Implante coclear en otitis media crónica: Revisión de literatura / Cochlear implantation in chronic otitis media: Literature review

La otitis media crónica (OMC) activa y colesteatomatosa se consideraban una contraindicación para el uso de implante coclear (IC) en el pasado. Actualmente, se han propuesto múltiples opciones quirúrgicas para el IC, de acuerdo con las características clínicas del paciente y el tipo de patología otológica prexistente. La cirugía del IC se puede realizar en un tiempo o en etapas, siendo fundamental intervenir un oído seco y estable previo a la instalación definitiva del electrodo para reducir complicaciones y obtener resultados auditivos satisfactorios. El IC es un tratamiento seguro y eficaz en pacientes con OMC. Múltiples reportes internacionales han evidenciado baja tasa de complicaciones mayores y óptimos resultados auditivos funcionales en pacientes con hipoacusia y OMC.

Supurative and cholesteatomatous chronic otitis media (COM) were considered a contraindication to cochlear implant (CI) use in the past. Currently, multiple surgical options have been proposed for CI according to the clinical characteristics of the patient and the type of pre-existing otological pathology. Cochlear implant surgery can be performed in a single time or in stages, being essential to intervene a dry and stable ear prior to the definitive installation of the electrode to reduce complications and obtain satisfactory hearing results. CI is a safe and effective treatment in patients with COM. Multiple international reports have shown a low rate of major complications and optimal functional hearing results in patients with hearing loss and COM.

Clinical manifestation and treatment of temporal bone tympanic plate fracture / 中华耳鼻咽喉头颈外科杂志

Objective: To elucidate the clinical manifestations of temporal bone tympanic plate fracture and the correlation between treatment time after injury and its prognosis, and to discuss the importance of early treatment of tympanic fracture. Methods: Retrospective analysis was carried out on the clinical data of 15 patients(17 ears)with temporal bone tympanic plate fracture from March 2006 to July 2019. The course of disease was less than 1 month (initial stage) in 7 cases (7 ears), 1 month to 6 months (middle stage) in 2 cases (3 ears), and 6 months or more (late stage) in 6 cases (7 ears). The symptoms, signs, CT findings, pure tone audiometry results, surgical methods and clinical efficacy of each group were summarized. Results: Most patients with temporal bone tympanic plate fracture were referred to otology department by maxillofacial surgery. Fracture occured indirectly with the chin or zygomatic region as the direct stress point. Thirteen of the 15 patients had mental region wounds or scars, and 14 patients had external acoustic canal bleeding immediately after injury. In the initial-stage group, hearing was mostly unchanged, while in the middle and late-stage groups, hearing loss was mainly caused by conduction factors. In the initial stage group, 6 cases/7 cases were cured by external acoustic canal packing; External acoustic canal stenosis or atresia occurred in 2 cases in the middle-stage group and were cured by external acoustic canal plasty. All the 6 patients in the late-stage group had external acoustic canal stenosis or atresia, among whom 5 patients with external acoustic canal cholesteatoma were cured by external acoustic canal plasty, and the other one patient with middle ear cholesteatoma was cured by modified radical mastoidectomy and tympanoplasty after external acoustic canal plasty for three times. Conclusions: Temporal bone tympanic plate fracture is a special type of temporal bone fracture. In the early stage of temporal bone tympanic fracture, bleeding of the external acoustic canal is the main symptom, and hearing is normal mostly. Advanced conductive deafness may result from external acoustic canal stenosis and/or cholesteatoma formation later. Bleeding of the external acoustic canal and irregular bulge of the anterior wall of the external acoustic canal with mental region wound are important signs for early diagnosis of temporal bone fracture. Temporal bone tympanic fracture should be paid attention to, early detection and timely treatment can avoid external acoustic canal stenosis and atresia.

Identification of risk factors for residual cholesteatoma in children and adults: a retrospective study on 110 cases of revision surgery / Identificação de fatores de risco para colesteatoma residual em crianças e adultos: um estudo retrospectivo de 110 casos de cirurgia revisionais

Abstract Introduction: Residual disease after cholesteatoma removal is still a challenge for the otorhinolaryngologist. Scheduled "second-look" surgery and, more recently, radiological screenings are used to identify residual cholesteatoma as early as possible. However, these procedures are cost-intensive and are accompanied by discomfort and risks for the patient. Objective: To identify anamnestic, clinical, and surgery-related risk factors for residual cholesteatoma. Methods: The charts of 108 patients, including children as well as adults, having undergone a second-look or revision surgery after initial cholesteatoma removal at a tertiary referral hospital, were analyzed retrospectively. Results: Gender, age, mastoid pneumatization, prior ventilation tube insertion, congenital cholesteatoma, erosion of ossicles, atticotomy, resection of chorda tympani, different reconstruction materials, and postoperative otorrhea did not emerge as statistically significant risk factors for residual disease. However, prior adenoid removal, cholesteatoma growth to the sinus tympani and to the antrum and mastoid, canal-wall-up 2 ways approach, and postoperative retraction and perforation were associated with a statistically higher rate of residual disease. A type A tympanogram as well as canal-wall-down plus reconstruction 2 ways approach for extended epitympanic and for extended epitympanic and mesotympanic cholesteatomas were associated with statistically lower rates of residual disease. A score including the postoperative retraction or perforation of the tympanic membrane, the quality of the postoperative tympanogram and the intraoperative extension of the cholesteatoma to the sinus tympani and/or the antrum was elaborated and proved to be suitable for predicting residual cholesteatoma with acceptable sensitivity and high specificity. Conclusion: Cholesteatoma extension to the sinus tympani, antrum and mastoid makes a residual disease more likely. The canal-wall-down plus reconstruction 2 ways approach seems safe with similar rates of residual cholesteatoma and without the known disadvantages of canal-wall-down surgery. The described score can be useful for identifying patients who need a postoperative radiological control and a second-look surgery.

