A tailored approach in cholesteatoma surgery.

PURPOSE: In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient. METHODS: Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes. RESULTS: Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB). CONCLUSION: The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

Reconstructive ossiculoplasty options in primary cholesteatoma surgeries with an intact stapes.

PURPOSE: In primary cholesteatoma patients, incus destruction with an intact and mobile stapes is a frequent finding. Different techniques have been described to restore the ossicular chain, including incus interposition, stapes augmentation and type III tympanoplasty. Controversy about postoperative hearing results in open versus closed surgical techniques exist. METHODS: We performed a retrospective analysis of clinical, surgical and audiometric data of patients with primary cholesteatoma surgery operated between 2010 and 2020, and a mobile stapes and one-stage ossicular reconstruction. Pre- and post-operative audiograms were compared for the different surgical groups, mainly focusing on postoperative air-bone gap. Mastoid pneumatization and ventilation was also considered. RESULTS: The mean postoperative air-bone gap (0.5-4 kHz) of the 126 included patients was 20 dB. Hearing after type III tympanoplasty (26 dB) was worse than incus interposition (19 dB) and stapes augmentation (20 dB). Hearing after an open (23 dB) versus closed (19 dB) surgical technique was significantly different. No improvement in air-bone gap was observed for the higher frequencies. CONCLUSION: A residual postoperative air-bone gap should be considered after primary cholesteatoma surgery with intact and mobile stapes. Incus interposition in closed cavity operation is the optimal situation, but open cavity surgery should not be avoided because of hearing. Extent of the disease is prioritized and poorer ventilation before and after surgery may affect postoperative hearing.

Combining bioengineered human skin with bioprinted cartilage for ear reconstruction.

Microtia is a congenital disorder that manifests as a malformation of the external ear leading to psychosocial problems in affected children. Here, we present a tissue-engineered treatment approach based on a bioprinted autologous auricular cartilage construct (EarCartilage) combined with a bioengineered human pigmented and prevascularized dermo-epidermal skin substitute (EarSkin) tested in immunocompromised rats. We confirmed that human-engineered blood capillaries of EarSkin connected to the recipient's vasculature within 1 week, enabling rapid blood perfusion and epidermal maturation. Bioengineered EarSkin displayed a stratified epidermis containing mature keratinocytes and melanocytes. The latter resided within the basal layer of the epidermis and efficiently restored the skin color. Further, in vivo tests demonstrated favorable mechanical stability of EarCartilage along with enhanced extracellular matrix deposition. In conclusion, EarCartilage combined with EarSkin represents a novel approach for the treatment of microtia with the potential to circumvent existing limitations and improve the aesthetic outcome of microtia reconstruction.

[Role of computed tomography in the preoperative diagnosis of otosclerosis]. / Stellenwert der Computertomographie in der präoperativen Diagnostik der Otosklerose.

BACKGROUND: Otosclerosis is an osteodystrophy of the otic capsule and presents with progressive conductive hearing loss. Imaging studies, especially computed tomography (CT) and cone-beam CT, have gained increased relevance in the diagnosis of otosclerosis. OBJECTIVE: This study investigated whether there is a correlation between the extent of otosclerosis in high-resolution or cone-beam CT and hearing loss in pure-tone audiometry. MATERIALS AND METHODS: Based on an existing classification of otosclerotic foci, a classification was established. Preoperative CT scans of patients undergoing stapedotomy between 2015 and 2019 were evaluated and classified by two independent otorhinolaryngologists. The preoperative pure-tone audiograms were analysed and compared to the results of CT. RESULTS: A total of 168 CT studies (i.e., 168 ears) in 156 patients with intraoperatively confirmed otosclerosis were included in our study. A correlation between the extent of the otosclerotic focus or the calculated scores and hearing loss in pure-tone audiometry (air conduction, bone conduction and air-bone-gap) could not be proven. CONCLUSION: Preoperative CT is not obligatory. However, preoperative imaging using CT or cone-beam CT can be helpful to confirm the diagnosis and exclude other middle or inner ear pathologies as well as in planning of the surgical procedure in the overall context of otoscopy and audiometry. A correlation with the degree of hearing impairment could not be demonstrated and remains unclear.

