Transmastoid and Transtemporal Drainage of Petrous Apicitis with Otitis Media.

BACKGROUND: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess. METHODS AND RESULTS: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms. DISCUSSION: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

Tuberculous otitis media with osteomyelitis of the regional craniofacial bones.

Tuberculosis is an uncommon cause of chronic suppurative otitis media. Delay in diagnosis can lead to delayed treatment, resulting in significant complications. We describe a case of tuberculous otitis media with osteomyelitis of the craniofacial bones in a 44-year-old woman with chronic painless suppurative otorrhea, not responding to antibiotics, hearing loss, and facial palsy. Chest X-ray was normal. Computed tomography of the temporal bone showed the destruction of the left zygomatic bone, clivus, and petrous part of the temporal bone. Polymerase chain reaction was positive for Mycobacterium tuberculosis (MTB), and histopathological findings showed caseous necrotizing tissues. Sputum culture was negative for MTB. The patient was successfully treated with surgery and anti-tuberculosis drugs. The polymerase chain reaction is a sensitive, rapid diagnostic tool used to diagnose TB. Surgical approaches and operative biopsy should be considered when the cause of the chronic purulent discharge is still unknown.

The Value of Diffusion-Weighted MRI in the Long-term follow-up After Subtotal Petrosectomy for Extensive Cholesteatoma and Chronic Suppurative Otitis Media.

OBJECTIVE: To report the long-term follow-up with diffusion-weighted magnetic resonance imaging (DW MRI) after subtotal petrosectomy (SP) with blind sac closure of the external auditory canal for extensive cholesteatoma and chronic suppurative otitis media. STUDY DESIGN: Retrospective clinical record study. SETTING: Tertiary referral center. PATIENTS: Thirty-one patients (31 ears) with extensive cholesteatoma and 17 patients (19 ears) with chronic suppurative otitis media without cholesteatoma who underwent SP between July 1995 and December 2015. INTERVENTIONS: All 48 patients were followed clinically and with DW MRI to rule out residual cholesteatoma. MAIN OUTCOME MEASURE: Residual cholesteatoma, indicated by a marked hyperintensity on non-echoplanar (non-EP) DW MRI. RESULTS: In the cholesteatoma group the mean interval between surgery and the latest DW MRI was 3.9 years. Seven patients presented with a residual cholesteatoma pearl. The mean interval between surgery and detection of residual disease was 3.7 years. In the chronic suppurative otitis media group the mean interval between surgery and the latest DW MRI was 5.3 years. Residual cholesteatoma was found in three patients. Mean interval between surgery and the detection of disease was 4.5 years. CONCLUSIONS: This study shows the importance of DW MRI in the follow-up after SP for cholesteatoma and chronic suppurative otitis media. A little higher residual cholesteatoma rate was found compared with earlier studies, where patients were followed only clinically. One may wonder whether reintervention is always needed or whether in selected cases with small pearls, one may still observe these by a watchful waiting policy with DW MRI.

Radiologic and surgical findings in chronic suppurative otitis media.

Our aim in this study was to evaluate the efficiency of preoperative temporal bone computed tomography (CT) in detecting pathologic conditions in patients with chronic suppurative otitis media (CSOM). The intraoperative findings and temporal bone CT results of 350 patients who were diagnosed with CSOM between September 1, 2010, and June 1, 2013, were compared. Comparison parameters were as follows: the presence of cholesteatoma, erosion of the outer ear bone canal, erosion of the middle ear chain, erosion of the dural plate, erosion of the lateral semicircular canal, erosion of the sigmoid sinus wall, and dehiscence of the facial canal. The contribution of CT was limited in showing the outer ear canal destruction, dural plate destruction, facial canal destruction, lateral semicircular canal destruction, and destruction of the sigmoid sinus wall. However, CT was more sensitive in detecting cholesteatoma and erosion of the ossicular chain. These results indicate that preoperative CT of patients with CSOM serves as an important guide for otolaryngologists, although there are limitations in the evaluation of the CT results.

[The use of cone beam computed tomography for diagnostics of chronic suppurative otitis media].