Resumo Introdução: A doença residual após a remoção do colesteatoma ainda é um desafio para o otorrinolaringologista. A cirurgia revisional programada e, mais recentemente, exames radiológicos são usados para identificar o colesteatoma residual o mais precocemente possível. Entretanto, esses procedimentos são dispendiosos e acompanhados de desconforto e riscos para o paciente. Objetivo: Identificar fatores de risco anamnésicos, clínicos e relacionados à cirurgia para o colesteatoma residual. Método: Foram analisados retrospectivamente os prontuários de 108 pacientes, crianças e adultos, que passaram por revisão cirúrgica após a remoção inicial do colesteatoma em um hospital terciário de referência. Resultados: Sexo, idade, pneumatização da mastoide, inserção anterior de tubo de ventilação, colesteatoma congênito, erosão dos ossículos, aticotomia, ressecção da corda do tímpano, diferentes materiais de reconstrução e otorreia pós-operatória não se mostraram fatores de risco estatisticamente significantes para a ocorrência de doença residual. Entretanto, remoção prévia da adenoide, crescimento do colesteatoma para o interior do seio timpânico e para o antro e a mastoide, abordagem de duas vias com canal wall-up e retração e perfuração pós-operatórias foram associados a uma taxa estatisticamente maior de doença residual. Um timpanograma tipo A, assim como a reconstrução de duas vias com a abordagem canal wall-down para colesteatomas com extensão para o recesso epitimpânico e/ou extensão epitimpânica e mesotimpânica, foram associados com taxas estatisticamente menores da doença residual. Um escore, que incluiu a retração ou perfuração pós-operatória da membrana timpânica, a qualidade do timpanograma pós-operatório e a extensão intraoperatória do colesteatoma para o seio timpânico e/ou antro, foi elaborado e se mostrou adequado para predizer colesteatoma residual com sensibilidade aceitável e alta especificidade. Conclusão: A extensão do colesteatoma para o seio timpânico, antro e mastoide torna a doença residual mais provável. A abordagem do tipo canal wall-down mais a reconstrução de 2 vias parecem seguras com taxas semelhantes de colesteatoma residual e sem as desvantagens conhecidas da cirurgia do tipo canal wall-down. O escore descrito pode ser útil para identificar pacientes que necessitam de controle radiológico pós-operatório e cirurgia revisional.

Recurrence of Cholesteatoma: A Retrospective Study Including 1006 Patients for More than 33 Years

Abstract Introduction Cholesteatomas are benign tumors consisting of skin, and growing inside a retraction pocket in the tympanic membrane. Cholesteatomas can occupy the entirety of the middle ear, and are known for their osteolytic capabilities. Surgery is the only curative treatment for cholesteatomas. Objective To describe the risk of recurrence after first-time surgically-treated middle- ear cholesteatoma (STMEC1) on the island of Funen from 1983 to 2015. Methods Cases of STMEC1 were identified in the Danish National Hospital Register. The medical records were reviewed. Time-to-event analyses were applied. The ears were followed from STMEC1 to a secondary cholesteatoma, emigration, death, or end of follow-up. Results Records from 1,006 patients with STMEC1 were reviewed. A total of 54 patients were submitted to surgery on both ears. The total sample consisted of 1,060 ears with STMEC1; 300 were children's (< 16 years) ears, and 760 were adult's ears. The total observation time was of 12,049 years. The overall estimated proportion with recurrence 5 years after surgery was of 37% in children and of 15% in adults. The older the child was at the first surgery, the risk decreased by 7% per year. In children, canal wall up (CWU) mastoidectomy without obliteration was associated with a hazard ratio for recurrence of 1.9 (95% confidence interval [95%CI]: 1.2-3.0) compared with CWU with obliteration. Conclusion Compared with adults, children were had 2.6 times more risk of recurrence. Procedures performed without mastoidectomy had the lowest risk of recurrence. In children, obliteration was associated with a significantly lower risk of recurrence. However, patients were not randomized regarding the surgical approach; thus, the association between approach and risk of recurrence was likely influenced by confounding factors.

