluminium acetotartrate 12%--combination preparations with corticosteroids are advised against in these cases.

No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients.

OBJECTIVE: The objective of this study was to validate measures taken to reduce the number of cerebrospinal fluid (CSF) leaks after removal of vestibular schwannomas to 0. STUDY DESIGN: This study was a retrospective case review. SETTING: The study was conducted at an otology/neurotology tertiary referral center (Gruppo Otologico, Piacenza, Italy). PATIENTS: Three hundred thirty-one vestibular schwannoma patients were studied. INTERVENTIONS: The enlarged translabyrinthine approach (TLA) was used in all cases, with a number of modifications in the last 200 patients. It was extended in 22 patients with blind sac closure of the external meatus, removal of the posterior bony canal wall, and obliteration of the Eustachian tube and middle ear. MAIN OUTCOME MEASURES: Whether patients had a leak through the wound, the nose (rhinoliquorrhea), or the ear (otoliquorrhea) was assessed. RESULTS: In an early group, the percentage of CSF leaks was 6.9%. On the basis of the evaluated causes, as time went by, technical modifications evolved. They consisted of 1) the total conservation of the fascioperiosteal flap, 2) obliteration of all petrosal cells possibly communicating with the middle ear, 3) removing the incus in a correct way, 4) closing the attic with periosteum, 5) obliterating the surgical cavity, leaving strips of abdominal fat with their medial ends inside the cerebellopontine angle, 6) suturing the musculo-periosteal layer in a correct way, and 7) fixing the skin flap to the underlying surface. The application of these modifications resulted in a total absence of CSF leaks in 200 consecutive patients thereafter. Also, no cases of meningitis were encountered. CONCLUSIONS: To our knowledge, this is the first series of 200 consecutive vestibular schwannoma patients operated by means of the enlarged TLA without a single CSF leak. When the appropriate measures are taken, the number of CSF leaks after removing tumors through the enlarged TLA must and can be reduced to 0.

Rat eustachian tube and its musculature.

The objective of this study was to evaluate the anatomy of the eustachian tube (ET) of the rat and the paratubal musculature. Microdissection and serial sections were used. The ET consists of collapsible membranous and membranocartilaginous segments and a noncollapsible bony segment. Tubal muscles are attached to the collapsible part; the salpingopharyngeus muscle (SPM) is well developed and consists of 3 distinct groups of muscle fibers; the tensor veli palatini muscle (TVPM) consists of 2 functionally different groups of fibers, but only 1 group assists in opening the ET. Attachment of the fibers of the SPM and TVPM that are involved in tubal opening is confined to the dorsal portion of the ET. This finding, together with the earlier observation that this part is mainly lined by squamous epithelium, strongly suggests that the dorsal part has a ventilatory function. The ventral portion of the ET, which is lined by ciliated-secretory epithelium and lacks the attachment of muscle fibers that can dilate the lumen, is assumed to serve clearance. The anatomic position of the levator veli palatini muscle suggests that this muscle contributes to the protective function of the ET. These findings are discussed with regard to the ET in humans.

The use of eardrops in an ENT department.

A survey of the pattern of usage of ototopical preparations in out-patients of the ENT department of a Dutch University Hospital has been performed. Data on clinical presentation and previous treatment of the patient, otoscopic results, prescribed current treatment and, if available, results of microbiological examination were collected. One-hundred and twenty-one evaluable patients were prospectively included. For 20% of the patients it concerned a first manifestation of the symptoms, 35% had a recurrence after a period free of symptoms and in 37% it concerned patients with persisting symptoms despite treatment. Forty-five percent of the patients' ears concerned had an intact tympanic membrane, in 25% a perforation was present and in 12% middle ear ventilation tubes were in situ. Thirty-five percent had already received previous treatment with ear drops. The species most often isolated was Staphylococcus aureus, followed by Pseudomonas aeruginosa. A wide range of products were prescribed. While previous treatment occurred with combination preparations, for current prescriptions, ofloxacin was most often used. Most patients received 2 to 3 drops 3 times a day for 7 to 10 days, which is in accordance with recommendations in the literature. Potentially ototoxic substances are regularly used in daily practice. Ofloxacin is widely used even thought it is not registered for this indication in the Netherlands and the development of resistance has to be taken into account. A new policy based on this survey is proposed, which will reduce the number of different preparations used and will eliminate ofloxacin from first the treatment.

