Mongolian Gerbils as a Model for the Study of Cholesteatoma: Otoendoscopic as a Diagnostic Tool

Abstract Introduction Cholesteatoma is a disease with significant clinical impact but is incompletely understood. The challenge of performing studies with long-term follow-up in humans is a factor that has restricted the advance of knowledge in this field. Thus, the use of animal models is highly pertinent, and the Mongolian gerbil model has emerged as one of the most useful. Objective The present study aims to evaluate, through serial otoendoscopies, the development and characteristics of pars flaccida retraction pocket and cholesteatoma in Mongolian gerbils after obliteration of the eustachian tube and compare it with the control group. Methods Forty Mongolian gerbils were divided into two groups of 20 animals each. In the intervention group, the animals were followed with serial otoendoscopies after eustachian tube obliteration. In the control group, the animals were only followed through serial otoendoscopies. Results At the end of the 16-week follow-up, cholesteatoma was present in 13 of 38 (34.2%) ears in the intervention group, and in 7 of 34 (20.6%) in the control group (p = 0.197). When we considered cholesteatoma and its potential precursor, pars flaccida retraction pocket, in a combined way, we verified it in 23 of 38 (60.8%) in the intervention group and in 11 of 34 (32.3%) in the control group (p = 0.016). Conclusions Over the 16 weeks of follow-up, serial otoendoscopies enabled us to evaluate the formation and development of pars flaccida retraction pockets and cholesteatomas in Mongolian gerbils and proved to be an excellent diagnostic tool.

Mongolian Gerbils as a Model for the Study of Cholesteatoma: Otoendoscopic as a Diagnostic Tool.

Introduction Cholesteatoma is a disease with significant clinical impact but is incompletely understood. The challenge of performing studies with long-term follow-up in humans is a factor that has restricted the advance of knowledge in this field. Thus, the use of animal models is highly pertinent, and the Mongolian gerbil model has emerged as one of the most useful. Objective The present study aims to evaluate, through serial otoendoscopies, the development and characteristics of pars flaccida retraction pocket and cholesteatoma in Mongolian gerbils after obliteration of the eustachian tube and compare it with the control group. Methods Forty Mongolian gerbils were divided into two groups of 20 animals each. In the intervention group, the animals were followed with serial otoendoscopies after eustachian tube obliteration. In the control group, the animals were only followed through serial otoendoscopies. Results At the end of the 16-week follow-up, cholesteatoma was present in 13 of 38 (34.2%) ears in the intervention group, and in 7 of 34 (20.6%) in the control group ( p = 0.197). When we considered cholesteatoma and its potential precursor, pars flaccida retraction pocket, in a combined way, we verified it in 23 of 38 (60.8%) in the intervention group and in 11 of 34 (32.3%) in the control group ( p = 0.016). Conclusions Over the 16 weeks of follow-up, serial otoendoscopies enabled us to evaluate the formation and development of pars flaccida retraction pockets and cholesteatomas in Mongolian gerbils and proved to be an excellent diagnostic tool.