Association between facial nerve second genu angle and facial canal dehiscence in patients with cholesteatoma: evaluation with temporal multidetector computed tomography and surgical findings / Associação entre o ângulo do segundo joelho do nervo facial e deiscência do canal facial em pacientes com colesteatoma: avaliac¸ão do osso temporal por tomografia com multidetectores e pelos achados cirúrgicos

Abstract Introduction: Otitis media, mastoiditis or the pressure effect of tumorous lesions such as cholesteatoma can be the cause of facial canal dehiscence and facial nerve paralysis. The most common segment involved in dehiscence is the tympanic segment and the second most common is the lateral aspect of the facial canal in the oval window area. Objective: To determine the prevalence of the facial canal dehiscence and the relationship between the angle at the second genu of the facial nerve and facial canal dehiscence. Methods: We evaluated the surgical findings in 113 patients who underwent surgery for cholesteatoma. Facial canal dehiscence was detected in 62 of the 113 patients. Patients were divided into two groups: Group 1, with dehiscence of the facial canal and Group 2, without dehiscence of the facial canal. Results: The mean angles at the second genu of the facial nerve in Groups 1 and 2 were 117.8º ± 9.63º and 114º ± 9.9º, respectively. There was a statistically significant difference between the mean angles at the second genu for the two groups (p = 0.04). Conclusion: In patients with dehiscence of the facial canal, the angle at the second genu was found to be wider than those without dehiscence.

Resumo Introdução: Otite média, mastoidite ou a compressão por lesões tumorais como o colesteatoma podem ser a causa da deiscência do canal facial e paralisia do nervo facial. A deiscência ocorre mais frequentemente no segmento timpânico, seguido do aspecto lateral do canal facial na área da janela oval. Objetivo: Determinar a prevalência da deiscência do canal facial e sua relação com o ângulo no segundo joelho do nervo facial. Método: Avaliamos os achados cirúrgicos para detecção de deiscência do canal facial em 113 pacientes submetidos à cirurgia de colesteatoma. A deiscência do canal facial foi observada em 62. Os pacientes foram divididos em dois grupos: Grupo 1, com deiscência do canal facial, e Grupo 2, sem deiscência do canal facial. Resultados: Os ângulos médios no segundo joelho do nervo facial nos grupos 1 e 2 foram 117,8º ± 9,63º e 114º ± 9,9º, respectivamente. Houve diferença estatisticamente significante entre os ângulos médios no segundo joelho para os dois grupos (p = 0,04). Conclusão: Em pacientes com deiscência no canal facial, foi observado que o ângulo do segundo joelho era maior do que naqueles sem deiscência.

Effects of cavity reconstruction on morbidity and quality of life after canal wall down tympanomastoidectomy / Efeitos da reconstrução da cavidade da timpanomastoidectomia com técnica aberta na morbidade e qualidade de vida

Abstract Introduction: Canal wall down tympanomastoidectomy is commonly used to treat advanced chronic otitis media or cholesteatoma. The advantages of canal wall down mastoidectomy are excellent exposure for disease eradication and postoperative control of residual disease; its disadvantages include the accumulation of debris requiring life-long otological maintenance and cleaning, continuous ear drainage, fungal cavity infections, and the occurrence of dizziness and vertigo by changing temperature or pressure. Objective: To evaluate whether cavity-induced problems can be eliminated and patient comfort can be increased with mastoid cavity reconstruction. Methods: In total, 11 patients who underwent mastoid cavity reconstruction between March 2013 and June 2013 comprised the study group, and 11 patients who had dry, epithelialized CWD cavities were recruited as the control group. The study examined three parameters: epithelial migration, air caloric testing, and the Glasgow Benefit Inventory. Epithelial migration, air caloric testing, and the Glasgow Benefit Inventory were evaluated in the study and control groups. Results: The epithelial migration rate was significantly faster in study group (1.63 ± 0.5 mm/week) than control group (0.94 ± 0.37 mm/week) (p = 0.003, p < 0.05). The mean slow component velocity of nystagmus of the study group (13.33 ± 5.36°/s) was significantly lower when compared to control group (32.11 ± 9.12°/s) (p = 0.018). The overall the Glasgow Benefit Inventory score was −7.21, and the general subscale, physical and social health scores were −9.71, −21.09, and +20.35, respectively in the control group. These were +33.93, +35.59, +33.31, and +29.61, respectively in the study group. All but the social health score improved significantly (0.007, 0.008, 0.018, and 0.181, respectively). Conclusions: Cavity reconstruction improves epithelial migration, normalizes caloric responses and increases the quality of life. Thus, cavity rehabilitation eliminates open-cavity-induced problems by restoring the functional anatomy of the ear.