Middle Cranial Fossa Approach: The Incudomalleolar Joint as a Reliable Landmark

Abstract Introduction The middle cranial fossa approach is performed by fewer neurotologists owing to a reduced number of indications. Consistent landmarks are mandatory to guide the surgeon in a narrow field. Objectives We have evaluated the incus and malleus head and the incudomalleal joint (IMJ) as a key landmark for identifying the superior semicircular canal (SSC) and to get oriented along the floor of the middle cranial fossa. Methods A combination of 20 temporal bone dissections and CT imaging were utilized to test and describe these landmarks. Results The blue line of the SSC is consistently identified along the prolongation of a virtual line through the IMJ and the angulation toward the root of zygoma. The mean distance from the zygoma toward the IMJ ranged from 1.60 to 1.90cm. Once the IMJ was identified, the blue line of the SSC was consistently found along the virtual line through the IMJ within 5 to 9mm. Conclusions The IMJ is a safe and consistent anatomical marker in the surgical approach to the middle cranial fossa floor. Opening the tegmen 1.5 to 2cm medial to the root of the zygoma and identifying the joint allows to trace a virtual line toward the SSC within 5 to 9mm. Knowledge of the close relationship between the direction of the IMJ and the superior canal can be used in all transtemporal approaches, thus orienting the surgeon in a rather narrow field with limited retraction of the dura and brain.

Middle Cranial Fossa Approach: The Incudomalleolar Joint as a Reliable Landmark.

Introduction The middle cranial fossa approach is performed by fewer neurotologists owing to a reduced number of indications. Consistent landmarks are mandatory to guide the surgeon in a narrow field. Objectives We have evaluated the incus and malleus head and the incudomalleal joint (IMJ) as a key landmark for identifying the superior semicircular canal (SSC) and to get oriented along the floor of the middle cranial fossa. Methods A combination of 20 temporal bone dissections and CT imaging were utilized to test and describe these landmarks. Results The blue line of the SSC is consistently identified along the prolongation of a virtual line through the IMJ and the angulation toward the root of zygoma. The mean distance from the zygoma toward the IMJ ranged from 1.60 to 1.90cm. Once the IMJ was identified, the blue line of the SSC was consistently found along the virtual line through the IMJ within 5 to 9mm. Conclusions The IMJ is a safe and consistent anatomical marker in the surgical approach to the middle cranial fossa floor. Opening the tegmen 1.5 to 2cm medial to the root of the zygoma and identifying the joint allows to trace a virtual line toward the SSC within 5 to 9mm. Knowledge of the close relationship between the direction of the IMJ and the superior canal can be used in all transtemporal approaches, thus orienting the surgeon in a rather narrow field with limited retraction of the dura and brain.

Audiological Outcome in Myringoplasties with an Intact Ossicular Chain: Is there a Difference between Chronic Otitis with or without Cholesteatoma?

Introduction Chronic otitis media (COM) with a central perforation or a concomitant cholesteatoma are both inflammatory lesions, however, with different etiologies. Both entities may present with an intact chain, and the final reconstruction is quite similar. Does it also apply for the hearing outcome? Objectives In a retrospective analysis, we investigated the preoperative hearing and the final hearing outcome of two groups of patients: those with COM and those with cholesteatoma, and compared various factors. Methods Patients operated between 2010 and 2019 were entered prospectively into a research database, and the integrity of the ossicular chain, the extent of the cholesteatoma, and the findings on computed tomography (CT) scans were retrospectively analyzed and correlated to the final hearing outcome. Results Out of 210 tympanoplasties for COM, 162 (80%) presented with an intact chain, and 85 (40%) ears could be analyzed. Out of 283 cholesteatoma surgeries, 53 (19%) ears presented with an intact chain. The preoperative air-bone gap (ABG) was worse in the COM group, but the postoperative ABG over the frequencies of 0.5 kHz and 4 kHz was the same (10 dB to 12 dB) in both groups, and remained within 20 dB in 90% (40 and 78 patients, respectively). The extension of the disease was rather limited in the cholesteatoma group (stages Ch1a and 1b), and better pneumatization and ventilation were beneficial for a good result. Postoperatively, the frequency of 4 kHz had the largest ABG (14 dB and 18 dB). Conclusion Overall, 80% of the patients with COM and less than 20% of those with cholesteatoma had an intact and mobile chain at surgery. Using equivalent surgical techniques for the tympanoplasty, the final outcome was almost the same for both groups, with a mean ABG of 10 dB to 12 dB.

