Quality of life after cholesteatoma surgery: comparison between surgical techniques.

Objective: To evaluate the long-term quality of life (QoL) in patients operated for cholesteatoma by canal wall-up tympanoplasty (CWUT) or canal wall-down tympanoplasty (CWDT) with mastoid obliteration. Methods: QoL was evaluated by the Chronic Otitis Media Questionnaire - 12 (COMQ-12). For each patient, the total score and three partial subscores, concerning disease activity, functional impairment and general impact on the patient's life were calculated. These scores were correlated with the surgical technique, as well as anatomical and functional results. Results: 68 procedures were classified as CWUT and 78 as CWDT with obliteration. The mean follow-up was 65 months. Total and partial COMQ-12 scores did not show any significant difference between the two groups. Correlation analysis showed a significant direct association between the postoperative Air-Bone Gap (ABG) and both the COMQ-12 total score and functional subscore in the CWUT group. Conclusions: This is the first study comparing CWUT and CWDT with obliteration with the COMQ-12, thus confirming the overlapping results in terms of QoL. These findings, together with the evidence of the significantly lower rates of recidivism, show that CWDT with obliteration should be considered as a good alternative to CWUT.

Pilot Study Assessing the Feasibility and Clinical Outcomes of Office-Based Ossiculoplasty.

OBJECTIVES:: The aim of this study was to assess the feasibility and safety of ossiculoplasty under local anesthesia in an office setting without sedation. METHODS:: Between May 2017 and November 2017, patients who presented with conductive hearing loss and known isolated ossicular discontinuities were offered ossiculoplasty under local anesthesia. Inclusion criteria included age ⩾ 18 years, adequate transcanal access, and the ability to lie supine for up to 45 minutes. Exclusion criteria included associated tympanic membrane perforation and the presence of middleear or mastoid cholesteatoma or infection. RESULTS:: Fourteen patients underwent the procedure. The mean age was 48.3 years (range, 19-74 years). Six were primary and 8 revision cases. There were 8 partial and 6 total prosthesis placements. The mean operative time was 34 minutes (range, 26-43 minutes). All patients tolerated the procedure to completion. There were no intraoperative complications. The mean air conduction pure-tone average was 76.6 dB and the mean bone conduction pure-tone average was 27.2 dB, with a preoperative air-bone gap of 49.9 dB. Air conduction pure-tone average significantly improved to 45.2 dB ( P < .0001). Air-bone gap significantly improved to 17.8 dB ( P < .0001). CONCLUSIONS:: Ossiculoplasty using partial or total prostheses can be safely performed in the office setting under local anesthesia without sedation in carefully selected patients. This has potentially significant patient and system benefits.

Discordancia clínica-gammagráfica en un caso de otitis externa maligna / Clinical-scintigraphy discordance in a case of malignant external otitis

Presentamos el caso de una paciente inmmunodeprimida, que desarrolló un cuadro de otitis externa con pobre respuesta al tratamiento convencional y posterior aislamiento de Pseudomona Aeruginosa en el cultivo de secreción ótica. El diagnóstico definitivo fue de otitis externa maligna. Nuestro objetivo es describir los hallazgos gammagráficos y analizar su correlación con los hallazgos clínico-quirúrgicos y valorar las posibles causas de la discordancia encontrada(AU)

We report the case of an immunocompromised female patient with external otitis, who developed a picture of external otitis with poor response to conventional treatment and subsequent isolation of Pseudomona Aeruginosa in the ear secretion culture. The final diagnosis was malignant external otitis. Our objective is to describe the scintigraphic findings as well as to analyze their correlation with the clinical pattern and to evaluate the possible causes of the discordance found(AU)

Predictors of surgical and hearing long-term results for inlay cartilage tympanoplasty.

OBJECTIVE: To determine the prognostic factors that affect surgical and audiologic outcomes in inlay tympanoplasty after long-term follow-up. DESIGN: Case series study. SETTING: Tertiary referral center. PATIENTS: Sixty-two patients who underwent 71 procedures were enrolled in the study. Patient ages ranged from 31 to 87 years (mean [SD] age, 61.2 [12.9] years). Mean (SD) follow-up was 635.7 (284.7) days. The inclusion criteria were (1) inlay cartilage tympanoplasty performed using local anesthesia via a transcanal route, (2) chronic otitis media with stable perforation, and (3) dry ear without middle ear disease. MAIN OUTCOME MEASURES: The success rate and hearing change at the last follow-up visit. RESULTS: The overall success rate was 87.3% at the last visit. Using multivariate analysis, sex, age, size of perforation, side of perforation, and the presence of diabetes mellitus and external auditory canal otomycosis did not affect the success. Smoking was the only independent factor for the prognosis of surgical outcome (odds ratio [OR], 8.16; 95% confidence interval [CI], 1.74-36.89; P < .006). On the other hand, age (OR, 6.62; 95% CI, 1.13-38.47; P = .03) and perforation size (OR, 0.11; 95% CI, 0.10-0.79; P = .03) were independent factors for the prognosis of audiologic outcomes. CONCLUSIONS: The frequency of failure was significantly higher for smokers than for nonsmokers. To quit smoking is highly recommended preoperatively for individuals scheduled for chronic otitis media inlay tympanoplasty intervention. Younger patients and those with larger perforations (>50%) were more likely to benefit from this operation.