Resumo Introdução: A timpanomastoidectomia com a técnica Canal Wall Down, ou técnica aberta, é comumente utilizada para tratar otite média crônica avançada ou colesteatoma. As vantagens da mastoidectomia pela técnica aberta são uma excelente exposição para a erradicação da doença e controle pós-operatório da doença residual; suas desvantagens incluem o acúmulo de detritos que requerem manutenção e limpeza otológica ao longo da vida, drenagem contínua da orelha, infecções fúngicas na cavidade e a ocorrência de tonturas e vertigem com alterações de temperatura ou pressão. Objetivo: Avaliar se os problemas induzidos pela cavidade podem ser eliminados e o conforto do paciente aumentado com a reconstrução da cavidade mastoide. Método: No total, 11 pacientes submetidos à reconstrução da cavidade mastoide entre março de 2013 e junho de 2013 constituíram o grupo de estudo, e 11 pacientes com cavidades secas e epitelizadas, operadas pela técnica aberta, foram recrutados como grupo controle. O estudo analisou três parâmetros: migração epitelial, prova calórica com estimulação a ar e o questionário Glasgow Benefit Inventory. A migração epitelial, a prova calórica e o Glasgow Benefit Inventory foram avaliados nos grupos de estudo e controle. Resultados: A taxa de migração epitelial foi significativamente mais rápida no grupo de estudo (1,63 ± 0,5 mm/semana) do que no grupo controle (0,94 ± 0,37 mm/semana) (p = 0,003, p < 0,05). A velocidade média do componente lento do nistagmo no grupo de estudo (13,33 ± 5,36°/s) foi significativamente menor se comparada ao grupo controle (32,11 ± 9,12°/s) (p = 0,018). O escore global do Glasgow Benefit Inventory foi de -7,21 e os escores da subescala geral, saúde física e social foram -9,71, -21,09 e +20,35, respectivamente, no grupo controle. Esses escores foram +33,93, +35,59, +33,31 e +29,61, respectivamente, no grupo de estudo. Todos, exceto o escore de saúde social, melhoraram significativamente (0,007, 0,008, 0,018 e 0,181, respectivamente). Conclusões: A reconstrução da cavidade melhora a migração epitelial, normaliza as respostas da prova calórica e aumenta a qualidade de vida. Assim, a reabilitação da cavidade elimina os problemas induzidos por cavidades abertas ao restaurar a anatomia funcional da orelha.

Cirugía endoscópica de oído para el manejo del colesteatoma atical / Endoscopic ear surgery approach for attic cholesteatoma treatment

RESUMEN El colesteatoma es la presencia de epitelio plano queratinizado en zonas neumatizadas del hueso temporal, cuya ubicación más frecuente es el ático. En la década de los noventa, se inicia el desarrollo de la cirugía endoscópica de oído, ofreciendo una nueva perspectiva en el tratamiento del colesteatoma. Se presentan dos casos clínicos de pacientes con colesteatoma atical. Se realiza abordaje endoscópico transcanal con resección macroscópica completa del colesteatoma. Audiometría posoperatoria evidencia mejoría de hipoacusia de conducción.

ABSTRACT The cholesteatoma is the presence of keratinized squamous epithelium in pneumatized areas of the temporal bone, its most frequent location is the attic. In the 1990s the development of the ear endoscopic surgery begins, offering a new perspective for cholesteatoma treatment. Two clinical cases of patients who present attic cholestatoma are described. A transcanal endoscopic approach with complete macroscopic resection was accomplished. Post-surgical audiometry shows improvement of the conductive hearing loss.

Sinus tympani y recidiva en cirugía de colesteatoma / Sinus tympani and recidiva in cholesteatoma surgery

RESUMEN Introducción: El sinus tympani (ST) es una de las áreas que más presenta colesteatoma residual. Recientemente se ha clasificado en 3 tipos de acuerdo a su morfología. Objetivos: Determinar el tipo de ST en los pacientes sometidos a cirugía de colesteatoma y analizar su impacto como factor de recidiva. Material y método: Revisión de fichas clínicas de pacientes sometidos a cirugía de colesteatoma entre los años 2004 y 2015 en el Hospital Regional de Concepción. Análisis de la tomografía axial computarizada (TAC) preoperatoria y posterior evaluación clínica de los pacientes operados mediante mastoidectomía canal wall down (CWD). Resultados: En el periodo descrito se operaron 271 oídos. El 60% de los casos analizados presentó ST tipo A y 40% ST tipo B. Se identificaron 12 casos de recidiva, 3 ST tipo B y 9 ST tipo A, sin diferencia estadísticamente significativa entre ambos. Discusión: Distinto a lo reportado en la literatura el tipo de ST más frecuente en nuestro estudio fue el tipo A, lo que podría corresponder a una variable étnica. Conclusión: El estudio preoperatorio con TAC es una herramienta útil para evaluar el tipo y compromiso del ST. Las diferencias anatómicas entre ST tipo A y B parece no ser un factor determinante de recidiva en mastoidectomías CWD.

ABSTRACT Introduction: Sinus tympani (ST) is one of the areas with the most residual cholesteatoma. Recently it has been classified in 3 types according to its morphology. Aim: To determine the type of ST in patients undergoing cholesteatoma surgery and to analyze its impact as a relapse factor. Material and method: Review of clinical files of patients submitted to cholesteatoma surgery between 2004 and 2015 at the Regional Hospital of Concepción. Preoperative computed axial tomography (CT) analysis and subsequent clinical evaluation of patients operated by canal wall down mastoidectomy (CWD). Results: In the described period 271 ears were operated. 60% of the cases analyzed had ST type A and 40% ST type B. Twelve cases of relapse were identified, 3 ST type B and 9 ST type A, with no statistically significant difference between the two. Discussion: Unlike to what is reported in the literature, the most common ST type in our study was type A, which could correspond to an ethnic variable. Conclusion: The preoperative study with CT is a useful tool to evaluate the type and commitment of ST. The anatomical differences between ST type A and B seems not to be a determinant factor of relapse in CWD mastoidectomies.