The objective of the present study was to estimate the potential of cone beam computed tomography of the temporal bone as a diagnostic tool for chronic suppurative otitis media. This method was employed to study the temporal bones of 33 patients presenting with chronic suppurative otitis media (18 cases of one-sided and 15 cases of two-sided inflammatory process). The results of the total of 48 sessions of beam computed tomography of the temporal bones were available for analysis. The age of the patients varied from 16 to 80 years. Seven of them presented with chronic suppurative otitis media in combination with cholesteatoma. The clinical symptoms of chronic suppurative otitis media were revealed by cone beam computed tomography in conjunction with the peculiarities of visualization of bone tissue destruction using this technique (both in the presence of cholesteatoma and without it). The rationale has been developed for the use of cone beam computed tomography in diagnostics of chronic suppurative otitis media.

A comparison of three MDCT post-processing protocols: preoperative assessment of the ossicular chain in otitis media.

The aim of this study was to examine and assess comparative values of HRCT-based multiplanar reformation (MPR), volume rendering (VR) and virtual endoscope built on three-dimensional (3D) shaded-surface display (SSD-based CTVE) for detections of ossicular chain's damage in patients with otitis media. 70 human ears from 70 patients suffering by chronic otitis media or cholesteatoma, who were examined with a preoperative multi-slice computer tomography (MSCT) examination and tympanoplasty in our hospital were collected. The patients ossicular chains were reconstructed with the aforementioned three protocols and assessed via a three-point scoring system by three radiologists. Then, all the patients ossicular chains were reviewed by a surgeon and a radiologist via the same three-point scoring system used during surgeries at same time. By calculation, the Youden's index and coincidence rate were acquired without a significant difference for display of malleus. With regard to the incus, the Youden's index and coincidence rate of VR and MPR did not show any difference, however, both were higher than CTVE. For representation of the stapes, the accuracy of these three modalities is very low; especially, for the CTVE. In conclusion, both MPR and VR are relative robust, and CTVE is not effective for evaluation of small ossicular structures, particularly the stapes. Furthermore, the VR images are real 3D ones. Therefore, it could be the more valuable protocols for detection of the damage of ossicular chain in the patients with otitis media, and should be further applied in the future work.

Management of otogenic lateral sinus thrombosis.

OBJECTIVE: To evaluate the changing clinical course and trends in management of otogenic lateral sinus thrombosis (OLST), in view of the rarity of the said lesion and antibiotic abuse. METHODS: A retrospective case study was done in 6 patients referred to our tertiary care centre with OLST over a period of three years from May 2007 to May 2010: Department of Otorhinolaryngology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - a tertiary care university teaching hospital under central government of India. Medical records of all the patients were scrutinized and data pertaining to patient profile, type of chronic suppurative otitis media (CSOM), clinical course with any other complication and management were tabulated. The said data was scientifically analyzed w.r.t. current medical literature on the subject. RESULTS: Clinically, it was observed that all patients had protracted CSOM - attico antral type, with history of rampant misuse of antibiotics. The attack of OLST in each case was triggered off by an acute attack of suppurative otitis media. Moreover, in all the cases OLST was masquerading as an intra-cranial complication, with no specific clinical features thereby causing missed diagnosis initially. All these patients were diagnosed by CT scan, and underwent modified radical mastoidectomy (MRM) with needle aspiration of sinus under antibiotic cover. The said treatment protocol resulted in excellent prognosis with no morbidity or mortality whatsoever. Pathologically, cholesteatoma was detected in 5 of the six cases with one case having only granulations. CONCLUSIONS: In this era of antibiotic abuse, the clinical presentation of OLST has altered substantially, and mimics other intra-cranial complication with vague signs and symptoms. There are conflicting views in contemporary medical literature regarding management of OLST. In our experience, MRM with needle aspiration under antibiotic cover is the treatment of choice for all cases of OLST associated with CSOM attico antral disease/cholesteatoma disease.

[Clinical and roentgenological diagnostics of the severity of mucositis in the patients presenting with chronic suppurative otitis media].