[Round window's movability measurements with helping of LDV in evaluation of ossicular chain functioning]. / Przydatnosc badania ruchomosci okienka okraglego za pomoca laser Doppler Vibrometer w ocenie rekonstrukcji lancucha kosteczek sluchowych w tympanoplastykach typu zamknietego.

UNLABELLED: Round window's movability measurements with helping of LDV in evaluation of ossicular chain functioning. AIM OF STUDY: Quantitive evaluation of round window movability in normal conditions and after malleus stapes assembly reconstruction were aims of the study. METHODS AND MATERIALS: In the experiment there were taken 10 non-frozen temporal bones harvested within 48 hours. Temporal bones specimens were prepared like in closed technique with antromastoidectomy and large posterior tympanotomy. Hearing system before and after MSA reconstruction were evaluated by measurement of round window movement. Measurements were performed at four frequencies: 1000 Hz, 2000 Hz, 4000 Hz, 8000 Hz. RESULTS: In the normal ossicular chain the biggest movability were stated at frequency of 1 kHz. After reconstruction at all frequencies measurements were significantly worse. In reconstructed ears the highest movabilities were stated at frequencies 2000 Hz and 4000 Hz. CONCLUSIONS: Round window movability could be measured by Laser Doppler Vibrometry in posterior tympanotomy approach. Before reconstruction the biggest movability were evaluated at 1000 Hz and after MSA at 2000 Hz

Motion of the tympanic membrane after cartilage tympanoplasty determined by stroboscopic holography.

Stroboscopic holography was used to quantify dynamic deformations of the tympanic membrane (TM) of the entire surface of the TM before and after cartilage tympanoplasty of the posterior or posterior-superior part of the TM. Cartilage is widely used in tympanoplasties to provide mechanical stability for the TM. Three human cadaveric temporal bones were used. A 6 mm x 3 mm oval cartilage graft was placed through the widely opened facial recess onto the medial surface of the posterior or posterior-superior part of the TM. The graft was either in contact with the bony tympanic rim and manubrium or not. Graft thickness was either 0.5 or 1.0mm. Stroboscopic holography produced displacement amplitude and phase maps of the TM surface in response to stimulus sound. Sound stimuli were 0.5, 1, 4 and 7 (or 8)kHz tones. Middle-ear impedance was measured from the motion of the entire TM. Cartilage placement generally produced reductions in the motion of the TM apposed to the cartilage, especially at 4 kHz and 7 or 8 kHz. Some parts of the TM showed altered motion compared to the control in all three cases. In general, middle-ear impedance was either unchanged or increased somewhat after cartilage reconstruction both at low (0.5 and 1 kHz) and high (4 and 7 kHz) frequencies. At 4 kHz, with the 1.0mm thick graft that was in contact with the bony tympanic rim, the impedance slightly decreased. While our earlier work with time-averaged holography allowed us to observe differences in the pattern of TM motion caused by application of cartilage to the TM, stroboscopic holography is more sensitive to TM motions and allowed us to quantify the magnitude and phase of motion of each point on the TM surface. Nonetheless, our results are similar to those of our earlier work: The placement of cartilage on the medial surface of TM reduces the motion of the TM that apposes the cartilage. These obvious local changes occur even though the cartilage had little effect on the sound-induced motion of the stapes.

Retroauricular tympanoplasty and tympanomastoidectomy under local anesthesia and sedation.

CONCLUSION: Retroauricular tympanoplasty and tympanomastoidectomy under local anesthesia with sedation can be well tolerated by the patient, with minimum discomfort. OBJECTIVES: To evaluate patient discomfort from pain, body/neck position, noise, and anxiety during tympanoplasties and mastoidectomies performed under local anesthesia with sedation. PATIENTS AND METHODS: This was a prospective study of 83 surgeries in 62 patients (28 type I tympanoplasties, 12 tympanoplasties with ossicular reconstruction, 40 canal wall up mastoidectomies, and 3 revision tympanoplasties). Local infiltration used lidocaine 2% with 1:100 000 epinephrine infiltrated in the retroauricular area and from below the pinna in a 'V' pattern. Sedation was achieved with 50 mg of intramuscular promethazine 1 h before surgery and intravenous midazolam (0.03 mg/kg) at the beginning of surgery. Subsequent doses of midazolam were given to maintain adequate sedation, up to 10 mg. The discomfort during surgery was assessed by the patient with a score from 0 to 4 (0 = no discomfort and 4 = extreme discomfort). RESULTS: Discomfort due to pain had a mean score of 0.83. Noise discomfort (from drilling and manipulation of instruments) had the lowest mean score (0.70), and discomfort from body and neck position had the highest mean score (1.51).