Development of the tubotympanum in the rat.

OBJECTIVE: To investigate the relationship between the anatomical maturation of the middle ear and that of the eustachian tube and paratubal muscles in the rat. DESIGN: Wistar rats ranging from gestational day 12 to postnatal day 40 were used. METHODS: Tissue specimens were examined with routine light microscopy and electron microscopy. Epithelial differentiation was studied immunohistochemically with antibodies to different cytokeratins. RESULTS: The epithelial lining of the tubotympanum showed differentiation-related cytokeratin expression throughout the whole developmental period. The mucociliary epithelium reached mature features around birth. A dorsal extension and its framing cartilage started forming around 5 days after birth. This extension became lined by stratified nonciliated epithelium and attained maturity around 10 days after birth concurrently with the attachment of the dilatory muscles. This process was immediately followed by aeration of the middle ear cavity. CONCLUSIONS: The continuous expression of cytokeratins demonstrates that the epithelial lining of the tubotympanum is only derived from the embryonal endoderm. Furthermore, this study demonstrates that the eustachian tube shows a two-stage postnatal development. First, the mucociliary system matures, providing protection/clearance when the animal starts respiration and swallowing. Subsequently, the dorsal part attains maturity. The features of the epithelial lining of the dorsal part of the eustachian tube and the coincidence of the maturation of this part with the attachment of the dilating muscle fibers and the aeration of the middle ear indicates that this part provides ventilation. These findings support the authors' hypothesis that different parts of the eustachian tube serve different purposes: clearance, protection and ventilation.

[Sluder's adenotonsillectomy: with or without endotracheal intubation?]. / Adenotonsillectomie volgens Sluder: met of zonder endotracheale intubatie?

OBJECTIVE: To assess differences in results and complications of adenotonsillectomy according to Sluder in children anaesthesized with or without endotracheal intubation. DESIGN: Retrospective descriptive study. SETTING: Ear, Nose and Throat department, Academic Hospital Nijmegen, the Netherlands. METHOD: The medical records were reviewed of 1011 children (511 non-intubated, before 1992, 500 intubated), and a questionnaire was sent to the parents regarding the postoperative period. RESULTS: The total proportion of postoperative haemorrhage was 4.35%; 5.1% in the non-intubated group, 3.6% in the intubated group (p > 0.05). In the intubated group there were more patients with postoperative fever (p < 0.01) but fewer with tonsillar remnants (p < 0.005). The procedure with intubation anesthesia took significantly more time (18 min versus 11 min). CONCLUSION: In a training situation the intubated procedure is advised because of available time. This does not apply to experienced specialists, who may even have fewer complications.

Fibroinflammatory pseudotumor of the ear. A locally destructive benign lesion.

We describe three cases of a fibroinflammatory pseudotumor (tumefactive fibroinflammatory lesion) of the middle and inner ear. The patients presented with total deafness in the affected ear and no response to caloric stimulation. The computed tomographic pattern showed destruction of inner ear structures and a typical widening of parts of the labyrinth. Magnetic resonance imaging performed in all three patients showed an extension greater than expected based on computed tomographic images of both areas of destruction, as well as areas of radiologic normality. An enhancing mass was seen in the inner ear with a characteristic extension into both the internal auditory canal and the middle ear. A transotic approach or subtotal petrosectomy was used to remove the tumor in all three cases. Although histologically benign, these tumors are locally destructive and, as such, behave like a neoplastic lesion. They are composed of fibrovascular tissue admixed with chronic inflammatory cells. To our knowledge, this is the first report on pseudotumors of the middle ear, inner ear, and internal auditory canal. Inflammatory pseudotumor used to be a somewhat confusing term for a recognized entity of unknown origin. It is likely that infection is an important contributing factor in the development of these lesions. Although surgical removal seems to be the treatment of choice, no clear judgment of its prognosis can be made owing to the rarity of this tumor.