Audiological Outcome in Myringoplasties with an Intact Ossicular Chain: Is there a Difference between Chronic Otitis with or without Cholesteatoma?

Abstract Introduction Chronic otitis media (COM) with a central perforation or a concomitant cholesteatoma are both inflammatory lesions, however, with different etiologies. Both entities may present with an intact chain, and the final reconstruction is quite similar. Does it also apply for the hearing outcome? Objectives In a retrospective analysis, we investigated the preoperative hearing and the final hearing outcome of two groups of patients: those with COM and those with cholesteatoma, and compared various factors. Methods Patients operated between 2010 and 2019 were entered prospectively into a research database, and the integrity of the ossicular chain, the extent of the cholesteatoma, and the findings on computed tomography (CT) scans were retrospectively analyzed and correlated to the final hearing outcome. Results Out of 210 tympanoplasties for COM, 162 (80%) presented with an intact chain, and 85 (40%) ears could be analyzed. Out of 283 cholesteatoma surgeries, 53 (19%) ears presented with an intact chain. The preoperative air-bone gap (ABG) was worse in the COM group, but the postoperative ABG over the frequencies of 0.5 kHz and 4 kHz was the same (10 dB to 12 dB) in both groups, and remained within 20 dB in 90% (40 and 78 patients, respectively). The extension of the disease was rather limited in the cholesteatoma group (stages Ch1a and 1b), and better pneumatization and ventilation were beneficial for a good result. Postoperatively, the frequency of 4 kHz had the largest ABG (14 dB and 18 dB). Conclusion Overall, 80% of the patients with COM and less than 20% of those with cholesteatoma had an intact and mobile chain at surgery. Using equivalent surgical techniques for the tympanoplasty, the final outcome was almost the same for both groups, with a mean ABG of 10 dB to 12 dB.

Intratemporal facial nerve schwannomas: multicenter experience of 80 cases.

PURPOSE: To provide more data on the clinical presentation and natural evolution of facial nerve schwannomas and to provide guidance for therapeutic decision making. METHODS: A retrospective case review of eighty patients diagnosed with a facial nerve schwannoma between 1990 and 2018 in ten tertiary referral centers in Europe was performed. Patients' demographics, symptomatology, audiometry, anatomical site (segments involved), size and whenever possible volume measurement were registered. RESULTS: At presentation, transient or persistent facial palsy was the most common symptom, followed by hearing loss. The schwannoma involved more than one segment in the majority of the patients with the geniculate ganglion being most commonly involved. Initial treatment consisted of a wait and scan approach in 67.5%, surgery in 30% and radiation therapy in 2.5% of the patients. Tympanic segment schwannomas caused mainly conductive hearing loss and were more prone to develop facial palsy at follow-up. Internal auditory canal or cerebellopontine angle schwannomas presented with significantly more sensorineural hearing loss. CONCLUSIONS: Although modern imaging has improved diagnosis of this tumor, choosing the best treatment modality remains a real challenge. Based on the literature review and current findings, more insights into the clinical course and the management of facial nerve schwannomas are provided.

[The comparison of malleostapedotomy in primary and revision stapes surgery for otosclerosis].