Uso de resonancia magnética con secuencia de difusión no-ecoplanar para la detección de colesteatoma en pacientes con cirugía de oído previa: presentación de 4 casos / Use of non-echo-planar diffusion-weighted magnetic resonance imaging for the detection of cholesteatoma in patients with previous ear surgery: presentation of 4 cases

El diagnóstico de colesteatoma es fundamentalmente clínico, pudiendo ser complementado con imágenes. Últimamente, el uso de resonancia magnética con secuencia HASTE ha surgido como herramienta diagnóstica sensible y específica para colesteatoma, permitiendo diferenciar éste del tejido inflamatorio-fibrótico presente en pacientes que han sido sometidos a cirugía de oído previa. En este trabajo se presentan cuatro casos de pacientes con antecedente de cirugía de oído y sospecha de colesteatoma en el mismo oído operado, realizándose RM HASTE y cirugía posterior. Obtuvimos una alta correlación entre la imagen y resultado quirúrgico. Se requiere mayor número de pacientes para determinar la sensibilidad y especificidad en el diagnóstico de colesteatoma en pacientes con cirugía de oídos previa.

The diagnosis of cholesteatoma is mainly established by clinical signs, and can be improved by radiological imaging. Recently, the use of magnetic resonance imaging (MRI) with HASTE sequence has emerged as a sensitive and specific diagnostic tool for cholesteatoma, which allows differentiating it from inflammatory-fibrotic tissue present in patients who have undergone previous surgery ear. Here, we present four cases of patients with a history of ear surgery and a suspected cholesteatoma in the same ear, performing HASTE MRI and subsequent surgery, presenting a high correlation between MRI and surgical outcome. More patients are needed to determine the sensitivity and specificity in the diagnosis of cholesteatoma inpatients with previous ear surgery.

Surgical management of middle ear cholesteatoma and reconstruction at the same time / Manejo quirúrgico del colesteatoma del oído medio y reconstrucción en un solo tiempo

Introduction: In the surgical management of cholesteatoma, one can opt for a closed technique (simple mastoidectomy) or open surgery (radical mastoidectomy). Open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery combines the advantages of both techniques, namely, adequate surgical exposure, eradication of cholesteatoma, and anatomical reconstruction of the middle ear structures. Objective: To evaluate the surgical results in the management of cholesteatoma through the technique of open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery. Methods: Prospective analytical observational study conducted between 2009 and 2012 with patients undergoing this surgical technique in the Hospital Universitario del Valle [University Hospital of Valle], performing preoperative clinical monitoring and quarterly postoperative tomography with previous assessments of hearing and pre- and postoperative audiometry. Results: Forty-five patients were studied. Mean postoperative follow-up was 28 months. Surgical success was achieved in 93.3% of patients, as measured by clinical and radiological follow-up. Hearing preservation was found after reconstruction of the hearing mechanism, based on measured audiometry, i.e., pure-tone average (PTA), using the statistical test for paired samples between preoperative and postoperative PTA. (95%CI -1.47-12.15). Residual cholesteatoma was present in 6.6% of cases; three to four times lower than the rate reported in the literature. Conclusions: This type of surgery can be considered a successful technique in the treatment of cholesteatoma in selected cases.

Introducción: El manejo del colesteatoma es quirúrgico. Se puede optar por una técnica cerrada (mastoidectomía simple) o técnica abierta (mastoidectomía radical). La mastoidectomía abierta con reconstrucción de la pared posterosuperior y reconstrucción del oído medio en un solo tiempo quirúrgico reúne las bondades de ambas técnicas: una adecuada exposición quirúrgica, erradicación del colesteatoma y reconstrucción anatómica de las estructuras del oído medio. Objetivo: Evaluar los resultados quirúrgicos en el manejo del colesteatoma con la técnica de mastoidectomía abierta con reconstrucción de la pared posterosuperior y el oído medio en un solo tiempo quirúrgico. Métodos: Estudio analítico observacional prospectivo realizado entre 2009-2012 con pacientes sometidos a esta técnica quirúrgica en el Hospital Universitario del Valle, realizándose un seguimiento clínico preoperatorio y postoperatorio trimestral, y evaluaciones previas con tomografía de oído y audiometría pre y postoperatoria. Resultados: Se estudiaron 45 pacientes. La media de seguimiento postoperatorio fue de 28 meses. Se alcanzó éxito quirúrgico en el 93.3% de los pacientes medidos por el seguimiento clínico y radiológico. Se encontró preservación de la audición después de la reconstrucción del mecanismo auditivo, medido con audiometría basada en el promedio tonal auditivo, mediante la prueba estadística para muestras pareadas entre la PTA preoperatoria y postoperatoria (IC95% -1.47-12.15). Se presentó colesteatoma residual en el 6.6%, tres a cuatro veces menor al reportado en la literatura. Conclusion: Este tipo de cirugía se puede considerar una técnica exitosa en el tratamiento de colesteatoma en casos seleccionados.

