Colesteatoma congénito gigante en paciente octogenario / Giant congenital cholesteatoma in an octogenarian patient

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Facial extention of ear pathology: infected cholesteatoma causing a parotid abscess.

A man in his early 30s presented with right-sided preauricular swelling and facial oedema. He had a history of acid injury to his right ear as a child resulting in pinna deformity and subsequent blind sac closure of the external auditory canal. Imaging showed abnormal ear anatomy and abnormal density of the right parotid gland. Antibiotic therapy prevented progression but did not resolve the symptoms. Therefore, the infected area was surgically drained. This showed an underlying cholesteatoma, a benign but locally destructive condition where keratinising squamous epithelium grows in the middle ear and mastoid. The infected region was drained and the cholesteatoma was excised. This led to full resolution of the infection. The patient is awaiting a follow-up diffusion-weighted MRI. This case was unusual as the disease had extended beyond the ear and we therefore wish to alert clinicians to cholesteatoma as a possible cause of facial swelling.

A Case of Recurred Cholesteatoma Removal via Middle Cranial Fossa Approach / 대한이비인후과학회지

Cholesteatoma is a benign disease but it has an aggressive feature that may lead to serious conditions. Many strategies have been introduced for the treatment cholesteatoma, yet no definite single method has been established: it should be treated respectively regarding the completion of cholesteatoma, conservation of tympanic mucosa, proper ventilation of middle ear and preservation of hearing. A 25-year old patient visited our clinic for right-sided facial paralysis of 5 days. The patient underwent canal wall down mastoidectomy 10 years ago due to cholesteatoma and a few revision surgeries under local anesthesia for recurrence. Pre-operative temporal bone CT showed suspected recurred cholesteatoma in internal auditory canal and labyrinthine segment of facial nerve nearby. The patient underwent a removal of cholesteatoma via middle cranial fossa approach. This case report is a successful completion of recurred cholesteatoma, for which no recurrence is shown. Facial nerve function is improved at postoperative 1 year.

A Study on Prognostic Factors of Primary and Revision Myringoplasty / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There is no consensus on the prognostic factors regarding pos-toperative recurrence after myringoplasty. In this study, we investigated the preoperative clinical findings and postoperative results after primary myringoplasty and compared them with those of revision myringoplasty. SUBJECTS AND METHOD: Computerized database of 861 clinical records of last 20 years were analyzed retrospectively for the subjects who underwent myringoplasty at the Department of Otolaryngology, University of Korea. All the surgeries were done under general or local anesthesia by senior surgeons. Primary and revision cases of myringoplasty or type 1 tympanoplasty followed up at least for longer than 3 months were only included in the study. Those other cases of tympanoplasty types, concomitant ossiculoplasty and/or mastoidectomy, or those with the presence of cholesteatoma and those that required repair during exploratory tympanotomy were excluded. RESULTS: 535 primary and 101 revision cases have met our inclusion criteria. Overall, in this study, the failure rates of primary and revision myringoplasty were 11.02% and 5.94%, respectively. Significantly different among the prognostic factors were such as sex, age, anesthesia, surgical approach, the presence of otorreha, size of eardrum perforation, external auditory canal narrowing, valsalva test, degree of pneumatization, graft materials, tympanoplasty type, previous mastoidectomy, the presence of bilateral otitis media influencing on myringoplasty revision, and the presence of otorrhea and sclerotic type of mastoid pneumatization. CONCLUSION: Among various prognostic factors of myringoplasty, poor prognostic factors were preoperative otorrhea and poor pneumatization.

Neuro-ophthalmic manifestations of a complicated cholesteatoma.

BACKGROUND: A cholesteatoma, also known as an epithelioma, is a mass of soft tissue that results from the accumulation of keratin protein debris enclosed by a layer of stratified squamous epithelium. CASE REPORT: A patient with cholesteatoma surrounding both internal carotid arteries presented with cerebral ischemic symptoms expressed as visual and ocular symptoms. Because of its location, mass effect, and potential stenosis of the internal carotids, this slow-growing tumor is potentially sight threatening. Asymmetric cupping of the optic nerves associated with symptoms such as dizziness, diplopia, or facial pain should be worked up carefully. CONCLUSION: The primary care optometrist can play an important role in the diagnosis and continued management of a patient with a cholesteatoma, carefully monitoring early signs of progression or change. This case illustrates how an intracranial lesion, away from the eye, can impact a number of ocular and visual functions.

