The Long-Term Stability of Fat-Graft Myringoplasty in the Closure of Tympanic Membrane Perforations and Hearing Restoration.

BACKGROUND/AIMS: This study was conducted to evaluate the long-term stability of fat-graft myringoplasty (FGM) for chronic tympanic membrane perforations, analyzing the perforation closure rate and re-gained hearing outcome with respect to the size and location of the perforations. METHODS: Between August 2007 and June 2018, a total of 193 patients who underwent FGM due to chronic tympanic membrane perforation at a tertiary referral center were enrolled and analyzed. RESULTS: The mean follow-up was 14.6 months (range 6-39). The complete perforation closure rate after FGM was 89.6%, with no statistical difference among the perforation size groups. The mean postoperative air-bone gap (ABG) was 11.0 dB and mean ABG improvement was 4.9 dB. CONCLUSION: Our FGM technique had a favorable tympanic closure rate for small to large perforations, and yielded relatively good hearing improvement in the mid-size perforation cases over long-term follow-up periods. According to the topographic evaluation of FGM, this procedure resulted in a reliable perforation closure rate and audiological results regardless of the perforation site.

Effect of middle ear gelfoam on hearing and healing process after tympanoplasty: A prospective randomized case-control study.

PURPOSE: This prospective randomized case-control study was performed to compare the surgical outcomes of our swing-door overlay tympanoplasty with or without absorbable gelatine sponge (AGS, gelfoam) packing in the middle ear cavity, according to the surgical procedure. METHODS: Fifty-seven patients who underwent swing-door overlay tympanoplasty by a single surgeon were enrolled in the study. The data of 30 patients of the gelfoam-packing group (GPG) and 27 patients of the non-gelfoam-packing group (NGPG) were prospectively collected and compared. RESULTS: Closure of the tympanic membrane was found to be successful in all patients at postoperative 3 months evaluation. NGPG showed a statistically better healing process compared to GPG; earlier epithelialization and less fascia edema in NGPG than in GPG (P < 0.05). The air-bone gap (ABG) measured at postoperative 1 and 2 months was smaller in NGPG than GPG, although there were no statistical differences. CONCLUSION: This study revealed earlier healing process and faster recovery of ABG in NGPG, thereby indicating that the gelfoam in the middle ear may interfere with both hearing recovery and the healing process of neodrum.

Surgical results of infected preauricular sinus: No need for delay.

OBJECTIVES: This study was performed to propose the proper surgical timing of infected preauricular sinus (PAS) by comparing surgical results of active infection PAS group (AIPASG) to infection-controlled/or non-infected PAS group (IC/NIPASG). METHODS: Two hundred and twelve patients with PAS who underwent surgical excision using minimal supra-auricular approach by one surgeon (S.N.P) in a tertiary referral center between Apr 1999 and Dec 2016 were enrolled in this study. Medical records of 36 patients of AIPASG at surgical time point and 176 patients of IC/NIPASG were collected and their surgical results were compared. Postoperative wound infection, recurrence, need of drain insertion or external compression dressing and other clinical parameters including age, sex, follow up duration and previous incision & drainage (I&D) history were investigated and statistically compared between two groups. RESULTS: There were no significant differences of various clinical parameters between two groups, except previous I&D history (24 among 36 patients of AIPASG and 12 among 176 patients of NI/ICPASG, P < 0.05). Post-operative immediate but mild wound erythema was observed in 11 among 212 patients with no statistical difference between two groups (4 among 48 ears of AIPASG and 7 among 219 NI/ICPASG, P = 0.105) and was controlled by short-term antibiotics and conservative management. Only 1 patient of NI/ICPASG needed a revision surgery of wound exploration and curettage. No more recurrence of infection during their long-term follow-up period was observed in both groups. CONCLUSION: There was no significant difference in the surgical results of minimal supra-auricular approach of PAS excision between AIPASG and NI/ICPASG. Therefore, we suggest that this surgical technique can be performed even in the infected PAS which does not quickly respond to the conservative treatment.

Clinical efficacy of standard simple elliptical incision following drain-less and subcutaneous suture technique in preauricular sinus surgery.

