Circumferential Subannular Tympanoplasty: Panacea for revision tympanoplasty.

OBJECTIVE: To evaluate the role of Circumferential Subannular Tympanoplasty [CST] in cases of Revision tympanoplasty. METHODS: A retrospective statistical analysis of data of 81 patients who underwent revision tympanoplasty with CST technique [essentially Type I tympanoplasty] was done. An intact graft at the end of 6 months was regarded as a surgical success. RESULTS: Overall, we recorded a surgical success rate of 97.5% [79 out of 81 cases] with a 100% surgical success for anterior perforations. There was no impact of size or site of perforation on the outcomes of revision tympanoplasty by this technique. In addition, a statistically significant hearing improvement was recorded in the study. The mean pre-operative and post-operative ABG were 33.85 dB and 18.87 dB respectively. The mean ABG closure was 14.89 dB. The value of "p" by Chi square test was found to <.05. CONCLUSION: CST is an excellent technique for revision tympanoplasty and seems to address the shortcomings of conventional onlay and inlay techniques.

Subjective Visual Vertical Testing in Patients With Chronic Suppurative Otitis Media.

OBJECTIVE: To analyze the results of the subjective visual vertical test using the "bucket method" in patients with chronic suppurative otitis media (CSOM). STUDY DESIGN: Cross-sectional, controlled study. SETTING: Outpatient otology clinic in a tertiary care hospital. SUBJECTS AND METHODS: Patients had CSOM, defined as the presence of chronic infection or inflammation of the middle ear cleft, associated with a perforation of the tympanic membrane, frequent or intractable middle ear suppuration, with or without cholesteatoma. Controls were selected using a nonprobability, purposive sampling method. We excluded patients with neurologic or metabolic diseases, cognitive deficits, otosclerosis, vestibular migraine, Ménière's disease, past use of ototoxic medication, or head and neck cancer. The volunteers were subjected to the subjective visual vertical test using the "bucket method." The results obtained in our study and control groups were analyzed using nonparametric tests. RESULTS: Our study comprised 51 patients with CSOM and 50 controls. In the CSOM group, we observed that 72.5% of the patients had vestibular symptoms in the past year, and 70.5% had abnormalities identified in at least 1 vestibular function test. The subjective visual vertical test revealed that patients with CSOM (with and without cholesteatoma) had significantly higher deviations of the true vertical as compared with controls (CSOM, 3.66°; controls, 0.76°; P < .001). CONCLUSION: Our results revealed that CSOM was associated with high rates of vestibular symptoms, abnormal vestibular function tests, and abnormal subjective vertical visual results.

Postoperative change in wideband absorbance after tympanoplasty in chronic suppurative otitis media.

OBJECTIVE: To identify the wideband absorbance (WBA) of reconstructed TM comparing with perforated and normal TM, and to investigate the efficacy of WBA to predict postoperative hearing outcome. METHODS: Ninety-eight adults (128 ears) with normal TM and 40 patients (40 ears) who were diagnosed with chronic suppurative otitis media (CSOM) and underwent tympanoplasty type 1 were enrolled. Pure tone audiometry and WBA were measured before and 6 and 12 months after surgery. Finally, only 29 patients in CSOM group completed all the tests. RESULTS: Significant differences in WBA were observed between normal ears, CSOM, and reconstructed ears at middle to high frequencies. During follow-up, absorbance decreased at low frequencies and increased at middle to high. Significant positive correlation at low to middle frequency was observed between change in air-bone gaps (ABG) and absorbance at corresponding frequencies. CONCLUSION: WBA in patients with CSOM was significantly different from normal TM, and a significant change in WBA was observed after tympanoplasty with improvement of ABG. WBA may be a useful tool for monitoring the postoperative change in absorbance of sound energy in the middle ear.

Evaluation of Type III Tympanoplasty Using Cartilage Ossiculoplasty in Cholesteatoma Ear Surgery.