Residual Cholesteatoma After Endoscopic-Assisted Canal Wall-Up Tympanomastoidectomy: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to determine the effectiveness of using endoscopes in reducing recidivism secondary to residual cholesteatoma after canal wall-up tympanomastoidectomy. STUDY DESIGN: Randomized clinical trial. SETTING: Tertiary referral center. PATIENTS: Patients with cholesteatoma, aged 7 to 70 years. INTERVENTIONS: Subjects were randomly allocated into two groups: endoscopic-assisted canal wall-up (EACWU; group 1) and conventional canal wall-up (CWU; group 2) techniques. Pars flaccida and pars tensa subgroups were analyzed according to the anatomic location of cholesteatoma origin. MAIN OUTCOME MEASURES: Presence or absence of residual cholesteatoma, based on second look surgery, diffusion-weighted magnetic resonance imaging, or video-otoscopy at 12 and 18 months after surgery. RESULTS: In total, 57 ears were analyzed: 29 in group 1 and 28 in group 2. Group 1 revealed residual disease in 17.2% of ears, whereas group 2 had residual disease in 35.7% (p > 0.05) of the ears. In the pars tensa cholesteatoma subgroup, the incidence of residual disease was 13.3% for EACWU and 47.1% for the CWU technique (p < 0.05). A tendency of reduced incidence was observed for cholesteatoma due to residual disease using EACWU. In addition, a statistically significant reduction in the residual disease was observed in the subgroup of pars tensa cholesteatomas. In this subgroup, the relative risk was 0.28, and the number needed to treat was 4.6. CONCLUSION: The use of the endoscope reduces the incidence of recidivism secondary to residual disease in pars tensa cholesteatomas. Endoscopic-assisted surgery may be useful in cases with an indication for canal wall-up tympanomastoidectomy. LEVEL OF EVIDENCE: 1b.

Tympanic membrane perforations: a critical analysis of 1003 ears and proposal of a new classification based on pathogenesis.

PURPOSE: To present a large series ears with tympanic membrane perforations (TMP), to describe their characteristics, and to propose a new classification system based on the pathogenesis of TMP. METHODS: This cross-sectional study was conducted at a tertiary university hospital with 1003 ears (792 consecutive patients with TMP in at least 1 ear). Otoendoscopy and audiometry were performed. Perforation measurements and their locations were digitally assessed. TMP with no suggestive signs of previous retraction were classified as Group 1, and those with possible previous retraction were classified as Group 2. Signs of retraction previous to the TMP, symptom length, perforation size and location, status of the contralateral ear, and hearing status were compared. RESULTS: Group 1 comprised 63.5% of the included ears. Compared to Group 2, Group 1 presented a higher rate of central perforations (99% vs. 53%), a shorter duration of symptoms, smaller perforations (mean area: 18.5% vs. 41.4%), a higher rate of perforations in the anterior quadrants, better hearing levels (mean tritonal gap: 23.9 dB vs. 29.2 dB), and a lower rate of abnormal contralateral ears (28% vs. 66%). CONCLUSION: The classification of TMP into two groups based on signs of previous retractions is feasible and indicates two different levels of disease severity. While the group without previous signs of retraction comprises ears with more limited disease, membranes with previous retraction seem to show more severe disease and, consequently, a less functional middle ear.

Extended-Wear Hearing Technology: The Nonimplantables.

A new category of hearing technology has emerged that comprises devices inserted deep into the ear canal. Although not implanted, they represent an extension of what is expected of a traditional hearing aid. There are advantages to these devices, but they are not suited for all individuals with hearing loss. This category consists of 2 devices currently available in the United States: Lyric (Phonak AG, Stafa, Switzerland) and Earlens (Earlens, Menlo Park, CA, USA).

The Role of Tympanic Membrane Retractions in Cholesteatoma Pathogenesis.

OBJECTIVE: To analyze the contralateral ear (CLE) of patients with cholesteatoma and to correlate the cholesteatoma growth pattern in the affected ear with the findings in the CLE. METHODS: Videotoscopy of both ears in 432 patients with cholesteatomas classified as posterior epitympanic (PEC), posterior mesotympanic (PMC), two routes, or undetermined. Tympanic membrane (TM) retractions were classified by location and severity and TM perforations according to signs of previous TM retraction. RESULTS: TM retraction was the most prevalent alteration in the CLE (42.6%). Cholesteatoma was observed in 17.4%. In patients with PEC, the retraction in the CLE was more frequent in the PF (66.7%) than in the PT (1.4%), and in those with two-route cholesteatoma, the retraction in the CLE most frequently involved both the PT and PF (65.6%; p < 0.0001). CONCLUSION: Our results confirm the essential role of TM retraction at least in the earlier phases of cholesteatoma pathogenesis.