The objective of the present study was to determine the prevalence of mucositis and its roentgenological manifestations in the patients presenting with chronic suppurative otitis media (CSOM). A total of 390 patients with CSOM (mesotympanitis) and 85 ones suffering CSOM with concomitant mucositis were available for the observation. The signs of mucositis were evaluated based on the patients' complaints, results of otomicroscopy, and computed tomography (CT) of the temporal bones. This randomized clinical study involving 390 patients presenting with CSOM revealed the signs of mucositis in 44.6% of the cases. Analysis of the results of temporal bone CT performed in 85 patients with CSOM and mucositis in the absence exacerbation has demonstrated the possibility of detecting mucositis and evaluating its severity from the changes in the airness of the tympanic cavity, attics, and antrum due to the presence of the pathological substrate in these regions.

Temporal bone erosion in patients with chronic suppurative otitis media.

OBJECTIVES: To analyse temporal bone erosion sites (including scutum, labyrinth, facial canal, mastoid tegmen, posterior fossa dural plate and sigmoid sinus plate) in patients with chronic suppurative otitis media (CSOM). METHODOLOGY: Retrospective case review in a tertiary referral centre. Medical records were reviewed from 905 patients (121 complicated; 784 non-complicated) who received a mastoidectomy as a minimum intervention for the treatment of CSOM. RESULTS: All types of temporal bone erosion were found to be more frequent in patients with complicated CSOM. Erosion in the scutum, mastoid tegmen, posterior fossa dural plate and labyrinth was observed significantly more frequently in complicated-CSOM patients with a cholesteatoma. Granulation/polyp tissue invaded the sigmoid sinus and facial canal at a rate similar to cholesteatoma. CONCLUSIONS: Our study demonstrates that bone erosion is more frequent in complicated-CSOM patients. Temporal bone erosion can be seen in both cholesteatomatous and non-cholesteatomatous CSOM patients. Granulation/polyp tissue was as important as cholesteatoma in the erosion of the facial canal and sigmoid sinus plate.

[Efficacy of high-resolution CT in differential diagnosis of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows].

OBJECTIVE: To evalute the efficacy of high-resolution CT(HRCT) in differential diagnosis and treatment of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows. METHODS: HRCT scanning was performed in 120 cases, 153 ears, with chronic otitis suppurative media and cholesteatoma otitis media, of which original data were processed with multi-planar reconstruction (MPR) and maximum intensity projection (MIP), the characteristics of the soft-tissue shadows' growth, window width or window leveling and bony destruction were respectively observed, as well as compared with the surgery findings. RESULTS: In 120 patients (153 ears), 109 ears were diagnosed as cholesteatoma otitis media, and 44 ears were diagnosed as chronic suppurative otitis media, among which 33 ears had granulation tissue and 11 ears had secretion. One hundred and seven ears were postoperatively diagnosed as cholesteatoma otitis media, among which 25 ears had granulation tissue. Among 46 ears of chronic suppurative otitis media, 35 ears had granulation tissue, and only 11 ears had secretion. A 98.6% diagnostic accuracy can be reached with HRCT in diagnosing cholesteatoma otitis media and chronic suppurative otitis media. The Youden's index was 0.98, 0.98 and 1.00 respectively with HRCT in diagnosing cholesteatoma, granulation tissue and secretion. CONCLUSIONS: Combination of the three different imaging methods, axial images, coronal MPR images and MIP images, can improve the efficacy of the HRCT diagnosis and definite chronic otitis media, which can be routinely used for surgery plan.

The value of preoperative CT scan of tympanic facial nerve canal in tympanomastoid surgery.