This prospective observational study evaluates the role of tympanoplasty type III in cholesteatoma ear disease during same sitting with mastoid surgery using cartilage ossiculoplasty. Forty patients of chronic suppurative otitis media-cholesteatoma disease were recruited in the study. All the patients had extensive cholesteatoma and underwent canal wall down mastoid surgery. Tympanoplasty type III, that is, stapes columella, minor columella, or major columella, was done in each case along with mastoid surgery depending upon the remnant ossicular status. Conchal cartilage graft was used for ossiculoplasty along with temporalis fascia graft. Hearing and graft uptake results were evaluated at the end of 6 months postoperatively. Of the 40 cases, 3 cases failed tympanoplasty. In the remaining 37 cases, a statistically significant hearing improvement (air-bone gap of 33 dB) was observed postoperatively. Seven cases underwent stapes columella, 13 cases underwent minor columella, and 17 cases underwent major columella tympanoplasty type III. Although a hearing improvement was recorded in all these subgroups, a statistically significant hearing gain was present only in tympanoplasty type III minor columella cases thereby underlying the importance of intact stapes. However, it is difficult to discern the type of tympanoplasty type III that the patient would undergo prior to the ear surgery.

Audiological function in a group of adults following myringoplasty: an exploratory study in South Africa.

INTRODUCTION: Chronic suppurative otitis media is a global middle ear disease with quality of life as economic implications, which are worse felt in low and middle income (LAMI) countries; thus the need for myringoplasty. This study aimed to explore audiological function in a group of adults following myringoplasty in South Africa, with an exploration of the possible influence of factors such as HIV/AIDS and type of surgical technique on hearing outcomes. METHODS: Within a retrospective chart review research design, 41 participant files for a six-year period from two academic hospitals in Johannesburg, South Africa, were reviewed. Data were analysed using both descriptive and inferential statistics. RESULTS: Participant files comprised of 16 males and 25 females between 18-63 years. Findings revealed that clinically, overall hearing improved post-operatively, as indicated by improved tympanometry findings, pure tone air-conduction and speech reception thresholds. Descriptively, the predictors of improved hearing outcomes post-operatively appeared to be HIV negative status and butterfly cartilage inlay surgery as a surgical technique adopted. Although clinically, hearing outcomes improved post-operatively at all air-conduction frequencies tested; these clinical improvements were only statistically significant at specific frequencies. CONCLUSION: Current findings provide useful initial evidence on the benefits of myringoplasty from the South African context; particularly because of the HIV/AIDS prevalence and its potential influence on middle ear disease and its management. Prospective efficacy studies with bigger sample sizes are recommended, with early identification strategies for middle ear disease to reduce the need for myringoplasty seriously considered bearing in mind the resource constraints.

Risk factors of sensorineural hearing loss in patients with unilateral safe chronic suppurative otitis media.

PURPOSE: Chronic suppurative otitis media (CSOM) is the major cause of hearing impairment, especially conductive hearing loss. Few patients also had sensorineural component, the sensorineural hearing loss (SNHL) in CSOM is controversial, especially for safe mucosal type. This study aims to assess the relationship between the frequency of SNHL development in patients with safe mucosal CSOM and its relation to patient's age, sex, duration of disease, size of perforation and different audiological findings. MATERIAL AND METHODS: This is a prospective study conducted from June 2016 to June 2017 in a tertiary referral hospital. 200 patients with unilateral mucosal type of CSOM with normal contralateral ear were included in the study. The diseased ears were taken as study ears and normal ears as control ears in all patients. Detailed otologic history, clinical and audiometric findings were recorded and analyzed. Results were statistically compared in all patients for both study and control ears using different parameters. RESULTS: Twenty patients had an average bone conduction threshold of all frequencies above 25dB, which implies SNHL (10%). The incidence of SNHL was statistically significant at higher speech frequencies. The incidence increased with the presence of Diabetes Mellitus, smoking, duration of disease, presence of active discharge and the increase in size of perforation. However, it is not age dependent and there was no difference between males and females. CONCLUSION: Safe mucosal CSOM can cause SNHL with multiple predisposing factors.

