Comparative study of unilateral conductive hearing loss in patients with an intact tympanic membrane.

BACKGROUND: The ossicular chain status is directly associated with the severity of conductive hearing loss (CHL) when the tympanic membrane (TM) is intact. AIMS/OBJECTIVES: To analyze the relationship between intraoperative findings and audiological data in patients with unilateral CHL and an intact TM. MATERIAL AND METHODS: Forty-three patients who underwent surgery at Xinhua hospital from January 1, 2012, to December 31, 2019, were included and categorized based on their intraoperative findings. Demographic data, intraoperative findings, and preoperative and postoperative audiological results of these patients were analyzed. RESULTS: Patients with ossicular chain disruption had significantly better outcomes than those with ossicular chain fixation (air conduction threshold [ACT]: 26.51 ± 8.82 vs. 44.08 ± 14.41 dB, p < .01; air-bone gap [ABG]: 10.66 ± 6.47 vs. 18.91 ± 9.32 dB, p = .04). Patients with ossicular chain deformities had a higher ACT (56.95 ± 13.81 vs. 44.56 ± 15.44 dB, p = .048) and a larger ABG (43.17 ± 9.94 vs. 33.02 ± 13.41 dB, p = .047) preoperatively than those with cholesteatoma; however, the postoperative outcomes between both patient groups were similar. CONCLUSIONS: Congenital ossicular chain anomalies had similar surgical outcome regardless of the pathology. In acquired cases, ossicular chain disruption had better audiological outcomes than ossicular chain fixation. SIGNIFICANCE: Ossicular chain reconstruction can significantly improve the hearing in patients with UCHL with intact TM.

Transcanal endoscopic ear surgery for traumatic ossicular injury.

Background: Transcanal endoscopic ear surgery (TEES) for traumatic ossicular injuries (TOI) is not well studied.Objectives: To analyze the treatment outcomes of TEES for TOI.Material and methods: Retrospective case review of fifteen patients (15 ears) with TOI was performed. The patients underwent an either ossiculoplasty or stapes surgery according to status of the ossicular chain using ear endoscopes. Postoperative audiometric results and complications were analyzed.Results: All subjects demonstrated improvement in their air conduction threshold and air-bone gap (ABG). The mean preoperative air conduction threshold and ABG were 55.3 dB (SD: 12.8) and 33.0 dB (SD: 9.5), respectively. Postoperatively, the air conduction threshold and ABG significantly improved to 28.1 dB (SD: 16.0) and 8.1 dB (SD: 4.5), respectively. Separation of the incudomalleolar joint accompanied by defect of the tegmen, which was not discernible on preoperative imaging, could be identified without additional incision or mastoidectomy. No patients experienced complications or a sensorineural hearing loss. Conversion to open approach was not necessary for any of the 15 procedures performed.Conclusion and significance: TEES for TOI yielded favorable audiometric results without any complication. TEES can provide an alternative method to manage TOI with the advantage of avoidance of skin incisions and mastoidectomy.

Conductive hearing loss with a "dry middle ear cleft"-A comprehensive pictorial review with CT.

Conductive hearing loss (CHL) commonly results from middle ear fluid and inflammation (otitis media). Less commonly in patients with CHL, the middle ear cleft is well aerated or 'dry' with absence of soft tissue or fluid clinically and on imaging. There are numerous causes for this but they can be clinically challenging to diagnose. This pictorial review aims to illustrate and discuss the CT features of both common and less common causes of CHL in patients with a "dry middle ear cavity".

Drill-induced Cochlear Injury During Otologic Surgery: Intracochlear Pressure Evidence of Acoustic Trauma.