BACKGROUND: The purpose of this study was to review our surgical strategy and outcomes of drain-less, subcutaneous suture technique in standard simple elliptical incision on preauricular sinus (PAS) cases. METHODS: The clinical records of 198 patients (247 ears) with PASs who were operated via standard simple elliptical incision with drain-less, subcutaneous suture technique by a single surgeon (K.H.P.) between January 2008 and December 2018 were reviewed for analysis. Patients' demographics, location of PASs, previous incision and drainage (I&D) history, previous surgical excision history, duration of follow-up, postoperative infection after surgery, and recurrence after surgery were analysed. RESULTS: Out of 247 PASs, 18 (7.3%) cases had postoperative infections and 11 (4.5%) cases showed recurrence. Postoperative infection rate were higher in previous I&D groups (PIDGs, 9.8%) and previous fistulectomy groups (PFGs, 10%), and also recurrence rates of PFGs (10%) was higher than those of fresh cases. However, there were no statistically significant differences between these groups. In addition, PAS patients with postoperative complications such as infection and recurrence were more common in male patients. CONCLUSION: We report a method of drain-less standard simple elliptical incision for the surgical removal of PAS and the outcomes of the surgery. Our method showed a low recurrence rate and low chance of wound infection postoperatively not only in fresh cases but also in pre-operative I&D cases and even previous fistulectomy cases. In conclusion, our method is proposed as an effective and safe method in all kind of patient groups, without presenting post-operative discomfort to patients.

Precise differential diagnosis of acute bone marrow edema and hemorrhage and trabecular microfractures using naïve and gamma correction pinhole bone scans.

OBJECTIVE: To analyze the performance of sequential naïve pinhole bone scan (nPBS) and gamma correction pinhole bone scan (GCPBS), reinforced by ImageJ densitometry and pixelized microfracture measurement, for making specific diagnoses of bone marrow edema (BME), bone marrow hemorrhage (BMH), and trabecular microfractures (TMF). METHODS: We prospectively examined BME, BMH, TMF, and normal trabeculae in 10 patients using sequential nPBS and GCPBS. The intensity of 99mtechnetium-hydroxydiphosphonate (99mTc-HDP) uptake was measured using a pixelized method and calculated using ImageJ densitometry in terms of arbitrary units (AU). This overall method was termed a visuospatial-mathematic assay (VSMA). We analyzed the ability of the calculated AU values to discriminate between the four states using GraphPad Prism software, with reference to previous morphological data. RESULTS: The calculated values were categorized as ≤50 AU for normal trabecula, 51-100 AU for BME, 101-150 AU for BMH, and ≥151 AU for TMF. The difference in uptake between normal trabecula and BME was significant and the differences among BME, BMH, and TMF were highly significant. CONCLUSION: VSMA is a useful technique for refining objective individual diagnoses and for differentiating and quantitating BME, BMH, and TMF.

Cartilage Fascia Composite Canalplasty for External Auditory Canal Cholesteatoma: Case Analysis and Long-term Surgical Results.

OBJECTIVE: To analyze surgical outcomes of cartilage-fascia composite canalplasty (CFCC) for external auditory canal cholesteatoma (EACC). STUDY DESIGN: Retrospective case review study. SETTING: Tertiary referral center. PATIENTS: A total of 13 patients with EACC (n = 14 ears due to one patient with bilateral EACC). INTERVENTION: Surgical method of CFCC using well designed-conchal cartilage and temporalis muscle fascia after complete removal of EACC. MAIN OUTCOME MEASURES: Clinical characteristics and EACC stages were determined by oto-endoscopic examination and computed tomography (CT) findings. The surgical results of CFCC were analyzed. RESULTS: The median age of patients was 43 years (range, 12-75 yr), with a male to female ratio of 6 to 7. EACC stages were from II to IV. Cortical bone erosion in the inferior part of the bony EAC was the most common finding. All patients had satisfactory results: no more ear symptoms related with cholesteatoma and no need of dressing. Postoperative hearing gain was observed in four patients. No complications or recurrence occurred during the mean follow-up period of 34.4 months. CONCLUSION: Surgical technique of CFCC was effective for EACC not responding to conservative management.