Cirugía del colesteatoma y audición / Cholesteatoma surgery and audition

Introducción: El colesteatoma es una entidad clínica que se presenta principalmente en edades medias de la vida. El tratamiento definitivo es quirúrgico, el cual apunta a erradicar la enfermedad, mientras que mantener o mejorar la audición es un objetivo secundario. Existen diversas técnicas quirúrgicas siendo la aticoantromastoidectomía con o sin preservación de la pared posterosuperior del conducto auditivo externo la más utilizada. Objetivos: Caracterizar a la población sometida a tratamiento quirúrgico del colesteatoma en el Hospital Clínico de la Universidad de Chile y determinar los cambios auditivos posoperatorios. Material y método: Se realiza un estudio descriptivo retrospectivo en donde se analizan los procedimientos quirúrgicos entre los años 2007y 2012. Se registran y analizan datos individuales, valores audiométricos pre y posoperatorios y tipo de cirugía realizada. Resultados: Se incluyen 143 pacientes con promedio de edad de 41 años, siendo el 56% de sexo masculino. El 54,5% fueron aticoantromastoidectomía; 21,6% aticoantrostomía; 16,7% aticoantromastoidectomía más timpanoplastía IIIA y 6,7% aticoantromastoidectomía más timpanoplastía IIIB. Los umbrales auditivos se mantuvieron en la aticoantrostomía, en la aticoantromastoidectomía y en la aticoantromastoidectomía con timpanoplastía tipo IIIB, mientras que la audición mejoró significativamente en las aticoantromastoidectomía con timpanoplastía tipo IIIA. Conclusión: La técnica mayormente utilizada en el Hospital Clínico de la Universidad de Chile para el manejo del colesteatoma es la aticoantromastoidectomía con o sin preservación de la pared posterosuperior del conducto auditivo. Aquellos pacientes a los que se les asocia una timpanoplastía tipo IIIA presentan una mejoría auditiva significativa.

Introduction: The cholesteatoma is a clinical entity that presents mostly in middle ages. The definitive treatment is surgery; which aims to eradicate the disease, while maintaining or improving hearing thresholds is a secondary goal. Several surgical techniques have been described, being the tympanomastoidectomy with or without preservation of the postero-superior wall of the external auditory canal the most commonly used. Aim: To characterize the population that underwent surgical treatment forcholesteatoma in the Clinical Hospital of the University of Chile and to determine the post-surgical hearing thresholds changes. Methods: Retrospective and descriptive study of the surgical procedures carried out between the years 2007 and 2012. Individual data, pre and post-surgical treatment audiometric values and types of surgery are registered and analyzed. Results: 143 patients were included with a 41 year age average, 56% were males. 54,4% of surgeries were tympanomastoidectomy; 21,6% atticotomy; 16,7% tympanomastoidectomy with type IIIA tympanoplasty and 6,7% tympanomastoidectomy with type IIIB tympanoplasty. Hearing thresholds were maintained in atticotomy, tympanomastoidectomy and tympanomastoidectomy with type IIIB tympanoplasty, while hearing thresholds improved in the tympanomastoidectomy with type IIIA tympanoplasty reconstruction. Conclusion: The most used technique for cholesteatoma treatment in the Clinical Hospital of the University of Chile was tympanomastoidectomy with or without preservation of the posterosuperior wall of the external ear canal. Patients who had a type IIIA tympanoplastyimproved their hearing thresholds.

Impacto da endoscopia no tratameno do colesteatoma / The impact of endoscopy on the treatment of cholesteatomas

Com índices relativamente baixos de lesão recorrente, o colesteatoma residual de orelha média se mostra, hoje, um dos maiores responsáveis pelos altos índices de recidiva da doença. Dada a limitação em visualizar, sob microscopia, todos os acidentes anatômicos distribuídos tridimensionalmente no osso temporal, a endoscopia surgiu como uma ferramenta auxiliar em otocirurgia e está se mostrando uma grande aliada no manejo da otite media crônica colesteatomatosa e na prevenção de sua recidiva. OBJETIVO: Avaliar, por meio de revisão bibliográfica, a importância da otoendoscopia no tratamento cirúrgico do colesteatoma e seu papel na prevenção de lesões recidivadas. MÉTODO: Realizou-se uma busca eletrônica entre março a junho de 2011, nas bases de dados MedLine e LILACS, selecionando-se estudos que analisavam a endoscopia como método auxiliar no manejo do colesteatoma. RESULTADOS: Aplicados os critérios de inclusão e exclusão, restaram três estudos avaliando a endoscopia na cirurgia do colesteatoma frente ao método microcirúrgico tradicional. CONCLUSÃO: Parece que a endoscopia deve ser incorporada à prática diária da otologia, dado seu impacto positivo no manejo da referida enfermidade.

Recurrent cholesteatoma is relatively uncommon. Residual middle ear cholesteatomas account for most of the cases of recurrent disease. The limited role of microscopy in the visualization of tridimensional anatomic alterations of the temporal bone led to the use of endoscopic examination as an additional tool in the realm of ear surgery. Endoscopy has significantly aided in the management of chronic cholesteatomatous otitis media and in the prevention of recurrent disease. OBJECTIVE: To review the literature and assess the relevance of endoscopy in the surgical treatment of cholesteatomas and in the prevention of relapsing lesions. METHOD: Searches on databases MedLine and LILACS were carried out between March and June of 2011 to select studies in which endoscopy was used in the management of cholesteatomas. RESULTS: Three studies comparing surgery aided by endoscopy and surgery performed with the aid of a microscope met the inclusion criteria. CONCLUSION: Endoscopy has positively impacted the management of cholesteatomas and should be used in cholesteatoma surgery.