HYPOTHESIS: Drilling on the incus produces intracochlear pressure changes comparable to pressures created by high-intensity acoustic stimuli. BACKGROUND: New-onset sensorineural hearing loss (SNHL) following mastoid surgery can occur secondary to inadvertent drilling on the ossicular chain. To investigate this, we test the hypothesis that high sound pressure levels are generated when a high-speed drill contacts the incus. METHODS: Human cadaveric heads underwent mastoidectomy, and fiber-optic sensors were placed in scala tympani and vestibuli to measure intracochlear pressures (PIC). Stapes velocities (Vstap) were measured using single-axis laser Doppler vibrometry. PIC and Vstap were measured while drilling on the incus. Four-millimeter diamond and cutting burrs were used at drill speeds of 20k, 50k, and 80k Hz. RESULTS: No differences in peak equivalent ear canal noise exposures (134-165 dB SPL) were seen between drill speeds or burr types. Root-mean-square PIC amplitude calculated in third-octave bandwidths around 0.5, 1, 2, 4, and 8 kHz revealed equivalent ear canal (EAC) pressures up to 110 to 112 dB SPL. A statistically significant trend toward increasing noise exposure with decreasing drill speed was seen. No significant differences were noted between burr types. Calculations of equivalent EAC pressure from Vstap were significantly higher at 101 to 116 dB SPL. CONCLUSION: Our results suggest that incidental drilling on the ossicular chain can generate PIC comparable to high-intensity acoustic stimulation. Drill speed, but not burr type, significantly affected the magnitude of PIC. Inadvertent drilling on the ossicular chain produces intense cochlear stimulation that could cause SNHL.

Surgical Management and Hearing Outcome of Traumatic Ossicular Injuries.

OBJECTIVE: The purpose of this study was to investigate etiological, clinical, and pathological characteristics of traumatic injuries of the middle ear ossicular chain and to evaluate hearing outcome after surgery. MATERIAL AND METHODS: Thirty consecutive patients (31 ears) with traumatic ossicular injuries operated on between 2004 and 2015 in two tertiary referral otologic centers were retrospectively analyzed. Traumatic events, clinical features, ossicular lesions, treatment procedures, and audiometric results were evaluated. Air conduction (AC), bone conduction (BC), and air-bone gap (ABG) were analyzed preoperatively and postoperatively. Amsterdam Hearing Evaluation Plots (AHEPs) were used to visualize the individual hearing results. RESULTS: The mean age at the moment of trauma was 27.9±17.1 years (range, 2-75 years) and the mean age at surgery was 33.2±16.3 years (range, 5-75 years). In 10 cases (32.3%), the injury occurred by a fall on the head and in 9 (29.0%) by a traffic accident. Isolated luxation of the incus was observed in 8 cases (25.8%). Dislocation of the stapes footplate was seen in 4 cases (12.9%). The postoperative ABG closure to within 10 and 20 dB was 30% and 76.7%, respectively. CONCLUSION: Ossicular chain injury by direct or indirect trauma can provoke hearing loss, tinnitus, and vertigo. As injuries are heterogeneous, they require a tailored surgical approach. In this study, the overall hearing outcome after surgical repair was favorable.

Influence of Ossicular Chain Damage on Hearing After Chronic Otitis Media and Cholesteatoma Surgery: A Systematic Review and Meta-analysis.

IMPORTANCE: Physicians should ideally be able to provide patients with chronic otitis media and/or cholesteatoma specific information about postoperative hearing outcome, based on their level of preoperative ossicular chain damage (OCD). OBJECTIVE: To identify the influence of preoperative OCD on hearing outcomes in patients after chronic otitis media and/or cholesteatoma surgery. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library databases were systematically searched for available evidence, without any constraints, on December 13, 2014, for articles published between January 1, 1975, and December 13, 2014. STUDY SELECTION: We reviewed the literature for articles assessing the prognostic value of OCD on postoperative hearing outcome (air-bone gap [ABG] in decibels), using Austin-Kartush criteria or independent OCD classification systems. We assessed relevance and validity using a self-designed critical appraisal tool based on the Cochrane Collaboration's risk of bias tool. DATA EXTRACTION: Characteristics of study populations and postoperative ABGs in decibels were extracted from all included studies by 4 authors (E.F.B., M.N.G., N.J.K., A.S.H.J.L.). RESULTS: The tested hypothesis was formulated before data collection. Primary study outcome was defined as postoperative adult hearing outcomes after COM and/or cholesteatoma surgery defined as mean postoperative ABG. Our search yielded 5661 articles. Nine articles with high relevance were included. Pooled results of studies using the Austin-Kartush criteria showed a significant (P < .001) difference in mean ABG in favor of group B, when comparing group B (patients with malleus present, stapes absent; 11.1 [95% CI, 10.3-11.8] dB) to group C (patients with malleus absent, stapes present; 15.7 [95% CI, 14.6-16.7] dB) and group B to group D (patients with malleus absent, stapes absent; 16.5 [95% CI, 15.2-17.9] dB). Three studies using independent OCD classification criteria found no influence of stapes structure (intact stapes suprastructure, 13.5 [95% CI, 10.3-16.7], 15.1 [95% CI, 11.8-18.3], and 21.9 [95% CI, 15.0-28.8] dB vs absent stapes structure, 12.8 [95% CI, 9.5-16.1], 19.5 [95% CI, 14.9-24.1], and 30.2 [95% CI, 24.7-35.8] dB) on postoperative ABG. One study reported a significant (P = .04) difference in mean ABG between patients with present (18.9 [95% CI, 15.7-22.1] dB) and absent (24.4 [95% CI, 20.2-28.6] dB) malleus. CONCLUSIONS AND RELEVANCE: Pooled results of Austin-Kartush studies showed that in patients with COM, with or without cholesteatoma, the malleus status is a significant predictor of postoperative hearing outcome, independent of the stapes condition. Studies reporting on individual ossicle status supported this finding by showing that only malleus condition influenced postoperative hearing outcome. These findings are based on level IV evidence, which indicates the need for future high-level evidence studies.