Hearing Status after Radical Mastoidectomy without Tympanoplasty.

OBJECTIVE: To find out the impairment of hearing associated with radical mastoidectomy by measuring the quantitative difference in the functional hearing level before and after radical mastoidectomy operation without tympanoplasty. STUDY DESIGN: Cross-sectional comparative study. PLACE AND DURATION OF STUDY: Department of Otorhinolaryngology and Head Neck Surgery, Bahawal Victoria Hospital, Bahawalpur and PNS Shifa Hospital, Karachi, from November 2009 to January 2013. METHODOLOGY: Eighty-five patients, diagnosed clinically as chronic suppurative otitis media with extensive cholesteatoma having history of ear discharge and hearing impairment for more than 6 weeks duration and requiring radical mastoidectomy for treatment, were included in this study. Pure tone audiogram was done before and after radical mastoidectomy. Hearing impairment was compared in each patient before and after the operation. RESULTS: Among the 85 patients, 54 (63.5%) were males and 31 (36.5%) were females, with the age ranged between 18 to 63 years, mean age being 42.31 4.8 years. The mean increase in hearing loss after radical mastoidectomy in air conduction was 7.19 dB, bone conduction was 4.16 dB, and air-bone gap was 3.75 dB (0.001). The ear became dry and safe in 82 patients (96.5%) out of a total of 85, and only 3 patients required revision surgery at a second stage. CONCLUSION: Radical mastoidectomy has a least negligible effect on hearing status and one should not limit this technique due to the concern of aggravated hearing in patients with extensive cholesteatoma at the cost of dry and safe ears, which should be of prime importance.

Correlation between sensorineural hearing loss and chronic otorrhea.

Many studies have attempted to correlate chronic otorrhea in children and in adults with the sensorineural hearing loss in the affected ear, with contradictory results. This loss might be the result of the likely toxicity of the bacteria involved, effects of inflammatory cytokines, or constant use of ototoxic antibiotics. All studies evaluated to date compared the affected ear with the normal contralateral ear. From the digitized archive of otologic surgery files of the Department of Otorhinolaryngology at Santa Casa de São Paulo School of Medical Sciences, the ears of patients with chronic otorrhea were evaluated visually and compared with the normal contralateral ears. Ears with otorrhea were also compared with ears of other patients with dry tympanic perforation. Ears with suppuration were evaluated for cholesteatoma. The duration of otorrhea was considered. The sensorineural hearing threshold was evaluated for the frequencies of 500, 1,000, 2,000, and 4,000 Hz. A total of 98 patients with chronic otorrhea and 60 with dry tympanic membrane perforation were evaluated. A correlation between sensorineural hearing loss and chronic otorrhea was observed when compared with both contralateral normal ears and dry perforated ears of other patients. No relationship between hearing loss and the duration of suppuration or cholesteatoma was found. Sensorineural hearing loss occurs in ears with chronic otorrhea. The duration of otorrhea and the etiology of suppuration did not influence the hearing loss.

Clinical, functional, and surgical findings in chronic bilateral otitis media with effusion in childhood.