Implantation of Bone-Anchored Hearing Devices Through a Minimal Skin Punch Incision Versus the Epidermal Flap Technique.

OBJECTIVE: To compare the minimal skin punch incision without additional skin incision or soft tissue reduction with the epidermal flap technique and soft tissue reduction, for the implantation of percutaneous bone-anchored hearing devices. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care referral center. SUBJECTS AND METHODS: Two hundred seventeen patients underwent 220 implantations. Sixty five cases underwent implantation by means of a skin punch resection without soft tissue reduction (punch group) and 155 cases underwent epidermal flap and soft tissue reduction (dermatome group). Main outcome measures were duration of surgery, perioperative adverse events, skin tolerance, and revision surgery. RESULTS: The duration of surgery was shorter in the punch group (p < 0.001). The percentage of normal to moderate skin reactions, by Holgers classification, was higher in the punch group (90%) than in the dermatome group (84%). No severe reactions occurred in the punch group, but did occur in 7% in the dermatome group. These differences, although clinically important, did not reach statistical significance (p = 0.071). The rate of revision surgeries was not significantly different between the two groups. The indication for revision was different: mainly for skin issues in the dermatome group, against implant dislocation in the punch group. CONCLUSION: The implantation of the currently available percutaneous bone-anchored hearing implants with a minimal skin punch resection shortened duration of surgery and improved postoperative appearance, while preserving a good skin tolerance. In the punch group, there were less skin issues leading to revision surgery, however we did observe more implant dislocations needing revision surgery.

Decision making in patients with natural myringostapediopexy: A study of the contralateral ear.

Naturally occurring myringostapediopexy frequently results in minimal hearing loss and is asymptomatic. Management decisions in such ears, however, often hinge on an appraisal of evolution toward cholesteatoma. The study of the contralateral ear has been used by our research team to infer the progression of chronic otitis media. This cross-sectional, comparative study describes the clinical findings of the contralateral ear in a series of patients with myringostapediopexy. This study included a historical and current sample of 46 patients divided into a pediatric (≤18 years) and an adult group. Patient distribution according to sex was similar (52.2% male), and 56.5% were adults. Mean conductive hearing loss ranged from 14.1 to 21.2 dB in ears with myringostapediopexy and from 16.0 to 26.6 dB in the contralateral ears according to the frequency assessed. The contralateral ear was normal in only 19.6% of the cases of myringostapediopexy. Central tympanic membrane perforation was found in 6.5% of the cases; perforation-retraction, in 17.4%; moderate or severe retraction, in 28.3%; and cholesteatoma, in 28.3%. The prevalence of cholesteatoma in the contralateral ear in the pediatric and adult groups was not significantly different (p = 0.5; χ(2) test). The presence of significant abnormalities, particularly cholesteatoma, in the contralateral ears suggests a probable unfavorable progression in cases of myringostapediopexy and may influence management decisions.

Punch and Drill: Implantation of Bone Anchored Hearing Device Through a Minimal Skin Punch Incision Versus Implantation With Dermatome and Soft Tissue Reduction.

OBJECTIVE: To compare 2 surgical techniques for implantation of a percutaneous bone anchored hearing device: (1) a minimal skin punch incision without additional skin incision or soft tissue reduction and (2) implantation with an epidermal flap and soft tissues reduction. STUDY DESIGN: Prospective study. SETTING: Tertiary care referral center. SUBJECTS AND METHODS: Forty patients consecutively implanted (18 males and 22 females). Twenty patients underwent implantation by means of epidermal flap and soft tissues reduction (dermatome group), and 20 patients underwent skin punch resection without soft tissues reduction (punch group). MAIN OUTCOME MEASUREMENTS: surgical adverse events, surgical time, skin healing, skin tolerance (Holgers classification), and skin appearance and implant failure. RESULTS: The surgical time was shorter with the punch technique (P < .05). The postoperative healing was satisfactory in both groups. All implants were loaded after the healing period. The skin tolerance was good in both groups by Holgers classification (punch, 85.7%/dermatome, 86%) with no significant difference. There were no severe adverse skin events in the punch group. The appearance of the skin around the implant was improved by the punch technique. CONCLUSION: The implantation of the currently available percutaneous bone anchored hearing implants with a minimal skin punch skin resection without additional skin incision or soft tissue reduction shortens the surgery and improves the postoperative appearance. The skin tolerance is at least as good as with techniques with that include soft tissue reduction.