Total ossicular reconstruction: The "mushroom technique".

OBJECTIVE: The "Mushroom technique" is introduced in this paper as an alternative technique to reconstruct the total ossicular chain by using autologous grafts where it is not possible to use the patient's ossicles, and to seal a peri-lymphatic fistula (PLF) if present. MATERIALS AND METHODS: This non randomized retrospective study covers 18 patients aged between 26 and 72 years, operated between January 2006 and March 2012 by the same surgeon using a retro-auricular approach. There were 13 males and 5 females, 12 right ears and 6 left ears. The three ossicles were damaged in 18 patients, a PLF was associated in 3 cases, and a tympanum perforation was present in 2 ears. Postoperative follow-up period was a minimum of 6 months and up to 6.5 years. The origin of 18 patient's disease was; post traumatic in 11 patients and post removal cholesteatoma in 7 patients. The "mushroom technique" was performed for all patients. The average Air Bone Gap (ABG) of each patient was calculated (frequencies 500, 1000, 2000 and 4000 Hz) both pre and 6 months postoperatively. RESULTS: There were no extrusion of the composite graft. In the three cases of PLF; the leak was sealed. And in the two ears with tympanum perforation; the perforation was closed. The average post-operative ABG is 25 dB while it was 45 dB before surgery. Average gain is 20 dB. Non sensorineural hearing loss ocurred. CONCLUSION: This technique has several advantages: The mounting footplate-fascia-connective tissue-bone-cartilage-perichondrium-tympanum is solid and long lasting, the rate of leak closure in case of PLF is improved; This technique closes the leak, the hearing results are satisfactory, the cost of autograft is null and the tolerance is excellent. On the other hand, it might be time consuming since it is a delicate looking procedure.

[Endoscopic ear surgery for traumatic ossicular disruptions].

Although endoscopic ear surgery (EES) has been used to perform middle ear surgery since 1993, it has not become as common in otologic surgery as it is in endoscopic sinus surgery. This report discusses the problems and the indications for EES in traumatic ossicular disruptions in two cases. Case 1 was a 33-year-old man with a left longitudinal temporal bone fracture who presented with mixed hearing loss, with an average hearing level of 45.0 dB in the left ear. He underwent EES, which revealed incudostapedial joint disrutption. Repositioning of the incus resulted in an improvement in hearing to 18.3 dB postoperatively. Case 2 was a 30-year-old man with a right mixed hearing loss of 56.7 dB. Computed tomography showed a right longitudinal temporal bone fracture and dislocation of the incus. EES revealed dislocation of the incus and fracture of the anterior crus of the stapes. A type IV tympanoplasty was performed, interpositioning the autologous incus between the footplate and the malleus handle. Postoperatively, the average hearing level was 18.3 dB, with a 1.7-dB air-bone gap. Traumatic ossicular disruptions are considered to be a good indication for EES.

[Diagnosis and treatment of traumatic ossicular chain disruption and dislocation].