Superiority of Second Stage Ossiculoplasty.

OBJECTIVE: To compare hearing results of single stage ossiculoplasty with second stage ossiculoplasty, and to provide a proper indication of operation options (single stage or second stage ossiculoplasty) according to patients' clinical conditions. STUDY DESIGN: Retrospective case review study. SETTING: Tertiary referral center. PATIENTS: A total of 175 patients with chronic otitis media. INTERVENTIONS: Tympanoplasty or mastoidectomy with tympanoplasty (M&T) as well as ossiculoplasty of either single or second stage between January 2009 and March 2016 by one surgeon (S.N.P.). MAIN OUTCOME MEASURES: Hearing outcomes evaluated by mean postoperative air-bone gap (ABG) and success rates in various subgroups of middle ear surgeries and different types of ossiculoplasty were analyzed. RESULTS: Among 175 patients, 120 underwent single stage ossiculoplasty, and 55 underwent second stage ossiculoplasty. The benefit of second stage ossiculoplasty in hearing results both at 3 months visit (p < 0.001) and 2 years visit (p = 0.003) were observed. The superiority of second stage ossiculoplasty was found in 20 dBHL cut off value with a statistical significance. The subgroups of canal wall down mastoidectomy and the first, non-revision middle ear surgery showed statistically significant benefits with second stage ossiculoplasty. CONCLUSION: Second stage ossiculoplasty has overall advantage in hearing results compared with single stage ossiculoplasty and could be more advantageous to the patient who needs canal wall down mastoidectomy or whose operation is the first middle ear surgery.

The Clinical Characteristics and Surgical Outcomes of Carcinoma of the External Auditory Canal: A Multicenter Study.

OBJECTIVE: To analyze the clinical characteristics and evaluate the surgical outcomes of carcinoma of the external auditory canal (CEAC). MATERIALS AND METHODS: Overall, 31 patients from four multicenter hospitals, who were diagnosed and surgically treated for CEAC in 2009-2014, were enrolled for this retrospective study. Medical records were reviewed to determine cancer stage according to the Pittsburgh classification. Clinical data of age, sex, site, initial symptoms, surgery extent, postoperative complications including recurrence, follow-up period, and current patient status were collected for analysis. Five-year cumulative survival rate was obtained using Kaplan-Meier method. RESULTS: At initial diagnosis, 22 patients were in the early stages (stage I: 15; stage II: 7) and 9 patients were in the advanced stages (stage III: 1; stage IV: 8). Lymph node metastasis was present in 5 patients and distant metastasis in 2. Of the 31 patients, 4 patients died (stage II: 1, stage IV: 3) during the follow-up period. Early-stage patients showed 100% 5-year estimated cumulative survival rate, whereas the advanced-stage patients showed 5-year estimated survival rate of 53.6% (p=.006). The overall survival rate of all enrolled patients was 90.3%. Although 5-year estimated disease-free survival rate of stage I was 100.0%, that for stage II was low at 30.0% because of considerable recurrences. CONCLUSION: The results of this multicenter study suggest that more aggressive treatment modality, including adjuvant therapy, is necessary for patients with CEAC with Pittsburgh stage II or more.

Long-Term Effects of Middle Ear Tendon Resection on Middle Ear Myoclonic Tinnitus, Hearing, and Hyperacusis.

OBJECTIVE: To evaluate the therapeutic effects of middle ear tendon resection (METR) on middle ear myoclonic tinnitus (MEMT) and to investigate its long-term effects on hearing and hyperacusis. MATERIALS AND METHODS: Thirty-seven patients with MEMT with a mean age of 33.2 ± 11.8 years were included in this study. METR was performed on all 37 MEMT patients (41 ears) between November 2004 and August 2016. The mean follow-up period was 16.1 months. We examined changes in tinnitus and accompanying stress and depression in patients after surgery, and examined the hearing changes and the occurrence of complications including hyperacusis. RESULTS: After surgery, 34 (91.9%) patients exhibited complete resolution of MEMT during their follow-up period, and 3 patients showed a partial response. The mean Visual Analog Scale (VAS) scores for tinnitus severity, the Tinnitus Handicap Inventory (THI), and stress index decreased significantly after surgery (p < 0.05, paired t test). No patient developed hearing loss or hyperacusis following surgery. Preexisting hyperacusis even improved in most of the patients with intractable MEMT after surgery. Recurrence of the symptom occurred in only 1 patient, who underwent revision surgery with improvement. We observed 1 case of postoperative delayed facial palsy with complete recovery in 2 weeks. CONCLUSIONS: METR seems to be an effective and safe treatment option for intractable MEMT, considering its high control rate of tinnitus and no long-term harmful effects on hearing and hyperacusis.