Evaluation of mastoid cavities after canal wall down mastoidectomy

To evaluate mastoid cavities after canal wall down procedures in terms of achieving a dry mastoid cavity, presence of residual or recurrent disease [Granulations and cholesteatoma]. Quasi-experimental study. The study was done in the ENT Department, CMH Rawalpindi Study was done in fourteen months from Nov 2006 to Jan 2008. Fifty patients undergoing canal wall down mastoidectomy were included. Their mastoid cavities were evaluated for persistence of discharge and recurrence of granulations and cholesteatoma after the surgery. After follow up period of 3 months, 8% patients had mild discharge, 12% had granulation and 2% patients had recurrence of cholesteatoma. Canal wall down mastoidectomies are very effective in controlling the recurrence of cholesteatoma, granulations formation and otorrhoea to a greater extent

Aplicação da ressonância magnética no acompanhamento da cirurgia do colesteatoma / The role of magnetic resonance imaging in the postoperative management of cholesteatomas

A tomografia computadorizada e ressonância magnética (RM) com seqüências convencionais têm baixa especificidade para a diferenciação entre tecido de granulação e recidiva de colesteatoma. OBJETIVO: Avaliar a aplicação da RM com sequência de difusão e pós-contraste T1 tardio na detecção de recidiva de colesteatoma. MATERIAL E MÉTODO: Realizado estudo transversal prospectivo de dezessete pacientes estudados no pós-operatório de colesteatoma utilizando RM de 1.5 T com seqüência difusão, T1, T2 e pós-contraste T1 tardio nos planos coronal e axial. Dois radiologistas avaliaram e decidiram em consenso a presença de foco de hipersinal na difusão e T2, iso/hipossinal em T1 e ausência de impregnação pelo contraste como suspeitos de recidiva de colesteatoma. Os achados da revisão cirúrgica foram comparados com o resultado da RM. RESULTADOS: Onze dos doze casos de recidiva de colesteatoma apresentaram hipersinal na difusão. Todos os pacientes com tecido de granulação na cavidade cirúrgica não apresentaram alteração de sinal na difusão. Um paciente com abscesso no conduto auditivo interno também apresentou hipersinal na difusão. A sensibilidade, especificidade, valor preditivo positivo e negativo foram respectivamente 91,6 por cento, 60 por cento, 84,6 por cento e 75 por cento. CONCLUSÃO: A seqüência de difusão combinada com pós-contraste tardio pode ser útil na diferenciação entre tecido de granulação e recidiva de colesteatoma.

Conventional CT and MRI scans have low specificity when it comes to differentiating granulation tissue from relapsing cholesteatoma. AIM: this paper aims to analyze the use of DWI and delayed post-contrast T1-weighed imaging in the detection of recurring cholesteatomas. MATERIALS AND METHOD: this is a cross-sectional prospective study that looked at 17 cholesteatoma patients postoperatively. All patients underwent diffusion magnetic resonance imaging at 1.5T, T1, T2, and delayed post-contrast T1 and images were produced from both coronal and axial planes. Two radiologists assessed the images and decided consensually that the presence of hyperintensive signal in DWI on T2, iso/hypointensive signal on T1, and absence of contrast uptake were indicative of relapsing cholesteatoma. Surgical review findings were compared to DWI scans. RESULTS: eleven of the twelve cases of recurring cholesteatoma presented hyperintensive signal in the DWI scans. None of the patients with granulation tissue in the surgical wound presented hyperintensive signal in the DWI scans. A patient with an abscess in the internal acoustic meatus also presented a hyperintensive signal in the DWI scans. Sensibility, specificity, positive predictive value and negative predictive value were 91.6 percent, 60.0 percent, 84.6 percent, and 75.0 percent, respectively. CONCLUSION: DWI combined with delayed post-contrast T1 SE sequence proved to be useful in the differential diagnosis of granulation tissue and recurring cholesteatoma.

Colesteatoma asociado a secuencia de labio y paladar hendidos / Cholesteatoma associated with a sequence of cleft lip and palate

El colesteatoma adquirido asociado a secuencia de labio y paladar hendidos constituye una secuela común en los niños como consecuencia de una función anormal de la trompa de Eustaquio. Se presenta el cuadro clínico-otológico, la otomicroscopia y la eficacia del tratamiento quirúrgico en una paciente de 9 años, afecta de labio y paladar hendido y colesteatoma en el oído derecho complicado con meningitis. Se destaca el riesgo de complicaciones de la otitis media con derrame crónico y la importancia de su diagnóstico precoz, en estadios previos a la formación del colesteatoma.

The cholesteatoma acquired associated with the sequence of cleft lip and palate is a common sequel in children as a result of a malfunction of the Eustachian tube. The clinical-otological picture, the otomicroscopy and the efficiency of the surgical treatment in a 9-year-old patient with cleft lip and palate and cholesteatoma on the right ear complicated with meningitis are presented. The risk for complications of otitis media with chronic effusion and the importance of its early diagnosis in stages previous to the formation of cholesteatoma are stressed.