OBJECTIVE: To investigate the diagnose therapy and the postoperative curative effect of traumatic ossicular chain disruption and dislocation. METHOD: Eight cases (8 ears) with traumatic ossicular chain disruption. Six cases of unilateral conductivity deafness, 2 of mixed deafness still with conductive primarily. Eight ears all were performed tympanic exploration and ossicular replacement prosthesis, 1 ear with TORP (total ossicular replacement prosthesis). 4 ears with PORP (partial ossicular replacement prosthesis), 2 with ossicular chain reset, 1 with artificial incus reconstruction. The treatment effect was compared by the preoperative and postoperative ABG (air bone gap). RESULT: Preoperative average ABG was 42. 9 dB, the average ABG 3 weeks after operation was 22.3 dB, which reduced 20.6 dB compared to the preoperative, having a statistically significant difference (t = 22.10, P < 0.01). The average ABG was 18.6 dB 6-8 months after operation, which reduced 24.3 dB compared to the preoperative, having a statistically significant difference (t = 12.813, P < 0.01). CONCLUSION: The conductivity hearing loss after traumatic ossicular chain disruption or dislocation is preferred operation treatment, and replacement should use different ways according to the operation in case, and the hearing improvement was obvious.

[Imaging of the temporal bone]. / Bildgebung des Schläfenbeins.

This article presents a review of diseases of the temporal bone which are relevant for radiologists in routine clinical practice. First the most prominent imaging methods will be briefly summarized with respect to the current state of the art and the most important aspects of cross-sectional anatomy of the temporal bone will be presented. This is followed by the presentation of various inflammatory diseases. Fractures (longitudinal, transverse and mixed fractures), auditory ossicle lesions and contusions of the labyrinth will be discussed in connection with injuries of the temporal bone. Tumors and tumor-like lesions and the clinical symptoms of otosclerosis and malformations will also be discussed. Finally the postoperative use of imaging methods will be presented. Special importance is given to the position of imaging techniques in the diagnostic chain and their evidential value. This is supplemented by special morphological imaging characteristics and aspects of differential diagnostics.

[Thermographic investigations during stapedotomy using a CO2 laser]. / Thermografische Untersuchung während der CO2-Laserstapedotomie.

BACKGROUND: Temporary sensorineural hearing losses after CO(2) assisted stapes surgery have been described in literature. Whether thermal effects are the reason for this side effect is still unclear. The specific aim of this research is to demonstrate the thermal spread during CO(2) laser stapedotomy using a high-speed infrared camera. MATERIAL AND METHODS: Thermal depth effects in physiological saline solutions were examined in cochlea models (glass capillary tube, crystal cuvette and temporal bone preparation). Temperature changes and exchange processes after CO(2) laser application were measured using a high-speed infrared camera. Visualization of gas bubbles triggered by vaporisation underneath the stapes footplate after CO(2) shot was achieved with a high-speed camera. The footplate perforations were performed with a scanner system using a micromanipulator (laser power 20 W, 0.6 mm diameter, continuous wave, duration of 40 ms). RESULTS: Homogenous temperature increases of more than 100°C were measured on the surface of the footplate and 0.25 mm within the capillary tube after single shot CO(2) laser stapedotomy. Gas bubbles may cause isolated temperature increases of up to 65 K. These effects were found in depths of up to 2 mm underneath the stapes footplate. CO(2) shots on the saline solutions with parameter used for initial laser application may lead to temperature increases between 20-65 K in depths of 3-6 mm. CONCLUSIONS: CO(2) applications to an opened inner ear with the same laser parameter used for initial shot on the stapes footplate should be avoided.

Ear-pick injury as a traumatic ossicular damage in Japan.

This retrospective study examined the etiology and treatment results for traumatic, conductive hearing loss in 22 patients who underwent surgery between 1998 and 2008 at Osaka Red Cross Hospital. All patients underwent computed tomography (CT) of the temporal bone preoperatively. The ear surgery comprised closure of the ruptured tympanic membranes and restoration of the sound-transmitting function of the ossicular chain. Their mean age was 30.3 years, and the average delay from injury until treatment was 6.0 years. Of the injuries due to foreign-body insertion, the most common cause was ear-pick injury. Incudostapedial disarticulation was the most common finding, which was diagnosed preoperatively using CT in seven cases and identified at surgery in 15 cases. Closure of the air-bone gap to within 10 and 20 dB was observed in 50.0 and 68.2% of the patients, respectively. The hearing threshold improved by 10 dB or more in 16 (72.7%) patients. If no improvement in hearing loss follows the absorption of hemotympanium or closure of an eardrum perforation, dislocation of the ossicular bones should be suspected. Ossicular reconstruction following trauma produces more stable and better hearing results, even after delayed treatment.

