Spontaneous tumour shrinkage in 1261 observed patients with sporadic vestibular schwannoma.

OBJECTIVE: To determine the rate of spontaneous tumour shrinkage in a group of patients with sporadic vestibular schwannoma managed with a 'wait and scan' approach. PATIENTS: All patients with a unilateral cerebello-pontine angle tumour resembling a vestibular schwannoma were registered prospectively in a national database in Denmark. Patients registered with tumour shrinkage were identified and all computed tomography and magnetic resonance imaging scans retrieved, re-evaluated and related to the clinical data. RESULTS: Of 1261 observed patients, 48 displayed spontaneous shrinkage (3.81 per cent). Mean absolute shrinkage was 6.25 mm, equivalent to 52.1 per cent. Absolute shrinkage correlated with tumour size and followup period, whereas relative shrinkage was significantly greater for tumours which were purely intrameatal at diagnosis. There was no correlation between age and the degree of shrinkage. CONCLUSION: Four per cent of sporadic vestibular schwannomas shrink spontaneously. These findings substantiate the 'wait and scan' strategy for tumours with a largest extrameatal diameter of up to 20 mm.

Residual tumour after vestibular schwannoma surgery.

OBJECTIVE: To evaluate residual tumour occurrence after vestibular schwannoma surgery, based on intra-operative registration and magnetic resonance imaging one year post-operatively. METHODS: Patients undergoing translabyrinthine surgery for vestibular schwannoma in Denmark between 1976 and 2008 were registered in a national database covering 5.5 million inhabitants. RESULTS: Translabyrinthine surgery was undertaken on 1143 patients. Of these, 978 had total, 140 near-total and 25 subtotal tumour excision, as assessed intra-operatively by the surgeon. One year after surgery, 65 per cent of small tumour remnants and 11 per cent of large tumour remnants were not visible on magnetic resonance imaging. The mean pre-operative size was significantly smaller for totally excised tumours, compared with near-totally and subtotally excised tumours. Revision surgery was performed for 14 patients (1.2 per cent), of whom 2 had received total, 5 near-total and 6 subtotal excisions initially. CONCLUSION: Most residual tumours disappear spontaneously, probably due to devascularisation. Few patients with a small residual vestibular schwannoma will require revision surgery or secondary radiotherapy.

Hearing outcomes of vestibular schwannoma patients managed with 'wait and scan': predictive value of hearing level at diagnosis.

AIMS: This study aimed to evaluate the predictive value of both hearing level (at various frequencies) and speech discrimination for forecasting hearing outcome after a period of observation, in patients with vestibular schwannoma. SUBJECTS: Over a 33-year period, 1144 patients with vestibular schwannoma were allocated to 'wait and scan' management, with annual magnetic resonance imaging and audiological examination. Two complete pure tone and speech discrimination audiograms were available for 932 patients. RESULTS: The predictive value of initial hearing level better than 10 dB for forecasting hearing outcome after observation increased from 59 per cent at 250 Hz to 94 percent at 4000 Hz. At diagnosis, hearing level of 10 dB or better at 4000 Hz was found in only 18 of the 932 VS ears, while good speech discrimination was found in 159 patients (17 per cent). Of the latter patients, 138 maintained good hearing after observation. CONCLUSION: In vestibular schwannoma patients, good high frequency hearing and good speech discrimination at diagnosis are useful tools in predicting good hearing after observation.

Change in hearing during 'wait and scan' management of patients with vestibular schwannoma.

AIM: To evaluate hearing changes during 'wait and scan' management of patients with vestibular schwannoma. SUBJECTS: Over a 10-year period, 636 patients have prospectively been allocated to 'wait and scan' management, with annual magnetic resonance scanning and audiological examination. RESULTS: At the time of diagnosis, 334 patients (53 per cent) had good hearing and speech discrimination of better than 70 per cent; at the end of the 10-year observation period, this latter percentage was 31 per cent. In 17 per cent of the patients, speech discrimination at diagnosis was 100 per cent; of these, 88 per cent still had good hearing at the end of the observation period. However, in patients with even a small initial speech discrimination loss, only 55 per cent maintained good hearing at the end of the observation period. CONCLUSION: After comparing the hearing results of hearing preservation surgery and of radiation therapy with those of 'wait and scan' management, it appears that, in vestibular schwannoma patients with a small tumour and normal speech discrimination, the main indication for active treatment should be established tumour growth.