Objective: To compare the effectiveness of primary malleostapedotomy with revision malleostapedotomy for otosclerosis. Methods: From April 2002 to December 2017, 70 consecutive patients with otosclerosis who underwent malleostapedotomy were reviewed. Depending on the primary malleostapedotomy (P-MS) or revision malleostapedotomy (R-MS), the patients were divided into P-MS group or R-MS group.The intraoperative findings and hearing results before and after surgery were compared between the two groups. ALL data were analyzed using SPSS 23. Results: Totally 73 malleostapedotomy were performed in 73 ears of 70 patients, including 38 P-MS and 35 R-MS. There was no significant difference between the two groups in sex ratio, age and operated ears (P>0.05 for all). The most common finding at P-MS was incus fixation (50.0%, 19/38) versus prosthesis displacement for R-MS (60.0%, 21/35) . Overall, the air-bone gap (ABG) improvement in P-MS were (18.1±8.2) dB in 0.5-3 kHz and (18.3±8.5) dB in 0.5-4 kHz, without significant difference to those in R-MS (P>0.05) . 31.4% of R-MS in 0.5-3 kHz and 22.9% R-MS in 0.5-4 kHz achieved an ABG<10 dB, significantly lower than those of P-MS (65.8% in 0.5-3 kHz and 57.9% in 0.5-4kHz; P<0.05). Failure (postoperative ABG>30 dB) occurred in 11.4% in R-MS and 0 in P-MS (for 0.5-3 kHz and 0.5-4 kHz). The incidence of postoperative sensorineural hearing loss (>10 dB increase in bone conduct) in R-MS group was 8.6% in 0.5-3 kHz and 0.5-4 kHz, without significant difference to those in P-MS (P>0.05) . 80.0% (20/25) of first R-MS achieved ABG<20 dB, compared to 37.5% (3/8) of second R-MS with ABG<20 dB. Conclusions: Although both P-MS and R-MS can significantly improve hearing, with similar risk of inner ear damage, R-MS is less effective and poses a higher risk of failure than P-MS. For patients with insufficient hearing improvement after first R-MS, conventional hearing aids or implantable hearing devices may be considered as an alternative.

Design and Synthesis of a Compound Library Exploiting 5-Methoxyleoligin as Potential Cholesterol Efflux Promoter.

5-Methoxyleoligin and leoligin are natural occurring lignans derived from Edelweiss (Leontopodium nivale ssp. alpinum), displaying potent pro-angiogenic and pro-arteriogenic activity. Cholesterol efflux from macrophages is associated with reverse cholesterol transport which inhibits the development of cardiovascular disease. Within this study, we developed a modular and stereoselective total synthesis of 5-methoxyleoligin which can be readily used to prepare a novel compound library of related analogs. The target 5-methoxyleoligin was synthesized exploiting a recently disclosed modular route, which allows also rapid synthesis of analogous compounds. All obtained products were tested towards macrophage cholesterol efflux enhancement and the performance was compared to the parent compound leoligin. It was found that variation on the aryl moiety in 2-position of the furan ring allows optimization of the activity profile, whereas the ester-functionality does not tolerate significant alterations.

Introducing the "ChOLE" Classification and Its Comparison to the EAONO/JOS Consensus Classification for Cholesteatoma Staging.

: Many previous attempts have been made to classify or categorize cholesteatomas. Recently, the European Academy of Otology and Neurotology and the Japanese Otological Society proposed a classification system based primarily on extension and complications. The European Academy of Otology and Neurotology/Japanese Otological Society consensus statement makes an effort to standardize reporting of surgical techniques. Internet-based multicenter studies are facilitated by increasing connectivity, but a mutually-agreed framework for reporting is necessary for results to be comparable across sites. New technologies compete with established standardized surgical approaches and need to be validated. It is definitively the right time to find a consensus on how to record and report surgical findings in cholesteatoma surgery. To stimulate this interesting discussion, we propose a ChOLE-classification system, which is based on the differentiation into extension (Ch), status of the ossicular chain at the end of surgery (O), complications (L), and degree of pneumatization and ventilation (E). A numeric rule is used to stage these cholesteatomas from I-III.

International Otology Outcome Group and the International Consensus on the Categorization of Tympanomastoid Surgery.