Early postoperative results in stapedectomy.

OBJECTIVE: To measure early audiometric changes after primary stapedotomy. STUDY DESIGN: Case series with chart review. SETTING: Academic inner-city hospitals. SUBJECTS AND METHODS: Consecutive patients operated on by the first author were included (only 1 ear in cases of bilateral surgery), and their audiometric results were reviewed. Data were analyzed from 45 ears. Air and bone audiometric measures were analyzed from 5 days post operation and 6 months post operation. Threshold shifts were quantified at 5 days and 6 months post operation. RESULTS: Overall results for the group were good, with 91% of patients achieving an air-bone gap less than or equal to 10 dB by 6 months post operation. Threshold shifts in at least 1 frequency were common at 5 days (62% of patients), but less so at 6 months (36%). Patients with shifts did not have worse overall outcomes at 6 months than those with no shifts. No difference in results was observed for the 2 prostheses used in this series. CONCLUSION: Early audiometric results after stapedectomy commonly reveal worsened bone conduction (postoperative threshold shifts), which may reflect cochlear trauma, but do not lead to poorer outcomes as measured by conventional methods.

Ossiculoplasty in missing malleus and stapes patients: experimental and preliminary clinical results with a new malleus replacement prosthesis with the otology-neurotology database.

OBJECTIVE: To present the preliminary results of new malleus replacement prosthesis combined with a total ossicular prosthesis in middle ear reconstruction in patients missing the malleus and stapes. STUDY DESIGN: Prospective experimental and nonrandomized clinical study. SETTING: Tertiary referral center. METHODS: An original titanium malleus replacement prosthesis (MRP) was designed to be inserted into the external auditory canal and to replace a missing malleus for various middle ear pathologies. The MRP was tested experimentally and clinically. The vibratory properties of the new prosthesis were measured using laser Doppler vibrometry. Ninety patients with missing malleus and stapes, undergoing 92 ossicular reconstructions were enrolled in this study from September 1994 to March 2012. Comparative analyses were made between a group of 34 cases of ossicular reconstructions with total prosthesis (TORP) positioned from the tympanic membrane to the stapes footplate (TM-to-footplate assembly) and a group of 58 cases of ossicular reconstructions with TORP positioned from a newly designed malleus replacement prosthesis (MRP) to the stapes footplate (MRP-to-footplate assembly). Preoperative and postoperative audiometric evaluation using conventional audiometry, that is, air-bone gap (ABG), bone-conduction thresholds (BC), and air-conduction thresholds (AC) were assessed. RESULTS: Experimentally, the vibratory properties of the MRP are promising and remain very good even when the MRP is cemented into the bony canal wall mimicking its complete osseous-integration, if this were to occur. This finding supports the short-term clinical results as in the TM-to-footplate group; the 3-month postoperative mean ABG was 23.3 dB compared with 12.5 dB in the MRP-to-footplate group (difference, 10.8; 95% confidence interval, 4.0-17.6); 37.0% of patients from the TM-to-footplate group had a postoperative ABG of 10 dB or less, and 48.1% of patients had a postoperative ABG of 20 dB or less, as compared with 58.1% and 79.1%, respectively, in the MRP-to-footplate group. The average gain in AC was 11.0 dB in the TM-to-footplate group as compared with 21.3 dB in the MRP-to-footplate group (difference, -10.3; 95% confidence interval, -18.2 to -2.4). CONCLUSION: The results of this study indicate that superior postoperative hearing thresholds could be achieved using a MRP-to-footplate assembly, compared with a TM-to-footplate assembly in patients with an absent malleus undergoing ossiculoplasty. The postoperative AC thresholds, after 3 months and 1 year, are significantly lower in patients treated with the MRP-to-footplate assembly.