CONCLUSIONS: The combined analysis of axial, coronal, and sagittal planes can increase the positive rate of diagnosis for dehiscence of the facial nerve canal. OBJECTIVE: The aim of this study was to evaluate the diagnostic value of high resolution computed tomography (HRCT) scanning of the condition of the tympanic portion of the facial nerve canal in patients with chronic otitis media. METHODS: A total of 76 ears of 72 inpatients with chronic suppurative otitis media and with cholesteatoma or granulation tissues in the attic were examined by routine HRCT. The condition (including dehiscence) of the tympanic portion of the facial nerve canal observed by CT on multi-planar images and surgical findings were recorded. RESULTS: The condition of the tympanic portion of the facial nerve canal observed by CT could be confirmed by surgical findings in 67/76 ears, but was not confirmed in 9/76 ears. Axial-transverse images could clearly show the position and length of dehiscence on the lateral wall of the facial nerve, while coronal images were superior to axial-transverse images in showing the bony circumference of the facial nerve, and sagittal images could show the inferior wall of the facial nerve canal more clearly than images on the former planes.

[Multispiral computed tomography for the assessment of the extent of surgical intervention in patients with chronic suppurative otitis media].

The utility of the data obtained by multispiral computed tomography (MSCT) for the choice of surgical techniques is discussed with special reference to chronic suppurative otitis media. Specific features of bone tissue destruction are described in patients with cholesteatoma and without it. Results of MSCT were used to estimate the optimal extent of surgical intervention. Intraoperative findings were in excellent agreement with MSCT data.

[Significance of CT in diagnosis of chronic suppurative otitis media].

OBJECTIVE: To investigate the methods of preoperative diagnosis and differentiation of different pathological tissue in middle ear and mastoid. METHODS: The temporal bone lamellar CT findings in 106 patients with chronic suppurative otitis media (including cholesteatoma) were retrospectively analyzed. The CT value of pathological tissue were measured for 183 times and were compared with the surgical findings and postoperative pathological findings to definitude the CT value range of different pathological tissue. Sixty patients taken from 106 patients at random were analyzed and made the diagnosis again by the same doctor team according to the CT value of the different pathological tissue and surrounding histoclasia resulted by pathological tissue. The diagnose accordance rate was compared with the routine diagnose report from radiology department. The predetective diagnosis was made in 10 patients with chronic suppurative otitis media according to clinical manifestation (pathological changes of tympanic membrane, nature of otorrhea, character of hearing), temporal bone lamellar CT finding (CT value of pathological tissue, surrounding histoclasia) to validate the value of this study for preoperative diagnosis and differentiation of different pathological tissue in middle ear and mastoid. RESULTS: The CT value of cholesteatoma, granulation tissue, cholesteatoma combined with granulation tissue, effusion, calcified tissue, thickened and polypoid membrane was respectively (46.6 +/- 10.3) Hu, (26.6 +/-7.4) Hu, (42.1 +/- 11.4) Hu, (- 24.6 +/- 9.2) Hu, (223.6 +/- 63.7) Hu, (23.8 +/- 8.5) Hu. The diagnose accordance rate in 60 patients who were analyzed and made diagnosis again according to the CT value of the different pathological tissue and surrounding histoclasia resulted by pathological tissue raised from 68. 3% to 81.7% ( P < 0.05) . The predetective diagnose accordance rate reached at 90% according to clinical manifestation, temporal bone lamellar CT. CONCLUSIONS: It was not reliable to diagnose and differentially diagnose different pathological tissue in middle ear and mastoid only by the CT value, however, the CT value could still be considered to be a very significant information. The accurate rates of diagnosis and differentiation of different pathological tissue in middle ear and mastoid obviously raised by synthetically analyzing various kinds of pathological tissues in middle ear and mastoid according to clinical manifestation, temporal bone lamellar CT finding.

[Post-traumatic cholesteatoma of temporal bone]. / Perlak pourazowy kosci skroniowej.

Posttraumatic cholesteatoma of the middle ear is a rare condition that may present years after temporal bone fracture. We present the 36 years old woman with acquired cholesteatoma of the middle ear and perilymphatic fistula six years after a temporal bone fracture. CT scan was extremely helpful in determining the sites of fracture and fasioning the surgical approach. The middle ear was cleaned with cholesteatoma, perilymphatic fistula was sealed with 3 layers of tissues and the ossicular chain was reconstructed in one stage. The presence of fracture lines in temporal bone years after trauma may prove hindered healing, which promotes migration of epithelium from external ear canal into the middle ear. We recomend long term follow-up in any patient with longitudinal temporal bone fracture with CT for any new otologic complaints.