Correlação da cadeia ossicular no transoperatório com achados histológicos de colesteatomas / Hystology findings' correlation between the ossicular chain in the transoperative and cholesteatomas

A Otite Média Crônica é definida pela presença de alterações teciduais inflamatórias irreversíveis na fenda auditiva. As lesões ossiculares são as mais prevalentes. OBJETIVO: Correlacionar o grau de comprometimento da cadeia ossicular, visualizada no transoperatório, com o grau histológico de inflamação e com a espessura da perimatriz de colesteatomas. TIPO DE ESTUDO: Estudo transversal. MÉTODOS: Descrições cirúrgicas de 71 pacientes foram revisadas. Colesteatomas coletados e fixados em formol 10 por cento e preparadas uma lâmina em Hematoxilina-Eosina e outra em Picrossírios. A leitura foi "cega", através de imagens digitais, no ImageProPlus. A análise estatística foi realizada através do coeficiente de Spearman, sendo considerados como estatisticamente significativos os valores de P≤0,05. RESULTADOS: Havia algum envolvimento da cadeia ossicular em 65 casos. O ossículo mais freqüentemente afetado era a bigorna, seguida pelo estribo e pelo martelo. Ao aplicarmos o coeficiente de Spearman entre o grau de comprometimento da cadeia ossicular com a idade do paciente à cirurgia, a espessura da perimatriz e o grau histológico de inflamação não foram detectadas correlações. CONCLUSÃO: Os nossos achados indicam que é praticamente universal o acometimento da cadeia ossicular na presença de colesteatoma. Não foi encontrada correção entre a erosão ossicular e os achados histológicos.

Chronic otitis media is hystopathologycaly defined as the presence of irreversible inflammatory tissue changes in the middle ear. Ossicular lesions represent the most prevalent change. AIM: to correlate the degree of ossicular chain changes seen during surgery with the inflammatory histological degree and the thickness of the cholesteatoma perimatrix. STUDY DESGN: Cross-sectional study. METHODS: Seventy-one descriptions of surgeries done in patients submitted to tympanomastoydectomy were reviewed. Cholesteatoma were collected and fixed in 10 percent formaldehyde. Two slides were made for each cholesteatoma, one stained with HE and another with picrossirius. Images were obtained from light microscopy and digitally processed and "blindly" analyzed using Image Pro-Plus Software. For statistical analysis we used Spearman's coefficient. Differences were considered statistically significant if P≤0.05. RESULTS: the ossicular chain was involved in 65 cases. The incus was the most frequently affected bone, followed by the stapes and the malleus. When the Spearman's coefficient was employed considering ossicular chain change degree with patient's age by the time of surgery, perimatrix thickness and histological degree of inflammation, correlations were not established. CONCLUSION: Our findings indicate that ossicular chain changes are practically universal when a cholesteatoma is present. We didn't find correlations related with bone erosion and cholesteatoma's histological findings.

Manejo clinicoquirúrgico de la otitis media crónica colesteatomatosa en el niño / Management clinicoquirúrgico of the chronic average otitis colesteatomatosa in the boy

El tratamiento de la otitis media crónica colesteatomatosa en los niños es controversial y difícil. Nos propusimos caracterizar a pacientes pediátricos con colesteatomas extensos e infección activa, así como identificar hallazgos otoscópicos y quirúrgicos, complicaciones, microbiología, eficacia del tratamiento antimicrobiano y afectaciones funcionales auditivas. Se realizó un estudio descriptivo prospectivo con 12 pacientes, en edades entre 4 y 15 años, operados mediante técnica abierta combinada con timpanoplastia y osiculoplastia entre el 2001 y el 2004. La evolución de los pacientes fue seguida hasta los 3 años después de la cirugía. Los hallazgos más frecuentes fueron la perforación epitimpánica posterior marginal (41,6 por ciento), lesión osicular total (50 por ciento), facial timpánico dehiscente y erosión del canal semicircular horizontal (45,4 por ciento). Las complicaciones intratemporales fueron las más frecuentes (50 por ciento). Se realizó reconstrucción tímpano-osicular a 8 pacientes y los resultados auditivos fueron satisfactorios en el 66,6 por ciento, mientras que la respuesta al antimicrobiano utilizado fue eficaz en el 100 por ciento. El uso de la técnica quirúrgica abierta unida a una correcta estrategia antibiótica es lo indicado en los niños con colesteatomas extensos y con infección activa.

The treatment of in children is controversial and difficult. We proposed ourselves to characterize pediatric patients with extensive cholesteatomas and active infection, as well as to identify otoscopic and surgical findings, complications, microbiology, efficiency of the antimicrobial treatment and functional auditive affections. A descriptive and prospective study was conducted among 12 patients aged 4-15 that were operated on by open technique combined with tympanoplasty and ossiculoplasty from 2001 to 2004. The evolution of the patients was followed during 3 years after surgery. The most common findings were posterior marginal epytimpanic perforation (41.6 percent), total ossicular injury (50 percent), tympanic facial dehiscence and erosion of the horizontal semicircular canal (45.4 percent). The intratemporal complications were the most frequent (50 percent). Timpano-ossicular reconstruction was performed in 8 patients, and the hearing results were satisfactory in 66.6 percent, whereas the response to the antimicrobial agent used was efficient in 100 percent of the cases. The use of the open surgical technique together with a correct antibiotic strategy is what is indicated in children with extensive cholesteatomas and active infection.