We conducted a prospective, observational study over a 3-year period to compare the clinical, functional, and surgical findings in children with chronic bilateral otitis media with effusion who underwent one of three different types of treatment. Our study population was made up of 150 patients-79 boys and 71 girls aged 24 to 84 months-who were randomly assigned to one of the three treatment groups of 50 patients each. One group was treated with myringotomy, tympanostomy tube insertion, and adenoidectomy (T+A group); another with a combination of physical conservative treatment and adenoidectomy (P+A group); and the third with physical conservative treatment alone (P-only group). Hearing levels and tympanogram trends were evaluated during a follow-up of 12 months. In the T+A group, we noted a stable normalization of hearing in 95 of the 100 ears. Treatment with the P+A combination resulted in an improvement of hearing in 79 ears, but the improvement was maintained in only 27 ears during 12 months of follow-up. In the group with the P-only regimen, an amelioration of hearing was registered in 76 ears, but it was unstable in all cases. A type A tympanogram was maintained during the follow-up period for 2 ears in the P+A group and for 4 ears in the P-only group. Myringotomy with a detailed examination of the tympanic cavity in all ears with prolonged abnormal audiologic results revealed that types C and B tympanograms, which were found in most ears in the P+A and P-only groups, corresponded to middle ear chronic inflammatory changes (retraction pockets, granulations, adhesions, etc.) Based on our findings, we conclude that the use of a physical conservative treatment with or without an adenoidectomy does not prevent the development of chronic adhesive and purulent otitis media.

[The comparative analysis of the clinical and morphological picture of the various forms of chronic suppurative otitis media].

We present the results of the surgical treatment of 300 patients presenting with chronic suppurative otitis media. The changes in the mucous membrane of the tympanic cavity were revealed in 61% of the patients with mesotympanitis while spreading cholesteatoma occurred in 48% of the cases of «dry¼ perforations. The cholesteatomic process was documented in 64% of the patients with epitympanitis, the remaining patients presented with the pyo-carious process. The efficiency of the surgical intervention on the «dry¼ ear of the patients with the tubotympanic form of chronic suppurative otitis media (CSOM) amounted to 91.4% compared with 85% in the case of the altered mucous membrane of the tympanic cavity, 85.5% and 92.9% in the patients with the pyo-carious and cholesteatomic forms of the tympano-antral lesions, respectively. Residual cholesteatomas were found in 7.8% of the patients suffering from epitympanitis during the three year follow-up period. It is concluded that the results of clinical and morphological observations taken together with intraoperative findings give reason to consider mesotympanitis to be a prognosticallyunfavourable form of chronic suppurative otitis media.

Otologic evaluation of patients with primary antibody deficiency.

Common variable immunodeficiency (CVID) represents the most frequent primary immunodeficiency, often encountered in the ENT clinical practice. The clinical spectrum of CVID is quite broad, but otitis media are certainly among the most common clinical manifestations. This prospective study enrolled 60 patients (34 males, 26 females) with a previous diagnosis of CVID with the aim of performing an otologic evaluation and a more precision characterization of incidence, diagnosis, and treatment of otitis media in this group of patients. In consideration that Eustachian tube dysfunction (ETD) could be the 'primum movens' of otitis media, we wanted to assess whether a Eustachian tube dysfunction was present in these patients. Besides, we propose a possible diagnostic algorithm of middle ear pathologies to use in all cases of primary antibody deficiency patients. Results of our otologic examination showed that: 5 % of patients had chronic suppurative otitis media, 25 % bilateral otitis media with effusion and 10 % reported unilateral OME with associated contralateral ETD. There was bilateral isolated ETD and unilateral isolated ETD in 5 and 15 % of patients, respectively. All patients with unilateral OME had associated contralateral ETD. Finally, 40 % of patients were bilaterally negative at otoscopic examination and all otologic tests.

Childhood otitis media is associated with dizziness in adulthood: the HUNT cohort study.

The objective of the study was to examine the association between otitis media in childhood and dizziness in adulthood. Longitudinal, population-based cohort study of 21,962 adults (aged 20-59 years, mean 40) who completed a health questionnaire in the Nord-Trøndelag Hearing Loss Study was conducted. At 7, 10 and 13 years of age, the same individuals underwent screening audiometry in a longitudinal school hearing investigation. Children found with hearing loss underwent an ear, nose and throat specialist examination. Adults diagnosed with childhood chronic suppurative otitis media (n = 102) and childhood hearing loss after recurrent acute otitis media (n = 590) were significantly more likely to have increased risk of reported dizziness when compared to adults with normal hearing as children at the school investigation and also a negative history of recurrent otitis media (n = 21,270), p < 0.05. After adjusting for adult age, sex and socio-economic status, the odds ratios were 2.1 [95 % confidence interval (CI): 1.4-3.3] and 1.3 (95 % CI: 1.0-1.5), respectively. This longitudinal cohort study suggests that childhood chronic suppurative otitis media and childhood hearing loss after recurrent acute otitis media are associated with increased risk of dizziness in adulthood. This might reflect a permanent effect of inflammatory mediators or toxins on the vestibular system. The new finding stresses the importance of treatment and prevention of these otitis media conditions.