Two Cases of Angioleiomyoma of the Auricle.

Angioleiomyoma is a benign tumor originating from the muscularis layer of blood vessel walls. It usually occurs in extremities, and the auricle is not a frequent site for the development of this tumor. We present two cases of auricular angioleiomyoma diagnosed after pathological examination along with a review of literature.

Childhood tinnitus: clinical characteristics and treatment.

PURPOSE: Troublesome tinnitus in children can have an impact on their lives leading to behavioral or psychological problems. The present study was designed to identify the clinical features of childhood tinnitus, to establish the treatment strategy for each tinnitus category and severity, and to assess the treatment outcomes. MATERIALS AND METHODS: Clinical data were retrospectively collected on 108 tinnitus patients in childhood and adolescence. The authors have classified tinnitus according to the acoustic source: otic (idiopathic subjective), myoclonic, and vascular tinnitus based on the tinnitus quality and appropriate diagnostic approaches. Treatment selection depended on the tinnitus category and severity. Treatment modalities included counseling, a simplified tinnitus retraining therapy, counseling with medications, and surgery. RESULTS: Of all 108 subjects, otic tinnitus was the most common form of childhood tinnitus (n=80) followed by myoclonic (n=21) and vascular tinnitus (n=6). The prevalence of otic tinnitus increased with age. The mean age of myoclonic tinnitus patients was younger than that of the others. The majority of otic tinnitus showed normal hearing. The origin of 81% of myoclonic tinnitus was middle ear muscles. Of all subjects, 67.6% had mild tinnitus responsive to counseling alone. Distressing tinnitus was most common in myoclonic tinnitus. Almost all patients (97%) who were followed up at 3 months (64%) showed improvements. CONCLUSIONS: We suggest that understanding the clinical characteristics of childhood tinnitus, establishing a diagnosis based on the acoustic source, and implementing appropriate therapy customized to the individual tinnitus category and severity would help clinicians to relieve tinnitus children of their troublesome tinnitus effectively.

Clinical characteristics of auricular keloids treated with surgical excision.

BACKGROUND AND OBJECTIVES: Differences in morphology of auricular keloids possibly contribute to distinct results of treatment. The aim of this study was to evaluate clinical characteristics of the auricular keloids according to the modified Chang-Park classification and to compare the results of treatment including recurrence rate between the subgroups. SUBJECTS AND METHODS: Clinical data of 15 patients of auricular keloids were retrospectively reviewed. The keloids were classified according to modified Chang-Park classification. Clinical characteristics, the presence of recurrence, and the duration required for the recurrence were compared. RESULTS: Eight out of 15 patients (53.3%) were single sessile type (type II), followed by 4 patients of pedunculated type, 1 patient of multiple sessile type, 1 patient of buried type, and 1 patient of mixed type, respectively. Recurrent keloids after previous surgeries were noted in 7 out of 15 patients and most of them (6 of 7, 85.7%) were sessile type. Three patients who underwent surgery at our department showed recurrence. CONCLUSIONS: The classification of auricular keloids according to morphologic patterns can assist surgeons in choosing the appropriate management.

Depiction of Nidi and Fibrovascular Zones of Osteoid Osteomas Using Gamma-Correction Tc-99m HDP Pinhole Bone Scan and Conventional Radiograph, and Correlation with CT, MRI, and PVC Phantom Imaging.