Recurrence of attic cholesteatoma: different methods of estimating recurrence rates.

One problem in cholesteatoma surgery is recurrence of cholesteatoma, which is reported to vary from 5% to 71%. This great variability can be explained by issues such as the type of cholesteatoma, surgical technique, follow-up rate, length of the postoperative observation period, and statistical method applied. The aim of this study was to illustrate the impact of applying different statistical methods to the same material. Thirty-three children underwent single-stage surgery for attic cholesteatoma during a 15-year period. Thirty patients (94%) attended a re-evaluation. During the observation period of 15 years, recurrence of cholesteatoma occurred in 10 ears. The cumulative total recurrence rate varied from 30% to 67%, depending on the statistical method applied. In conclusion, the choice of statistical method should depend on the number of patients, follow-up rates, length of the postoperative observation period and presence of censored data.

Reasons for reperforation after tympanoplasty in children.

In 116 children and 124 ears with non-cholesteatomatous chronic otitis media operated on during a 13-year period from 1968 to 1980 via transcanal tympanoplasty and followed with several re-evaluations 15-27 years after operation, the causes of reperforation have been analysed. In total, 14 ears (11%) had reperformation; in 7 ears (5.6%), the reperforations occurred early (during the first 3 months) and in 7 ears late (after 6 months), but most often the reperforations occurred after 10 years. The early reperforations were presumably failures in surgery. Less experienced surgeons and inflamed, wet middle ear mucosa during the primary surgery seemed to be the two most important causal factors. Young age at surgery, size and site of the perforation and Eustachian tube function seemed to be of no importance for reperforation. The early reperforations were closed at surgery and remained closed into adulthood. The reasons for late reperforations are less clear; they were presumably caused by acute otitis media with perforation in an atrophic part of the drum, which did not heal. The reperforations were small, but it was possible to close all of them surgically if the patients wanted to be reoperated. It is concluded that tympanoplasty, even in young children, is a rewarding option with good and stable results.

Results of tympanoplasty in children after 15 to 27 years.

Results of tympanoplasty in children with noncholesteatomatous chronic otitis media are presented in a 16- to 27-year follow-up. During the 13-year period from 1968 to 1980, 116 children (124 ears) were operated on, and they were submitted to several follow-ups with audiometry and otomicroscopy. The attendance at the last follow-up was 70%, and the minimum time since surgery for these patients was 15 years. All dry ears were operated on transcanally with a fixed ear speculum, without any lateral incision of the ear canal skin. Cumulatively, in total, 14 ears (11%) had reperforation: 7 ears early and 7 ears late. At 6 months, there were 6% early reperforations; some were surgically closed and some reappeared later, even after several years, as late perforations. At 2 to 15 years of follow-up, there were 4% reperforations, and at 16 to 27 years, 6%. Hearing was good and stable. The results were the same in ears operated on at the ages of 2.5 to 7 years and 8 to 14 years, as well as with preoperatively positive and negative Valsalva maneuvers. In total, 14% of ears were revised during the entire observation period. It is concluded that transcanal tympanoplasty, even in young children, has good long-term stability and can definitively and permanently solve the problem of noncholesteatomatous chronic otitis in children.

Cholesteatoma in children, predictors and calculation of recurrence rates.

The aim of the study was to evaluate the long-term recurrence rate after surgery for acquired cholesteatoma in children, to search for predictors of recurrency and to analyse the impact of the applied statistical method on the outcome of the results. During a 15-year period, 114 children underwent first-time surgery for acquired cholesteatoma. The patients were re-evaluated with a median observation time of 5.8 years, range 1-16 years. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24% using standard incidence rate calculation, applying Kaplan-Meier survival analysis the recurrence rate was 33%. Recurrent disease occurred significantly more frequent in children < 8 years, with negative preoperative Valsalva, ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function, large cholesteatoma and erosion of the ossicular chain, are at special risk of recurrence and should be observed several years after surgery.