Effect of ciprodex on graft healing in tympanoplasty.

The present study was conducted to evaluate whether the administration of ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex)-soaked gelfoam during tympanoplasty has adverse effects on graft healing. Records of patients who had undergone tympanoplasty with Ciprodex-soaked gelfoam packing placed in the middle and external ear canal were reviewed. The time to heal for each patient and the number of postoperative perforations/complications were recorded. Sixty-four charts met the inclusion criteria. Most procedures were primary type I tympanoplasties with temporalis fascia grafts. Healing of the tympanic membrane was documented in 95.3% of patients, and mean time to healing was 49 d. Two patients who underwent revision tympanoplasty failed to exhibit healing at any visit after surgery. Postoperative complications were infrequent. Patients with Ciprodex-soaked gelfoam packing placed during tympanoplasty showed an overall rate of healing of 95%. Although this study is limited by its retrospective design, the data suggest that the use of Ciprodex during tympanoplasty has no detrimental effect on postoperative graft healing.

Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the original pathogen.

OBJECTIVES: (1) To determine the relationship between acute otitis media (AOM) pathogens isolated in cases of early clinical recurrence of AOM (occurring within 1 month from completion of therapy) to the original pathogens causing the initial AOM episode; and (2) To determine whether shorter time intervals between completion of antibiotic therapy and clinical recurrences of AOM are associated with higher rates of true bacteriologic relapse. PATIENTS AND METHODS: From 1995 through 2000, 1077 infants and young children ages 3 to 36 months with AOM were enrolled in double tympanocentesis (performed on Day 1 in all patients and Days 4 to 6 in those initially culture-positive) studies. Of these, 834 (77%) completed successfully the antibiotic treatment [pathogen eradication on Days 4 to 6 of therapy or no pathogen on middle ear fluid (MEF) culture on Day 1 and clinical improvement at end of therapy]. Patients were followed for 3 to 4 weeks after completion of therapy, and additional MEF cultures were obtained if clinical recurrence occurred. True bacteriologic relapse was defined as the presence of a pathogen identical with that isolated before therapy by serotype and pulsed field gel electrophoresis for and by pulsed field gel electrophoresis for Streptococcus pneumoniae and beta-lactamase production for Haemophilus influenzae. RESULTS: MEF cultures were performed in 108 consecutive patients with early recurrent AOM. One hundred pathogens were isolated at recurrence in 88 of 108 (81%) patients: 54 H. influenzae; 45 S. pneumoniae; and 1 Moraxella catarrhalis. Most recurrent AOM episodes developed during the first 2 weeks of follow-up; 39 (36%), 38 (35%), 21 (19%) and 10 (9%) recurrent AOM episodes occurred on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively. In most patients these episodes were caused by a new pathogen. True bacteriologic relapses were found in 30 (28%) of 108 patients whose MEF cultures were positive for 35 pathogens: 13 of 108 (12%) S. pneumoniae; 12 of 108 (11%) H. influenzae; and 5 of 108 (5%) both. When timing of recurrent AOM after completion of therapy was analyzed, true bacteriologic relapses were found in 16 of 39 (41%), 10 of 38 (26%), 3 of 21 (14%) and 1 of 10 (10%) of all episodes on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively (P = 0.01). The respective rates for were 11 of 17 (65%), 3 of 10 (30%), 3 of 13 (23%) and 1 of 5 (20%) (P = 0.02). For H. influenzae the respective rates were 8 of 19 (42%), 9 of 23 (39%), 0 of 8 (0%) and 0 of 4 (0%) (P = 0.02). CONCLUSIONS: Most recurrent AOM episodes occurring within 1 month from completion of antibiotic therapy are in fact new infections. Most of the true bacteriologic AOM relapses occur within 14 days after completion of therapy, but even during this time interval most of the recurrences are caused by new pathogens. H. influenzae is very unlikely to cause true bacteriologic AOM relapses 14 days or later after completion of therapy.

Bone cements as adjuvant techniques for ossicular chain reconstruction.