Diagnostic and prognostic utility of measuring tumor necrosis factor in the peripheral circulation of patients with immune-mediated sensorineural hearing loss.

OBJECTIVES: To characterize levels of tumor necrosis factor (TNF; formerly known as tumor necrosis factor α), a well-established proinflammatory cytokine, in patients with immune-mediated sensorineural hearing loss (IM-SNHL) and to determine the role of this cytokine in identifying steroid-responsive hearing loss. DESIGN: Prospective case-control study. SETTING: Tertiary care academic medical center. PATIENTS: A total of 11 control subjects and 85 patients with clinical and audiometric characteristics of IM-SNHL (autoimmune inner ear disease and sudden SNHL combined) treated with corticosteroids were enrolled in the study. Patients were categorized as steroid responders (n = 47) and steroid nonresponders (n = 38). Peripheral venous blood was used to determine the total amount of plasma TNF by enzyme-linked immunosorbent assay. Peripheral blood mononuclear cells (PBMCs) were isolated and treated with in vitro dexamethasone. Treated and untreated PBMCs were then analyzed for release of soluble TNF protein into conditioned supernatants as well as expression of TNF messenger RNA (mRNA). MAIN OUTCOME MEASURES: Mean plasma levels of TNF, unstimulated and dexamethasone-stimulated PBMC-secreted levels of TNF, and TNF mRNA levels in unstimulated and dexamethasone-stimulated PBMCs. RESULTS: Steroid nonresponders had the highest mean baseline plasma levels of TNF compared with steroid responders and control subjects (27.6, 24.1, and 14.4 pg/mL, respectively) (P = .03). For patients with IM-SNHL with a high baseline plasma levels of TNF (>14.4 pg/mL), the mean TNF secreted by PBMCs was 59.1 pg/mL, which decreased to 7.2 pg/mL with in vitro dexamethasone stimulation in the responder group, while the mean TNF secreted by PBMCs was 11.2 pg/mL, which slightly increased to 11.7 pg/mL with in vitro dexamethasone stimulation in the nonresponder group (P = .04). CONCLUSIONS: The level of TNF can be used as both a diagnostic and prognostic cytokine for IM-SNHL. For patients presenting with a sudden change in hearing threshold, a high baseline plasma TNF from the peripheral circulation is supportive of the diagnosis if it is greater than 18.8 pg/mL, with a positive predictive value higher than 97%. In addition, this study demonstrates that for patients with IM-SNHL and high plasma levels of TNF, their clinical response to oral glucocorticoids can be predicted by their in vitro PBMC response to dexamethasone. This algorithm may further guide optimal medical treatment and possibly avoid the deleterious adverse effects of administering glucocorticoids to those patients who would not benefit from their effect.

KTP versus CO2 laser fiber stapedotomy for primary otosclerosis: results of a new comparative series with the otology-neurotology database.