Cholesteatoma of the tympanic part of the temporal bone.

This article presents accounts of two patients with cholesteatoma of the tympanic part of the temporal bone, located immediately lateral to the tympanic annulus (and with an intact tympanic membrane). The lesions were located deep in the anterior and inferior walls of the canal, especially in the vaginal process of the tympanic part. These more severe cases required surgical correction (removal of the sac of cholesteatoma) with very good results. Pathogenesis and differential diagnosis are discussed.

Diagnosis of the pathological exposure of the mastoid portion of the facial nerve by CT scanning.

CONCLUSIONS: High resolution CT imaging can provide useful information about the pathological exposure of the mastoid portion of the facial nerve before mastoid surgery and can assess the injury site of the facial nerve after operation. OBJECTIVES: To evaluate the diagnostic value of high resolution CT scanning of pathological exposure of the mastoid portion of facial nerve and provide valuable information for otologic surgery, and to analyse the cause of facial nerve paralysis after operation. MATERIALS AND METHODS: Routine CT scanning was used to examine patients with chronic suppurative otitis media and external auditory canal cholesteatoma preoperatively by axial-transverse and coronal views. If there was any pathological exposure of the mastoid portion of the facial nerve on CT imaging, then this was compared with intraoperative findings. In addition, one patient who had suffered postoperative facial nerve paralysis was also examined by CT scanning to determine whether any pre-existing pathological exposure of facial nerve could be found. RESULTS: Through routine CT scanning six patients with chronic suppurative otitis media and three patients with external auditory canal cholesteatoma were found to have pathological exposure of the mastoid portion of the facial nerve. Coronal views could more clearly show the size and the position of the exposure; the corresponding surgical findings (pathological exposure) for the facial nerve could be confirmed in all nine patients. CT imaging could also show that the patient who had suffered postoperative facial nerve paralysis did indeed have pre-existing pathological exposure of the mastoid portion of the facial nerve.

[Association of Bezold's abscess and sigmoid sinus thrombosis. A case report]. / Association d'un abcès de Bezold et d'une thrombophlébite du sinus sigmoïde. A propos d'un cas.

Bezold's abscess and sigmoid sinus thrombosis are both classic complications of otitis media. However, since the introduction of antibiotics both have become very rare. Very few cases of these complications occurring concomitantly have been reported. We describe the clinical case of a 45 year old male with a 10 year history of neglected right ear cholesteatoma. The patient presented to our department with a 10 day history of purulent right otorrhea, otalgia, increasing headach, pyrexia and suppurating right parapharyngeal mass. CT scan confirmed right middle ear cholesteatoma associated with ipsilateral Bezold abscess and and sigmoid sinus thrombosis. Treatment was by mastoidectomy, broad spectrum intravenous antibiotics and anticoagulation. The patient made a full uncomplicated recovery. The association between chronic middle ear disease, sigmoid sinus thrombosis and Bezold abscess are discussed.

[Evaluation of maximum intensity projection in HRCT in the diagnosis of the destruction of ossicular chain in chronic otitis media].

OBJECTIVE: To observe the ossicular chain structure with maximum intensity projection (MIP) and to evaluate the diagnostic value of it in the destruction of ossicular chain in chronic otitis media (COM). METHOD: Sixty-eight patients (136 ears) were scanned with HRCT. The original data was processed with MIP reconstruction technique. The images of the ossicular chain structure in normal ears were observed, while the images in suffering ears were compared with the findings in operation. RESULT: In normal ears, the ossicular chain structure was shown clearly by MIP, which can also display three-dimensional images of the ossicular chain. In the suffering ears of chronic otitis media of cholesteatoma type, granuloma type and simple type, MIP displayed the destruction of ossicular chain in 39 ears, 5 ears and 0 ear respectively, which was observed in 39 ears, 6 ears and 0 ears respectively in operation. CONCLUSION: MIP technique in HRCT can display the ossicular chain spatial structure clearly, which is very helpful to evaluate the destruction of ossicular chain in chronic otitis media (COM) and to make accurate operation plan.