PURPOSE: For the precise imaging diagnosis of osteoid osteoma (OO), the identification of the nidus and fibrovascular zone (FVZ) is essential. However, the latter sign has received little attention because it is difficult to demonstrate. We applied the recently introduced gamma correction (GC) to depict the FVZ on pinhole bone scan (PBS), conventional radiography (CR), and computed tomography (CT). Non-gamma correction MRI was also analyzed for reference. METHODS: Ten patients with histologically proven diagnoses of OO were enrolled in this retrospective study. PBS, CR, and CT were processed by GC to demonstrate the nidi and FVZ as distinct yet integrating components of OO. PBS was performed using a 4-mm pinhole collimator 3 h after iv injection of 925 to 1,110 MBq (25 to 30 mCi) of Tc-99m HDP, and anteroposterior and mediolateral CR and transverse CT were taken according to the standard technique. MRI sequences included T1- and T2-weighted images. For gamma correction, we utilized the Photo Correction Wizard program of ACD Photo Editor v3.1. A team of three qualified nuclear physician-radiologists, two nuclear physicians, and one MRI specialist read bone scans, radiographs, and MRIs of OO according to each specialty, and orthopaedic aspects and histology were reviewed by one qualified orthopedic surgeon and two qualified pathologists, respectively. Each observer first read the images separately with basic information about the aim of the study given and then in concert. Interpretive disagreement was settled by discussion and consensus. RESULTS: On pinhole scan, nidi were presented as areas of intense tracer uptake in all cases, and, importantly after GC, a thin ring-like zone with lower tracer uptake became visible in seven out of ten cases. GCCR also revealed a thin lucent zone that circumscribed the nidi in six out of ten cases and GCCT in two of four cases. MRI, without GC, presented nidi with high signal in the center and a thin ring-like zone with low signal in the periphery in five out of six cases. Ring-like zones were 1-2 mm in thickness and circumscribed the nidus as an integrated part and, hence, were morphologically interpreted as FVZ. Histologically, the presence of a variously mineralized FVZ was confirmed in four cases, but individual locus-by-locus image-histology correlation could not be accompolished because specimens were fragmentary. In the FVZ, tracer uptake was lower than in nidi, presumably reflecting that bone metabolism in the two parts differs as in their histology. Statistically, no significant correlation existed between the duration of symptoms and imaging demonstrability of the FVZ (Spearman's test r = -0.057, p = 0.877), but parallelism existed in the demonstrability of the FVZ among GC PBS, CR, and CT, and non-correction MRI. CONCLUSIONS: GC was useful to enhance the resolution of PBS, CR, and CT in OO so that both the nidi and FVZ were separately imaged. The use of CG PBS and CR in combination is recommended for the specific diagnosis of OO with information about bone metabolism and anatomical characteristics. PBS and CR are economical and widely available.

The use of an immunohistochemical diagnostic panel to determine the primary site of cervical lymph node metastases of occult squamous cell carcinoma.

Cervical lymph node metastases from unknown primary sites account for approximately 3% to 9% of all head and neck malignant lesions. Squamous cell carcinoma is the most common type of cervical metastatic carcinoma. Our aim was to investigate the possibility of determining the site of primary tumors using an immunohistochemical diagnostic panel in metastatic cervical lymph nodes. Expression profiles of cytokeratins, 5/6; 8/18; 10; 13; 14; and 19, p16, and pRb were evaluated in 101 consecutive patients with cervical nodal metastasis who had undergone neck dissection to treat known head and neck squamous cell carcinoma (primary sites: 16, oral cavity; 38, oropharynx; 26, hypopharynx; 21, larynx). Cytokeratin 10 was more frequently expressed in oral cavity primary tumors, whereas cytokeratin 19 staining was more frequently observed in tumors originated from the pharynx and larynx. The expression of p16 and altered pRb status (0% or >50%) were more frequently observed in oropharynx primary tumors. To select the best subset among the 8 antibodies tested, classification and regression tree analysis was performed. The analysis correctly classified the four primary sites (25.0% of oral cavity, 89.5% of oropharynx, 30.8% of hypopharynx, and 57.1% of larynx) using 5 variables (histologic subtype, p16, cytokeratins 10 and 19, and pRb). The p16 was the single best predictor. The classification tree method using immunostaining profiles of p16, cytokeratins 10 and 19, or pRb may be helpful in the identification of the primary site of metastatic squamous cell carcinoma with occult primary.