OBJECTIVE: To compare the 3-month postoperative hearing results after laser stapedotomy using a flexible potassium titanyl phosphate (KTP) or CO2 laser fiber in patients with primary otosclerosis. STUDY DESIGN: Prospective nonrandomized clinical study. SETTING: Tertiary referral center, 862 stapedotomies were performed in 818 study patients between November 2006 and July 2011. METHODS: Otosclerotic stapes fixation was treated with flexible KTP laser fiber in 410 patients (431 stapedotomies) and with flexible CO2 laser fiber in 408 patients (431 stapedotomies). Their preoperative and postoperative audiometric results were compared.Logistic regression analyses were performed to evaluate the main effect of laser fiber type and the effect after adjustment for independent predictors of a postoperative air-bone gap (ABG) 10 dB or lower. RESULTS: In the KTP laser group, the mean postoperative ABG was 4.3 dB compared with 3.1 dB in the CO2 group (difference, 1.1; 95% confidence interval, 0.4-1.9). In 90.4% of the patients in the KTP group, the postoperative ABG was 10 dB or lower, as compared with 96.5% in the CO2 group. The mean postoperative ABG at 4 KHz was 5.4 dB with KTP and 2.2 dB with CO2 (difference, 3.2; 95% confidence interval, 2.2-4.2). Sensorineural hearing loss was reported by 1 patient with KTP laser (0.3%) and by none with CO2 laser. "Type of laser" and "sex" were independent predictors of ABG 10 dB or lower. The chance to achieve a postoperative ABG 10 dB or lower for male subjects is 95%, when treated with CO2 laser and 85% when treated with KTP laser. For female subjects, these chances are 97% and 94%, respectively. CONCLUSION: The use of the CO2 laser fiber may be associated with better hearing results than the KTP laser fiber, regarding the ABG closure within 10 dB.

Ossiculoplasty in intact stapes and malleus patients: a comparison of PORPs versus TORPs with malleus relocation and Silastic banding techniques.

OBJECTIVES: To compare hearing results in patients undergoing ossiculoplasty using either partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) with Silastic banding and malleus relocation techniques in cases with malleus and stapes both present and mobile. STUDY DESIGN: Prospective nonrandomized clinical study. SETTING: Tertiary referral center. METHODS: Five hundred eighty-five patients undergoing ossiculoplasty were enrolled in this study from April 1991 to May 2010. Comparative analyses were made between a group of 304 patients who underwent ossiculoplasty with partial prosthesis positioned from the malleus to the stapes head and 281 patients who underwent ossiculoplasty with total prosthesis positioned from the malleus to the stapes footplate. Preoperative and postoperative audiometric evaluation using conventional audiometry, that is, air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were assessed. RESULTS: In the PORP group, the mean postoperative ABG was 13.1 dB compared with 8.9 dB in the TORP group, (95% confidence interval [CI], 2.2-6.2 dB; p ≤ 0.001). Fifty-four percent of patients from the PORP group had a postoperative ABG of 10 dB or less, compared with 68.9% in the TORP group (mean difference, 14.6%; 95% CI, 6%-23%; p < 0.001). The postoperative ABG was closed to within 20 dB in 70.4% of cases in the PORP group compared with 86.9% in the TORP group (mean difference, 14.5%; 95% CI, 10%-23%; p < 0.001). CONCLUSION: In patients with an absent incus and intact stapes and malleus, ossicular reconstruction with TORP combined with our malleus relocation and Silastic banding technique results in significantly better hearing outcomes compared with reconstructions with PORP.

Revision stapedotomy: operative findings and hearing results. A prospective study of 652 cases from the Otology-Neurotology Database.

OBJECTIVE: To identify the causes of failure of primary stapes surgery and to evaluate the hearing results of revision stapes surgery in a consecutive series of 652 cases. STUDY DESIGN: Prospective nonrandomized clinical study. SETTING: Tertiary referral center. PATIENTS: Six hundred thirty-four patients who underwent 652 consecutive revision stapes operations from April 1992 to December 2007 were enrolled in this study. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric evaluation using conventional audiometry, namely, air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds, were assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 15 years. RESULTS: The most frequently identified reason for primary surgery failure was incus erosion (27.6%) and prosthesis displacement (18.2%). The postoperative ABG was closed to 10 dB or less and 20 dB or less in 63.4 and 74.6% of cases, respectively. The mean 4-frequency postoperative ABG was 11.5 dB as compared with 28 dB preoperatively (mean difference, 16.5 dB; 95% confidence interval [CI], 15.1-17.9 dB, p < 0.0001). The mean 4-frequency postoperative air-conduction thresholds were 45.7 dB compared with 58.7 dB preoperatively (mean difference, 13 dB; 95% CI, 11.4-14.6 dB, p < 0.0001). The mean 4-frequency postoperative bone-conduction thresholds were 34 dB compared with 30.6 dB preoperatively (mean difference, -3.5 dB; 95% CI, -4.4 to -2.5 dB, p < 0.0001). A significant postoperative sensorineural hearing loss (>15 dB) was observed in 2.9% of cases in this series. CONCLUSION: Improvement of a conductive hearing loss after initial unsuccessful primary or revision stapes surgery can be accomplished with further revision but is occasionally modest.