[Swollen ear canal, not always innocent]. / Een gezwollen gehoorgang, niet altijd onschuldig.

A swollen ear canal: not to be underestimated. The role of radiology in three patients with problems due to unaccomplished otitis externa is discussed. The choice between CT scanning and MRI in selected cases is balanced.

Primary sarcoma of the lung: a clinical study with long-term follow-up.

Primary pulmonary sarcoma is an extremely rare tumor. In more than 30 years, only 22 patients with PPS were seen in our hospital; 18 patients (82%) underwent operation. Radical resection is the only curative treatment in patients with primary pulmonary sarcoma. All 4 patients (18%) who did not undergo operation died within 17 months. All 7 patients (32%) in whom no radical resection could be performed died between 10 months and 16 years after operation. Total resection of the tumor could be performed in 11 patients (50%). Of these, 7 are still alive (64%), and 1 patient died of an unrelated cause after 25 years (mean follow-up, 13.5 years). Histologic diagnosis in these patients was leiomyosarcoma in 4, malignant schwannoma in 2, and fibrosarcoma and undifferentiated sarcoma in 1 each. Median survival for all patients was 24 months. Actuarial 5-year survival was 44% for all patients. Small tumor diameter and low-grade malignancy are statistically significant favorable prognostic factors. No patient with grade 1 tumor died; the median survival was 60 months for grade 2 sarcomas, and 17 months for grade 3 sarcomas. No patient with a completely resected small primary pulmonary sarcoma had recurrence or metastasis.

The use of the startle reflex measurement in patients with various types of fixation of the ossicular chain.

The results of startle and acoustic stapedius reflex measurements can be used to subclassify various types of fixation of the ossicular chain. Reflex measurements were performed on a group of subjects with normal hearing and on a group of patients with surgically verified ossicular chain fixation. In 97% of the subjects with normal hearing (n = 30), reproducible impedance changes were observed as part of a startle reaction and four different reaction patterns could be distinguished. In a subgroup of subjects with normal hearing who had a relatively, statistically significant, high acoustic reflex threshold, a characteristic response was found which was most probably caused by contraction of the tensor tympani muscle only. The same response was detected in 77% of the patients (n = 22) with otosclerosis. In the remaining 23%, no middle ear impedance changes occurred as part of a startle reaction. In five out of six patients with fixation of the malleus, no response was observed. Although the startle reflex measurement is a valuable tool for distinguishing between stapes fixation and multiple ossicular chain fixations, the results are not conclusive.

Inflammatory pseudotumor of the subglottis.

A rare case of an idiopathic inflammatory pseudotumor of the larynx is described. Management consisted of midline vertical thyrotomy with anterior cricoid splitting, excision of the subglottic tumor and temporary stenting of the lumen with a siliconized tube. While these lesions are benign, the therapeutic consequences of misdiagnosis can be serious. Effective treatment consists of surgical excision, which results in a permanent cure.

The mucosal lining of the Eustachian tube of the rat.

This report deals with a microscopical study on the Eustachian tube of the rat. The tube consists of a small membranous part and a larger part which is supported by cartilage to a varying extent. The epithelial lining is composed of pseudostratified ciliated epithelium and squamous epithelium, both arranged in coherent fields, extending from nasopharynx to the middle ear cavity. The ciliated epithelium, which is continuous with the tracts of ciliated epithelium in the middle ear, provides morphological evidence for the existence of a mucociliary transport system. The part of the tube, that is lined by squamous epithelium is suggested to be involved in facilitating the passage of air. The observations made on the secretory elements refer to a different function of goblet cells and the subepithelial compound glands in Eustachian tube physiology.