The International Otology Outcome Group (IOOG) was founded in 2017 to encourage and facilitate international collaboration with regard to the surgical outcome of ear surgery. This report outlines the methodology and recommendations of the consensus-based categorization of tympanomastoid surgery produced by the IOOG. The IOOG Steering Committee used the acronym SAMEO-ATO to categorize tympanomastoid operations, representing the stage of surgery, approach, mastoid bone extirpation, external bony wall repair, obliteration of the mastoid cavity, access to the middle ear, tympanic membrane reconstruction, and ossicular reconstruction. A modified Delphi technique was used to obtain international consensus. The expert panels included the chairpersons from 21 otology societies. The approval rate of the SAMEO-ATO system from the otology societies was 95%. The SAMEO-ATO scheme was presented at the 31st Politizer Meeting for field testing. There were no objections or serious concerns raised. Some international otologists wished to see more surgical categories included to reflect the varieties of surgical techniques, but they accepted that it would make the whole system cumbersome. In addition to providing an international categorization of tympanomastoid surgery, the IOOG Steering Committee plans to introduce a common otology dataset that the international otology community could use to record their surgical outcome. The high level of international consensus on the IOOG categorization of tympanomastoid surgery supports this tool for surgeons to pool their surgical data into a large database for research and comparative audit.

Risk factors for hypocalcaemia after completion hemithyroidectomy in thyroid cancer.

BACKGROUND: Hypocalcaemia (HC) is the most common complication after thyroid surgery in differentiated thyroid cancer and leads to a prolongation of the hospital stay. While risk factors for HC after total thyroidectomy (TE) are well investigated, only few studies have been published about HC risk factors after completion of thyroidectomy. Our aim was to identify potential risk factors for HC after completion of TE and to compare these incidences with figures from primary total TE. MATERIALS AND METHODS: A retrospective cohort study was undertaken including patients undergoing completion of TE between 2002 and 2013 in our tertiary care centre. Patients with hypocalcaemia (group 1) after undergoing second surgery were compared to normocalcaemia patients (group 2) with respect to gender, age, type of thyroid cancer, time interval between surgeries, pre/postoperative calcium and parathyroid hormone (PTH) levels, clinical hypocalcaemia signs and calcium substitution (intravenous, oral). Hypocalcaemia was defined as <2.10 mmol/l, hypoparathyroidism as <15pg/ml. RESULTS: 34 (25 female, 9 male) patients were included. A total of 12 patients (33%) developed a hypocalcaemia (group 1). Three patients out of these also presented with hypoparathyroidism. One patient in each group showed clinical signs of hypocalcaemia. Calcium substitution was necessary in six cases in group 1 and in one case in group 2. There was a significant difference between the groups concerning postoperative PTH (25.1 vs 37.6 pg/ml) and calcium levels (1.87 vs 2.27 mmol/l) (p <0.05). Group comparison shows no significant relationships between all other parameters (age, gender, type of thyroid cancer and duration of interval between surgeries). Logistic regression analysis identified a low preoperative serum calcium level as the only dominant factor indicating postoperative hypocalcaemia. CONCLUSIONS: A hypocalcaemia rate of 33% (12/34) and a hypoparathyroidism rate of 9% (3/34) after completion of thyroidectomy in our cohort is comparable to primary total thyroidectomy. A low preoperative calcium level is a significant risk factor for postoperative hypocalcaemia after completion of thyroidectomy. The prediction of hypocalcaemia still remains difficult since it has multifactorial causes.

Titanium incus interposition ossiculoplasty: audiological outcomes and extrusion rates.