A nonrandomized comparison of potassium titanyl phosphate and CO2 laser fiber stapedotomy for primary otosclerosis with the otology-neurotology database.

OBJECTIVES/HYPOTHESIS: To compare short-term hearing results in patients undergoing laser stapedotomy for primary otosclerosis using either the flexible potassium titanyl phosphate (KTP) or CO(2) laser fiber. STUDY DESIGN: Prospective nonrandomized clinical study at a tertiary referral center. METHODS: Two hundred fourteen patients undergoing 214 stapedotomies for otosclerotic stapes fixation were enrolled in this study from January 2008 to January 2010. Comparative analyses were made between a group of 107 patients who underwent stapedotomy with the flexible KTP laser fiber and 107 patients who underwent stapedotomy with the flexible CO(2) laser fiber. Preoperative and postoperative audiometric evaluation at 3 months using conventional audiometry, namely, air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds, were assessed. RESULTS: In the KTP laser group the postoperative ABG was 4.3 dB compared to 3 dB in the CO(2) group, which is a mean difference of 1.3 dB (95% confidence interval [CI], -0.3 to 2.8; P = .10). Of the patients from the KTP group, 92% had a postoperative ABG of 10 dB or less, as compared to 97% in the CO(2) group (mean difference 5%; 95% CI, -10 to 1; P = .14). The postoperative ABG at 4 kHz was 4.9 dB in the KTP and 2.2 dB in the CO(2) group, which is a mean difference of 2.7 dB (95% CI, 0.6-4.7, P = .01). No sensorineural hearing loss was reported. CONCLUSIONS: The use of the CO(2) laser fiber appears to be associated with slightly better hearing results than the KTP laser fiber, especially when assessed at the 4 kHz frequency.

The contralateral ear in chronic otitis media: a series of 500 patients.

OBJECTIVE: To study the contralateral ear of patients with chronic otitis media (COM). DESIGN: Transversal. SETTING: Tertiary referral center. PATIENTS: A total of 500 consecutive patients who had been diagnosed as having COM with or without cholesteatoma. INTERVENTIONS: Digital otoendoscopy was performed on both ears. MAIN OUTCOME MEASURE: Pathologic alterations in the contralateral ear. RESULTS: In 75.2% of the patients, the contralateral ear was found to have some structural abnormalities; 60.4% of the patients presented with COM without cholesteatoma, and in this group, 69.9% had an abnormal contralateral ear. In those with cholesteatoma, the contralateral ear was found to be abnormal in 83.3%. The most frequent finding in both groups was retraction of the tympanic membrane. CONCLUSIONS: Patients with COM in 1 ear have a high chance of presenting with some degree of disease in the contralateral side. We believe that our findings suggest that COM should be ideally approached not as a static pathological incident affecting 1 ear but rather as an on-going process that may affect both ears.

Surgical findings and long-term hearing results in 3,050 stapedotomies for primary otosclerosis: a prospective study with the otology-neurotology database.