Heparin binding-epidermal growth factor-like growth factor for the regeneration of chronic tympanic membrane perforations in mice.

We aim to explore the role of epidermal growth factor (EGF) ligand shedding in tympanic membrane wound healing and to investigate the translation of its modulation in tissue engineering of chronic tympanic membrane perforations. Chronic suppurative otitis media (CSOM) is an infected chronic tympanic membrane perforation. Up to 200 million suffer from its associated hearing loss and it is the most common cause of pediatric hearing loss in developing countries. There is a need for nonsurgical treatment due to a worldwide lack of resources. In this study, we show that EGF ligand shedding is essential for tympanic membrane healing as it's inhibition, with KB-R7785, leads to chronic perforation in 87.9% (n=58) compared with 0% (n=20) of controls. We then show that heparin binding-EGF-like growth factor (5 µg/mL), which acts to shed EGF ligands, can regenerate chronic perforations in mouse models with 92% (22 of 24) compared with 38% (10 of 26), also with eustachian tube occlusion with 94% (18 of 19) compared with 9% (2 of 23) and with CSOM 100% (16 of 16) compared with 41% (7 of 17). We also show the nonototoxicity of this treatment and its hydrogel delivery vehicle. This provides preliminary data for a clinical trial where it could be delivered by nonspecialist trained healthcare workers and fulfill the clinical need for a nonsurgical treatment for chronic tympanic membrane perforation and CSOM.

Evaluation of vestibular function in patients with chronic suppurative otitis media.

OBJECTIVE: The objective of this study was to assess vestibular functions in patients with chronic suppurative otitis media (CSOM) with and without sensorineural hearing loss. STUDY DESIGN: This was a prospective case study performed at a tertiary referral university hospital. Sixty patients with CSOM were included, and patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae were excluded. PATIENTS AND METHODS: The patients underwent basic audiological evaluation, and clinical and instrumental vestibular evaluation. The incidence and extent of vestibular dysfunction in patients with CSOM were analyzed. RESULTS: A total of 42 males and 16 females with a mean age of 29.5 years were included in this study. Forty ears had tubotympanic disease and 19 had cholesteatoma. There were 14 ears with sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the cases. Rotatory chair abnormalities were found in 70% of the cases, caloric hypofunction was found in 61.6%, and vestibular myogenic evoked potentials were abnormal in 25%. The only positive correlation with vestibular dysfunction was the duration of disease. CONCLUSIONS: The vestibular system is significantly affected in cases with CSOM. Both semicircular canals and the saccule are affected. All patients with long-standing CSOM should be evaluated for vestibular dysfunction irrespective of their hearing levels.

Eustachian tube function in patients with inner ear disorders.