Findings at exploratory tympanotomy for conductive hearing loss.

INTRODUCTION: Despite advances in imaging and other diagnostic tests, it is often impossible to establish with confidence a pre-operative diagnosis in a patient with a conductive hearing loss. METHODS: We studied a series of 340 exploratory tympanotomies for conductive hearing loss carried out by a single surgeon. RESULTS: The most common operative diagnosis was otosclerosis (n = 164, 48.2 per cent). Ossicular discontinuity was found more commonly than previously reported (n = 103, 30.3 per cent). A small but significant number of patients were found to have cholesteatoma (n = 7.2 per cent). CONCLUSIONS: This information is of value when discussing potential findings at surgery for conductive hearing loss. While otosclerosis is the commonest finding in such cases, a significant number of patients have defects of the ossicular chain.

[Treating traumatic ossicular chain disruption with epitympanum approach following tympanotomy].

OBJECTIVE: To evaluate the therapeutic effects of epitympanum approach tympanotomy in treating traumatic ossicular chain disruption. METHOD: Ten patients with temporal bone fracture and trauma of ear, whose CT scan of temporal bone showed that Malleoincudal joint irregular shape in the axial view and incudostapedial joint dislocation in the coronal view, were included in this study, Virtual endoscopy showed Malleoincudal joint separation, incudostapedial joint dislocation and interruption, ossicular chain disruption in all patients. The surgical approach was opening the atticus via temporal line, remaining the intact posterior and superior wall of external acoustic meatus, exposing the atticus and posterior tympanic cavity sufficiently, and treating the lesions of ossicular chain. RESULT: One patient with the long process of the incus fracture, adopted the fitted incus prosthesis between the handle of the malleus and the head of the stapes. Six patients with Malleoincudal joint separation or incudostapedial joint dislocation, 3 patients with incus body dislocation completely, adopted incus positioning two articulation decis. The air-conducting hearing levels had an enhancement of 25-50dB in average after surgery. CONCLUSION: The effect of intact canal wall epitympanum approach ossicular reposition in treating traumatic ossicular chain disruption is satisfying.

[Evaluation of the virtual endoscopy on traumatic ossicular chain disruption pre- and post-operation].

OBJECTIVE: To evaluate the clinical use of virtual endoscopy in the traumatic ossicular chain disruption with intact tympanum pre- and post-operation. METHODS: The series consisted of 17 cases with temporal bone fracture and 4 cases with tympanum contusion. All were examinated with a high resolution spiral CT by axial and oblique coronal planes of the temporal bone. Three-dimensional reconstruction was processed using the virtual endoscopy software. Ten cases of traumatic ossicular chain disruption were performed with intact canal wall epitympanum approach Ossicular reposition. Eleven patients with facial paralysis were performed ossiculoplasty and facial nerve decompression. Nine cases re-examinated virtual endoscopy after operation. RESULTS: Seventeen cases with temporal bone fractures and traumatic ossicular chain disruption, including 3 cases with the long process of the incus fracture, 9 cases with incus bone dislocation, and 5 cases with incus shedding. In the 4 cases of tympanum contusion, 2 cases with incus bone dislocation, 2 cases with incus bone shedding. The axial plane of temporal bone CT could only showed the fracture line and the hammer and incus bone irregular shape. Perioperatively virtual endoscopy showed hammer incus joint separation, incus stirrup dislocation and joint deformation. Surgery confirmed that the incus body was torn off below the hammer following bone displacement, soft tissue wrapped articular surface, incus and stapes just connected with soft tissue. During the tympanum contusion operation could see incus bone-shedding was valgus. Three to six months after surgery, re-examinated virtual endoscopy showed incus bone dislocation ossicular chain was restored to normal, temporal bone shedding ossicular chain connecting almost intact Hearing increased significantly to the level of practical hearing. The coincidence of traumatic disruption of the ossicular chain by virtual endoscopy and surgery was 100%. CONCLUSION: Virtual endoscopy was valuable for providing accurate assessment and individual program for treating and following-up the traumatic ossicular chain disruption.