Regulation of Gap Junctional Intercellular Communication in Human Keratinocyte Cells / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Unlike the normal skin, cholesteatomas characterized by hyperproliferative keratinocytes exhibits up-regulation of connexins (Cxs) and gap junctional intercellular communication (GJIC). Currently, there are no appropriate clinical methods that can inhibit cholesteatoma progression nor are there available optimal in vitro models of cholesteatomas. The objectives of this study were to identify the regulating materials that control GJIC using human keratinocyte cells (HaCaT) and to get preliminary information about how to inhibit cholesteatoma progression with an aim to make in vitro models. MATERIALS AND METHOD: Acetic acid (AA), H2O2, dexamethasone, retinoic acid (RA), or green tea extracts-epicatechin (EC) and epigallocatechin gallate (EGCG) were used for this study. After HaCaT cells were cultured with chemicals for 24 hours, cytotoxicity was quantitatively analyzed by cell counting and Neutral-red uptake test. Reverse transcriptase-polymerase chain reaction, Western blot and immunocytochemistry were performed to analyze the change of Cx expression. GJIC was functionally evaluated with scrape-loading dye transfer (SLDT). RESULTS: After the 24-hour culture, H2O2 or EGCG (100 microM) were observed to have interfered with cell growth. In the Western blot, Cx26 and Cx30 showed higher up-regulation by EGCG or dexamethasone, but less down-regulation by AA or H2O2 than the control. In comparison with the control, immunocytochemistry (Cx26, Cx43) showed less expression and abnormal location of Cxs under AA, H2O2, or 50 microM EGCG than the control, and increased up-regulation or equal expression under 5microM EGCG, EC, RA, or dexamethasone was greater than the control. In SLDT, dye transfer was significantly lower in AA-, H2O2-, dexamethasone-, or RA-treated cells than in the control cells. EC showed higher dye transfer than the control cells. CONCLUSION: The expression of Cxs and GJIC on human HaCaT keratinocytes can be up- or down-regulated by chemicals such as AA, H2O2, dexamethasone, or EC. These results may be useful information in understanding the progression or inhibition mechanisms of cholesteatomas.

Partial ossicular reconstruction: comparison of three different prostheses in clinical and experimental studies.

OBJECTIVE: To compare the reconstruction results of a long incus process defect using 3 different partial ossicular replacement prostheses (PORP). STUDY DESIGN: Temporal bone experiments and retrospective case review. SETTING: Tertiary referral center. EXPERIMENTAL MATERIAL AND PATIENTS: The experimental study was performed on 18 temporal bones; 66 patients with retraction pockets, chronic otitis media with or without cholesteatoma. INTERVENTIONS: Ossiculoplasty using 3 different PORP: titanium angle prosthesis, autologous incus interposition, and titanium clip prosthesis. MAIN OUTCOME MEASURES: Laser Doppler vibrometry in temporal bones measured transmission properties of the PORP. Patients were retrospectively assessed up to 5 years after surgery. Audiologic data were analyzed for preoperative and postoperative air conduction and air-bone gap at 0.5, 1, 2, 3, and 4 kHz. Statistical analyses compared the outcome in the experimental and clinical setting. RESULTS: Experimentally, the titanium PORP showed similar transmission properties because the overall difference to the intact specimen was -4.14 +/- 0.59 dB for the titanium angle prosthesis and -4.61 +/- 0.57 dB for the titanium clip prosthesis. The transmission after an autologous incus interposition was significantly worse (-9.32 +/- 0.39 dB, p < or = 0.001) compared with the other prostheses. Patients' mean postoperative air-bone gap was 25.5 +/- 1.2 dB and less than 20 dB in at least 66% of cases without any significant differences between the groups. CONCLUSION: In the clinical setting, the confounding factors that influence the acoustic outcome after partial ossiculoplasty obscure the prosthesis-related transmission factors that can otherwise be derived in the experimental setting. The results do not generally favor the use of 1 specific prosthesis, rather they suggest that the correct choice of a prosthesis be based on the anatomic and pathophysiologic conditions found in the individual patient.

"Just look," he said.

Five personal examples are given illustrating the general principle that one can see if one looks or, conversely, that one cannot see anything that one believes not to exist.