New modification of hot-water irrigation in the treatment of posterior epistaxis.

BACKGROUND: Tamponade treatment for epistaxis is painful and traumatic to the nasal mucosa, and may necessitate hospitalization for several days. Hot-water irrigation (HWI) was introduced as a treatment of epistaxis more than 100 years ago. In a previous study the treatment proved to be effective, less painful, and less traumatic, and required a shorter hospital stay than tamponade treatment. However, HWI has the risk of aspiration during treatment. To minimize this risk, a special catheter has been designed. OBJECTIVES: To evaluate the modified HWI and to compare the results with tamponade treatment, with respect to patient compliance, effectiveness, recurrence of bleeding, pain, complications, and length of hospital stay. PATIENTS: A total of 122 patients, hospitalized for posterior epistaxis, were randomized to receive either HWI or tamponade treatment. RESULTS: In the HWI group, 31 (55%) of the patients could be discharged from the hospital after the initial treatment only, compared with 29 (44%) of the patients treated with tamponade. Using a 10-cm visual analog scale, the mean pain score during treatment was 4.7 in the HWI group compared with 7.5 in the tamponade group. The mean hospital stay was 2.9 days for the HWI group vs. 4.0 days for the tamponade group. After discharge from the hospital, necrosis or synechia was found on rhinoscopy in 12 patients (40%) in the tamponade group compared with none in the HWI group. CONCLUSIONS: Compared with tamponade treatment, HWI is as effective, requires a significantly shorter hospital stay, is less traumatic to the nose, and is significantly less painful.

Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma.

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.

Prevalence of eardrum pathology in a cohort born in 1955.

The aim of this study was to compare the prevalence of the different types of eardrum pathology in a cohort of adults not previously treated by grommet insertion with corresponding findings obtained in a cohort previously treated with grommet insertion. A cohort born in 1955 were invited to a screening examination including otomicroscopy. In the untreated cohort, retraction of Shrapnell's membrane was found in four per cent of the ears compared to 20 per cent in the cohort treated with grommets. Tensa pathology, including atrophy and myringosclerosis, was found in six per cent of the ears in the untreated cohort and in 17 per cent in the treated cohort. Normal eardrums were found in 91 per cent of the ears. Despite the increased awareness of secretory otitis, as well as the increased rate of surgical treatment, the prevalence of eardrum pathology seems to be increasing. The reasons for this are discussed.

A cohort study of point prevalence of eardrum pathology in children and teenagers from age 5 to age 16.

The aim of this prospective study was to estimate the prevalence of different types of eardrum pathology in a cohort of children and teenagers up to the age of 16. Among this initial group of 373 subjects, repetitive screening trials including otomicroscopy and tympanometry were performed from age 5 to 16 years. All clinical pathology of Shrapnell's membrane and the pars tensa was recorded systematically. At age 5 years, pathology of the eardrum was found in 19% of ears examined. At succeeding follow-ups until the age of 16 years, the prevalence of eardrum pathology increased to 33%. The tympanometric profile improved significantly from 49% of children with negative middle ear pressure at age 5 years to 4% at age 16 years. The patency of the eustachian tube was estimated in the group with eardrum pathology and compared to the group with no eardrum pathology. Our findings show that, despite improvement of middle ear ventilation through childhood, the prevalence of pathological changes of the eardrum seems to increase. The reason for this increase is discussed.

Autoinflation as a treatment of secretory otitis media. A randomized controlled study.

This study was undertaken to evaluate the effect of a new method of autoinflation as an alternative treatment of secretory otitis media. Up to 80% of all children experience one or more episodes of eustachian tube dysfunction and secretory otitis media before school age. Common treatment of this condition is insertion of a ventilation tube in the tympanic membrane. Because of the very high incidence of secretory otitis media in childhood, insertion of ventilation tubes is the most frequently performed operation under general anesthesia in children. In addition to possible anesthetic complications, insertion of ventilation tubes may be associated with purulent suppuration, pathologic findings in the eardrum, and hearing impairment. One hundred children were consecutively randomized to undergo either autoinflation, using a new device, or placed in a control group. The children were between 3 and 10 years of age and were entered into the study after having had secretory otitis media for at least 3 months, as verified by tympanometric findings. Tympanometry was repeated at 2 weeks and at 1, 2, and 3 months after the children were entered into the study. After 2 weeks of autoinflation, the tympanometric conditions were improved in 64% of ears, unchanged in 34%, and deteriorated in the remaining 2%. In the control group, tympanometric findings were improved in 15% of ears, unchanged in 71%, and deteriorated in the remaining 14%.