This study aimed to evaluate the benefit but also the extrusions, dislocations, and failures of a titanium incus prosthesis along with the long-term audiological outcomes. We prospectively collected data from 139 patients undergoing ossiculoplasty using the Fisch titanium incus prosthesis between 2001 and 2016. Overall, 126 patients with at least 6 months of follow-up (mean 4.5 years, range 6-155 months) were analyzed. Patients were grouped as "extrusion" (n = 9, 7%) if the prosthesis extruded, "failure" (n = 22, 18%) if a reoperation was needed concerning the prosthesis, and "stable" (n = 95, 75%) if the prosthesis remained functional in the middle ear. Mean postoperative air bone gaps (ABG) for 0.5-3 kHz for the overall group and the stable group were 19.8 (±11.9) and 15.3 (±7.5), respectively. Long-term results of stable group revealed an ABG (0.5-3 kHz) below 10 dB in 25% and below 20 dB in 81% of the patients. Atelectasis was the most frequent cause of extrusion, which occurred after a mean time of 28.7 months (range 15-48 months). Mean timing for reoperation was 30.7 months (range 5-131 months) in the failure group. There was no significant difference in mean postoperative ABG among patients with or without cholesteatoma, primary or staged ossiculoplasty in cholesteatoma, presence or absence of malleus head at the time of ossiculoplasty, open or closed cavity surgeries, or the degree of pneumatization of the temporal bone. The Fisch titanium incus prosthesis is a reliable alternative to using autologous incus for interposition ossiculoplasty, with similar hearing outcomes. Using this prosthesis, a 15 dB ABG should be expected.

[Benefit of Bimodal Stimulation with Cochlear Implant and Hearing Aid in Elderly Patients]. / Cochlea-Implantation ab dem 70. Lebensjahr ­ Nutzen der bimodalen Versorgung mit Hörgerät und CI.

Cochlear implant (CI) surgery is the standard of care for postlingual deafness in adults. A hearing aid (HA) for the non-implanted ear is normally used if residual hearing is available. There is limited data on bimodal stimulation in elderly patients. We compare the outcome of bimodal stimulation and analyzed the correlation of bimodal benefit and residual hearing in elderly patients. 22 patients≥70 years were implanted with a single-sided CI from 2002 till 2014. 17 patients use a HA on the non-implanted ear (bimodal). In a retrospective chart review we analyzed the audiological benefit (pure tone average, speech recognition). Time to follow-up was 6 month to 12 years. The subjective benefit was assessed using a structured questionnaire. The speech recognition (monosyllabic word testing in quiet @ 65 dB SPL) showed a score of 61% in bimodal condition vs. 53% with CI alone (p=0.35). There was no statistically significant correlation between residual hearing in the lower frequencies (250 Hz, 500 Hz and 1 kHz) and bimodal benefit. Most elderly patients benefit from bimodal stimulation. In quiet and in comparison with CI alone, most patients showed some improvement in word recognition scores using bimodal fitting, and all of them were using the contralateral hearing aid all day long. Postlingual deafened elderly patients fitted with a unilateral CI require a short rehabilitation period. In case of contralateral hearing aid fitting, regular control of the hearing aid should not be overlooked.

Leoligin, the Major Lignan from Edelweiss (Leontopodium nivale subsp. alpinum), Promotes Cholesterol Efflux from THP-1 Macrophages.

Leoligin is a natural lignan found in Edelweiss (Leontopodium nivale ssp. alpinum). The aim of this study was to examine its influence on cholesterol efflux and to address the underlying mechanism of action. Leoligin increases apo A1- as well as 1% human plasma-mediated cholesterol efflux in THP-1 macrophages without affecting cell viability as determined by resazurin conversion. Western blot analysis revealed that the protein levels of the cholesterol efflux transporters ABCA1 and ABCG1 were upregulated, whereas the SR-B1 protein level remained unchanged upon treatment with leoligin (10 µM, 24 h). Quantitative reverse transcription PCR further uncovered that leoligin also increased ABCA1 and ABCG1 mRNA levels without affecting the half-life of the two mRNAs in the presence of actinomycin D, a transcription inhibitor. Proteome analysis revealed the modulation of protein expression fingerprint in the presence of leoligin. Taken together, these results suggest that leoligin induces cholesterol efflux in THP-1-derived macrophages by upregulating ABCA1 and ABCG1 expression. This novel activity suggests leoligin as a promising candidate for further studies addressing a possible preventive or therapeutic application in the context of atherosclerosis.