Endoscopic Tympanoplasty / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Modern endoscopes provide a direct access into the hidden recesses of the middle ear using a minimally invasive approach. The authors employed endoscopes in a transcanal tympanoplasty and analyzed the results for the further application of these endoscopic procedures to various otologic surgeries. MATERIALS AND METHOD: 15 ears with chronic otitis media and 2 ears with congenital cholesteatoma were operated under local anesthesia using 2.7 mm and 4 mm rigid endoscopes, a camera, and a monitor. RESULTS: The structures in the posterior tympanum were directly visualized with 0 endoscope in all cases without removal of the overlying bone. The attic was visualized with 70 endoscope after removal of the incus. 15 tympanoplasties were performed in 14 cases of chronic otitis media and in 1 congenital cholesteatoma. Staged tympanoplasties were performed for the other 2 cases. The intraoperative aid postoperative courses were uneventful in all cases. All cases showed closure of' the perforation and 15 cases showed favorable hearing results postoperatively. CONCLUSION: The endoscopes directly visualized the structures in the posterior tympanum and the transcanal endoscopic tympanoplasties showed closure of the perforation and favorable hearing results postoperatively. With the employment of these endoscopes, minimally invasive otologic surgeries will be possible on the ears with narrow canal, adhesive otitis, ossicular abnormalities, and other abnormalities.

Solubilization of keratin debris in conservative treatment of middle ear cholesteatoma: an in vitro study.

A variety of solutions were tested in vitro to find a suitable solvent which could be used in clinical practice for cholesteatoma debris. Though a little weak as a solvent, a liquid soap composed mainly of plant oil did not cause irritation of the middle ear mucosa, and was thought to be a promising solvent with which to rinse away tenacious debris, especially when used in combination with hydrogen peroxide.

Oral ciprofloxacin in the management of chronic suppurative otitis media without cholesteatoma in children: preliminary experience in 21 children.

The current medical management of children with chronic suppurative otitis media without cholesteatoma unresponsive to local treatment and oral antibiotics is intravenous antibiotic therapy in the hospital setting. We studied the efficacy and toxicity of oral ciprofloxacin in chronic suppurative otitis media. Twenty-one children received oral ciprofloxacin, 30 mg/kg/day. Ear discharge was positive for bacteria resistant to other oral medications and susceptible to the quinolones. The mean duration of treatment was 16.7 days. In 18 children suppuration ceased and 3 failed their first course. During a mean follow-up of 15.4 months, 6 children remained free of ear, nose and throat problems. Otorrhea recurred in 12 children. Ear cultures were positive for organisms susceptible to amoxicillin in 5 of them. In 7 cases Pseudomonas aeruginosa was again isolated from otorrhea. Repeated antibiotic therapy was advocated only in 3 (2 responded to ciprofloxacin; 1 failed ciprofloxacin and was cured by ceftazidime). Adverse clinical effects were not observed. Transient neutropenia was observed in 1 child. There was no change in the height percentile. The results of this study show that children with chronic suppurative otitis media without cholesteatoma can be effectively treated with oral ciprofloxacin. This novel approach may prevent hospitalization.

The effect of isotretinoin on propylene glycol-induced cholesteatoma in chinchilla middle ears.

Previous studies have shown that propylene glycol causes inflammatory changes and cholesteatoma when applied to chinchilla middle ears. Vitamin A and synthetic analogues are essential for the normal differentiation of epithelial tissues. The purpose of this study was to determine whether the administration of isotretinoin to chinchillas would prevent propylene glycol exposure from inducing middle ear cholesteatomas. Sixteen chinchillas received 90% propylene glycol to the left middle ear and normal saline to the right. Half the animals were placed in the experimental group and received a daily dose of isotretinoin of 2 mg/kg for 7 days prior to propylene glycol administration and then for 6 weeks until killed. At 6 weeks, cholesteatoma was found in six of eight ears treated with propylene glycol in animals receiving isotretinoin. Two animals in the control group died. Three of the remaining eight had cholesteatoma. No ears treated with saline had cholesteatoma. We conclude that isotretinoin, in our chinchilla model, does not prevent propylene glycol-induced cholesteatoma formation.

Ciprofloxacin for the treatment of chronic ear disease.

The treatment of chronic ear disease is often difficult and frustrating. Patients typically present with a history of chronic, persistent otorrhea that has failed to respond to multiple topical and oral antibiotics. Organisms that are resistant to multiple antibiotics are common. Ciprofloxacin has been shown to be effective against a wide range of gram-negative and gram-positive organisms. To evaluate the role of ciprofloxacin in the treatment of chronic ear disease, 21 patients who failed routine therapy for chronic ear disease were prospectively treated with oral ciprofloxacin. Prior to therapy, all ear cultures grew Pseudomonas aeruginosa, Staphylococcus aureus or other gram-negative organisms. Ninety-five percent of patients completing therapy showed either improvement or cure. Only one patient failed to improve. Ciprofloxacin has been shown to be effective in the management of chronic ear disease.