Hearing loss in tympanosclerosis caused by grommets.

The aim of the present study was to determine the degree of hearing impairment caused by tympanosclerosis of the eardrum as a result of grommet insertion. During the period 1977 to 1978 we treated 146 children who had bilateral secretory otitis with adenoidectomy, insertion of a ventilation tube on the right side, and myringotomy on the left. The children were reexamined 2 to 3 years and again 6 to 7 years postoperatively, and hearing was evaluated at 250, 1000, and 4000 Hz. Tympanosclerosis was demonstrated in 59% of the children on the side with grommet insertion compared with 13% in the contralateral ear. Hearing was slightly inferior in ears with tympanosclerosis compared with ears without tympanosclerosis, but the difference was small and nonsignificant. The hearing impairment caused by tympanosclerosis was less than 0.5 dB, which is inconsequential and cannot serve as an argument against the use of ventilation tubes. However, further studies with longer observation periods are warranted.

Antibiotic treatment of children with secretory otitis media. A randomized, double-blind, placebo-controlled study.

A double-blind, randomized, placebo-controlled clinical trial was conducted to evaluate one month of amoxicillin-clavulanate potassium treatment of children with secretory otitis media. In total, 264 children, aged 1 to 10 years, were randomly assigned to either antibiotic or placebo treatment; 43 patients were excluded during treatment, equally distributed in both groups, leaving 221 patients completing the trial. The inclusion criterion was a type C2 and type B tympanometry result of at least three months' duration. Tympanometry was performed every month for 12 additional months. At the end of the treatment period, the disease was reversed in 61% in the antibiotic-treated group compared with 30% in the placebo-treated group (P less than .0001), and the improvement was persistently significant in favor of antibiotic for eight months. The effect was present in all age groups and independent of laterality of disease. The middle-ear status at the end of treatment was the determining factor for the outcome of tympanometry the year following treatment. From the end of treatment, there was no difference between tympanometry in a patient having been treated with the antibiotic and a patient having been treated with placebo. Antibiotic treatment shifts the individual patient from poor to better tympanometric conditions, so antibiotics can be recommended in the treatment of secretory otitis media before inserting ventilating tubes.

Dynamics of eardrum changes following secretory otitis. A prospective study.

Children with secretory otitis who, during the period from 1970 through 1975, had been treated with adenoidectomy and insertion of ventilating tubes were reexamined three to eight years after treatment and, again, ten to 16 years after treatment. The changes of the tympanic membranes were analyzed with regard to the occurrence of attic retractions and changes of the pars tensa of the membranae tympani. At the first follow-up examination, varying degrees of attic retractions were found in 37% of ears and, at the second follow-up examination, in 27% of ears. This general improvement was mainly due to normalization of the slight retractions, whereas the frequency of severe retractions increased. Pathology of the pars tensa of the membranae tympani was found in 57% of ears at the first examination and comprised the following: tympanosclerosis (19%), tympanosclerosis and atrophy (10%), atrophy (22%), atrophy and pexi (3%), and adhesive otitis (3%). At the second follow-up examination, pathology of the pars tensa of the membranae tympani occurred in 58.05% of ears and was distributed as follows: tympanosclerosis (26%), atrophy and tympanosclerosis (11%), atrophy (14%), atrophy and pexi (5%), adhesive otitis (2%), and sinus cholesteatoma (0.5%).

Treatment of secretory otitis and pneumatization.

In 33 children, median age 4 years, with bilateral secretory otitis, adenoidectomy was performed, a grommet was inserted in the right ear, and paracentesis was done on the left side. Seven years postoperatively x-rays were taken of the children's mastoid cell systems and these were measured by planimetry. A significantly larger cell system was found on the side with grommets, which is considered to support the environmental theory of pneumatization.