HYPOTHESIS: The osseointegrative capacity of medical-grade bone cement can be used to improve fixation and prevent displacement of an ossicular prosthesis in a guinea pig model. BACKGROUND: Successful ossiculoplasty requires a firm connection between the vibrating tympanic membrane and the inner ear. In patients requiring revision ossiculoplasty, half of failures are due to prosthesis displacement. Bone cements have been used as prosthetic material in craniofacial surgery, and their adhesive and osseointegrative properties make them ideal for use in ossicular reconstruction. METHODS: Twenty-four adult male guinea pigs underwent a postauricular surgical approach for access to the middle ear. Hydroxyapatite and Dahllite cements were used in an alternating fashion to fix ossicular bone. Four animals were killed immediately to demonstrate mechanical bonding of the ossicles at the time of application. Nineteen animals were killed 8 weeks postoperatively to assess bonding capacity and histologic inflammation. RESULTS: Both cements mechanically bonded the ossicles at the time of application, but Dahllite cement set faster in the moist environment of the middle ear space. Histologic examination showed bonding of the ossicles with both cements, with little evidence of inflammation or foreign body reaction. CONCLUSIONS: Hydroxyapatite and Dahllite bone cements showed evidence of osseointegration with ossicular bone in the guinea pig model. Further studies are under way to determine the osseointegrative capacity of Dahllite cement between the guinea pig malleus and a partial prosthesis, and any ototoxic effects with use in the middle ear.

Experimental investigations of the use of cartilage in tympanic membrane reconstruction.

BACKGROUND: Temporalis fascia, perichondrium, and cartilage are commonly used for reconstruction of the tympanic membrane in middle ear surgery. Cartilage grafts offer the advantage of higher mechanical stability, particularly in cases of chronic tubal dysfunction, adhesive processes, or total defects of the tympanic membrane, in contrast to fascia and perichondrium, which presumably offer better acoustic quality. HYPOTHESIS: The purpose of this study was to determine the acoustic transfer characteristics of cartilage of varying thickness and its mechanical deformation when exposed to fluctuations in atmospheric pressure. METHOD: Ten pairs of cartilage specimens from the cavum conchae and the tragus were obtained from fresh human cadavers. Young's modulus was determined by mechanical tension tests and statistically evaluated using the t test. The acoustic transfer characteristics of an additional 10 specimens were measured by a laser Doppler Interferometer after stimulation with white noise in an external auditory canal--tympanic membrane model. Mechanical stability was determined by measuring displacement of the cartilage using static pressure loads of < or = 4 kPa. RESULTS: Young's modulus determinations for conchal and tragal cartilage were 3.4 N/mm2 and 2.8 N/mm2, respectively, but the difference was not significant. Acoustic testing showed a 5-dB higher vibration amplitude in the midfrequency range for conchal compared with tragal cartilage, but the difference was not significant. Reducing cartilage thickness led to an improvement of its acoustic transfer qualities, with a thickness < or = 500 microm resulting in an acceptable acoustic transfer loss compared with the tympanic membrane. CONCLUSION: Both conchal and tragal cartilage are useful for reconstruction of the tympanic membrane from the perspective of their acoustic properties. The acoustic transfer loss of cartilage can be reduced by decreasing its thickness. A thickness of 500 microm is regarded as a good compromise between sufficient mechanical stability and low acoustic transfer loss.

Experimental use of fibrin tissue adhesive in middle ear surgery.

The biocompatibility of a new tissue adhesive was tested. Its major advantages are adhesions, hemostasis, and the promotion of wound healing. In experimental surgery on 43 middle ears of chinchillas, documented by histological evidence obtained 45 days after operation, the validity of the following two hypotheses was established. That fibrin tissue adhesive placed upon the footplate of the stapes is biologically compatible, biodegradable and does not cause toxic, inflammatory or foreign body reactions, or other tissue damage to middle ear structures. That a small piece of bone glued on the long process of the incus with fibrin tissue adhesive shows permanent tissue union. In addition, in cases where the inner ear was accidentally opened by surgically subluxating the stapes and adhesive was free to enter the vestibule, evidence was obtained that there was no damage to inner ear structures. This finding deserves further investigation.

The applicability of porous polyethylene for tympanoplasty; an animal experimental study.

The problem of a replacement material for the reconstruction of the posterior wall of the auditory canal, as well as for the obliteration of the radical cavity has not been solved satisfactor;ly so far. In order to examine the possible applicability of porous plastics, the posterior wall of the auditory canal of guinea pigs was first removed and then reconstructed using porous polyethylene and filling the bulla tympanica with fine polyethylene chips. One third of the animals had an infected middle ear at the time of implantation. Histologic assessments were made until 24 weeks after implantation. In 80% of the animals the implant settled well, even in cases where the middle ears had been originally infected. By proliferation of vessels and connective tissue, the polyethylene had almost been completely integrated into the surrounding tissue after one week. Extent and frequency of metaplastic osseous growth was greater inthe chip-filled bulla than in the reconstructedposterior wall(Fig. 9). After four weeks, the new osteoid substance was firmly connected with the regional bone (Fig. 4). According to these results, it would seem possible to use porous polyethylene even for the nonaseptic implant bed as it is found in the chronically infected middle ear.