The influence of Eustachian tube (ET) dysfunction on the inner ear fluid pressure and thus on the inner ear function in Meniere's disease has been discussed controversially. So far, most of the studies examining ET function in inner ear disorders indirectly analyzed ET function by tympanometric methods. The present study directly studied ET function in inner ear disorders by sonotubometry. Healthy subjects and patients with Meniere's disease, sudden sensorineural hearing loss, cholesteatoma and chronic suppurative otitis media were examined by sonotubometry. Mean increase of sound pressure intensity (dB) and mean duration of sound pressure increase (s) were analyzed. Highest mean increase of sound pressure intensity was seen in healthy subjects when using >5 dB peaks (11.6 ± 0.7 dB) and >0 dB peaks (9.6 ± 0.6 dB). Comparative analysis including bilateral ears showed decreased ET function in patients with cholesteatoma (p = 0.002) and in patients with Meniere's disease (p = 0.003) when using >0 dB peaks. Examination of each specific ET opening maneuver showed impaired ET function in pathological ears of patients with cholesteatoma and with Meniere's disease, during yawning (p = 0.001; p < 0.001), dry swallowing (p = 0.010; p = 0.049), Toynbee maneuver (p = 0.033; p = 0.032) and drinking (p = 0.044; p = 0.027). Mild ET dysfunction is detected in patients with Meniere's disease by direct sonotubometric assessment of ET function.

[One-step rhinootosurgery. Clinical, economic and social aspects].

The objective of this work was to estimate from the clinical, economic, and social standpoints the efficacy of medical aid provided to the patients with chronic suppurative otitis media (CSOM) and concomitant pathology of the nasal cavity by means of the one-step surgical intervention. The study included a total of 208 patients presenting with CSOM of whom 108 ones were treated by the traditional multistage method and the remaining 108 by simultaneous rhinootosurgery. The latter approach was shown to be much more efficacious in terms of clinical, economic, and social considerations.

[The acceleration of remission after exacerbation of chronic suppurative otitis media following functional-reconstructive operations on the middle ear].

This study had the objective to enhance the efficacy of the surgical treatment of the patients presenting with chronic suppurative otitis media by means of reduction of the time needed to achieve persistent remission of the disease in the framework of a complex of therapeutic and rehabilitative measures making possible the surgical intervention on the middle ear regardless of the activity of the inflammatory process and its severity. Sixty five patients with chronic suppurative otitis media were examined and treated to estimate the clinical efficiency of the proposed complex of therapeutic and rehabilitative measures. It is maintained that this complex allows to achieve the positive results of reconstructive and restorative surgery without waiting for the development of long-term remission.

[A new method for the fixation of sound-conducting elements of the middle ear during ossiculoplasty].

The objective of the present work was to estimate the possibilities of the application of platelet-enriched plasma as a filtering material for ossiculoplasty. The results of surgical interventions on 120 patients presenting with chronic suppurative otitis media are reported. All the patients underwent closed-type sanation surgery (differential atticoanthrotomy) including either complete or partial restoration of the sound conduction mechanism in the middle ear. Platelet-enriched plasma was applied into the tympanic cavity of 55 patients as a fixing material for the reconstruction of the chain of the auditory ossicles. Ossiculoplasty without additional fixation was performed in 65 patients comprising the control group. The results of the study indicate that a clot of platelet-enriched plasma may be a good fixing material for the reconstruction of the entire chain of auditory ossicles and can be used for all types of ossiculopasty.

[Results of application of platelet-enriched autogenous plasma for the treatment of patients after middle ear surgery].

A total of 39 patients presenting with chronic suppurative otitis media were examined and treated based at the Department of Otorhinolaringology, Kursk Regional Clinical Hospital. The results of the study indicate that a group of patients treated with the use of platelet-enriched autogenous plasma simultaneously with sanation surgery and tympanoplasty underwent accelerated healing of the postoperative cavity and restoration of hearing compared with the patients who received the traditional treatment.

[Chronic purulent otitis media].

This lecture reviews up-to-date information on the classification, etiology, pathogenesis, clinical features, diagnostics, surgical and conservative treatment of chronic purulent otitis media. It is maintained that surgical intervention including sanative and reconstructive procedures as well as hearing improvement measures is currently the preferred approach to the treatment of the disease in question. Special attention is given to different variants of sanative surgery in combination with tympanoplasty. The author emphasizes that the conservative therapy of chronic otitis media has the objective to eliminate exacerbation of the chronic process and does not substitute the surgical treatment.