The use of fluoroquinolones in chronic otitis suppurativa.

The present review covers fluoroquinolone usage in chronic otitis suppurativa (COS) in case of chronic otitis media, cholesteatoma, radical mastoid cavity infection and chronic or relapsing otitis externa. A total of six publications were included in the final evaluation. Enoxacin was effective in 35%; ciprofloxacin (five publications) was used in 82 patients with 67% effectivity in otitis externa and otitis media and 61% effectivity in radical mastoid cavity infection. No serious adverse reactions were reported. The promising efficacy of otitis media and otitis externa and safety profile needs further confirmation in double blind prospective clinical studies, that will provide a firm basis for changing the current treatment schedules of COS.

[Middle ear implants (Tübingen type) of Al2O3 ceramics. Follow-up to 6 years after surgery]. / Mittelohrimplantate (Typ Tübingen) aus Al2O3-Keramik. Verlaufsbeobachtung bis 6 Jahre nach Operation.

Since 1980 we have been using Al2O3 ceramic implants in some reconstructions of the ossicular chain. We began interposing a small autologous cartilage perichondrium disk between implants of this type and the ear-drum after having observed the first cases of imminent extrusion and of extrusion. Thus about half the implants in our first follow-up study. in 1984, were shielded by a cartilage disk; in 1984 91 patients (108 ears) were examined. 64 of the same patients (66 ears) consented to be re-examined in a second follow-up study in 1986. Of the 66 Al2O3 ceramic implants in the smaller sampling 43 had a cartilage overlay, and 23 did not. The implants without a cartilage overlay had been in situ for 3 to 6 years, and on average for 59 months; those with a cartilage overlay had been in situ for 3 to 6 years, and on average for 59 months; those with a cartilage overlay had been in situ for 2 to 5 years, and on average for 39 months. Both studies show the feasibility of markedly reducing the risk of imminent extrusions and extrusions, which occur when the cavum tympanum is poorly ventilated and the ear-drum retracts. The extrusion rates for Al2O3 middle-ear implants with and without a cartilage overlay were 5% and 16% respectively from 1980 to 1986. The great majority of ears examined showed a residual air-bone-gap of 0 to 20 dB in the frequency range between 0.5 and 2 kHz. Our audiometric results were essentially the same in 1984 and 1986.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aluminum oxide ceramic implants (Tübigen type) in middle ear surgery. Report of clinical experiences]. / Aluminiumoxid-Keramik-Implantate (Typ Tübingen) in der Mittelohrchirurgie. Klinischer Erfahrungsbericht.

Since 1980 we have used Tübingen middle ear implants of aluminum oxide in some reconstructions of the ossicular chain. So far such implants have been inserted in 129 operations on 106 patients. Follow-up examinations have been performed on 108 ears (91 patients). Post-operative observation periods have varied from 6 to 46 months, with an average duration of 22 months. In the last two years, since observing the first extrusions and imminent extrusions of implants, we have begun inserting a small autologous cartilage-perichondrium disk between implant and eardrum. Follow-up examinations have shown that insertion of cartilage lowers the rates of extrusion and imminent extrusion. It should be noted, however, that the average observation period for implants with cartilage has been somewhat shorter than for those without cartilage. Good audiometric results have been obtained with Al2O3-ceramic implants. Moreover, insertion of a cartilage-perichondrium disk demonstrably contributes to an improvement of audiometric results. As our clinical study shows, an Al2O3-ceramic implant is quite suitable for reconstructive surgery of the ossicular chain when an alloplastic implant is needed. At the same time we strongly advise insertion of a cartilage-perichondrium disk between the eardrum and the implant.

Mastoid development in ancient and modern populations. A longitudinal radiological study.

The effect of otitis media on the human mastoid process in a common milieu over a millennium was evaluated by comparing two present and four ancient populations. Temporal bone pneumatization patterns indicate that otitis media and mastoiditis existed in antiquity, and there were more altered pneumatization patterns in skulls from the era following European contact than from eras before European contact. Pneumatization patterns were similar in ancient skulls and in a preponderantly white male population mostly born before antibacterial availability. Both ancient and modern pre-antibacterial era temporal bones show more effect of otitis media during childhood than is found in present day schoolchildren. Reasons for differences are explored. It is inferred that upper respiratory tract infections were prevalent in the Upper Missouri River Basin during the past millennium. Furthermore, microbiological agents with virulence similar to today's flora were prevalent in this region more than 1,000 years ago.