OBJECTIVE: To evaluate with a new otologic database the results of primary stapes surgery for otosclerosis with up to 14 years of follow-up in a consecutive series of 2,525 patients operated on by the same surgeon with the same technique (stapedotomy and vein graft interposition) and to provide online access to the complete data of this study for the reviewers. To study the effect of specific operative findings (obliterative otosclerosis and simultaneous malleus ankylosis) and age at the time of surgery on the long-term outcome. STUDY DESIGN: Prospective clinical study using a new computerized otologic database. SETTING: : Tertiary referral center. PATIENTS: Two thousand five hundred twenty-five patients who underwent 3,050 stapedotomies for otosclerotic stapes fixation were enrolled in this study from January 1991 to December 2004. Separate analyses were made for two unique pathologies (92 cases of obliterative otosclerosis and 19 cases of simultaneous malleus ankylosis) diagnosed during surgery and for patients in two age brackets (or=65 yr [302 patients]). INTERVENTION: Stapedotomy with vein graft interposition and reconstruction with either a Teflon piston, a bucket handle prosthesis, or a total prosthesis. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were all assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 14 years. RESULTS: Overall, the postoperative ABG was closed to 10 dB in 94.2% of cases. The mean four-frequency postoperative ABG was 1.7 dB compared with 25.6 dB preoperatively. The mean four-frequency bone-conduction thresholds were unchanged postoperatively. A significant postoperative sensorineural hearing loss (SNHL; >15 dB) was seen in 0.5% of cases in this series. Postoperative ABG was achieved to within 10 dB in 95% of cases of obliterative otosclerosis and in 64.7% of cases of simultaneous malleus ankylosis. A significant postoperative SNHL (>15 dB) was seen in 4.8% of cases of obliterative otosclerosis and was not observed in any cases of simultaneous malleus ankylosis. Postoperative ABG was achieved to within 10 dB in 93.5% of cases in the pediatric series and in 94.5% of cases in the senior series. A significant postoperative SNHL (>15 dB) was seen in 0.7% of cases in the senior group but was not observed in the children. CONCLUSION: Using a new otologic database, our series confirms that stapedotomy with vein graft interposition for otosclerotic stapes fixation is a safe and successful treatment for long-term hearing improvement. The deterioration in hearing with time after stapedotomy did not exceed the rate of hearing loss because of presbyacusis. Therefore, argon laser stapedotomy with vein graft interposition is our preferred surgical technique in the treatment of otosclerosis. Obliterative otosclerosis and simultaneous malleus ankylosis may be encountered during stapedotomy. Our study shows that reasonable success rates can still be expected in these situations. Stapedotomy results in the elderly and in children are comparable to those obtained in patients of other groups of age undergoing surgery for otosclerosis without an increased risk for complications.

Ossiculoplasty with intact stapes and absent malleus: the silastic banding technique.

OBJECTIVE: To report an original method of ossicular reconstruction with intact stapes and absent malleus. Ossiculoplasty is performed with a total ossicular replacement prosthesis positioned from the stapes footplate to the under-surface of the tympanic membrane, using a Silastic banding technique to stabilize the prosthesis. STUDY DESIGN: A prospective study of ossicular reconstruction using the Silastic banding technique. A consecutive series of cases with intact stapes superstructure and missing malleus handle (Austin-Kartush Group C) is presented. SETTING: One tertiary referral center. PATIENTS: Ninety-nine patients who underwent total ossicular reconstruction with Silastic banding technique were enrolled in the study from January 2000 to December 2002. INTERVENTIONS: Ossiculoplasty with total ossicular replacement prostheses with Silastic Rubber Band for chronic otitis media and non-inflammatory disease. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap, bone-conduction threshold, and air-conduction threshold were assessed. Postoperative audiometry was performed at the 6th, 9th, 12th, 18th, 24th, and 36th months. RESULTS: Overall, a postoperative air-bone gap closed to within 10 dB was achieved in 61.5% of cases. An air-bone gap smaller than 20 dB was obtained in 77% of cases. Postoperative improvement of air-conduction thresholds by at least 20 dB was found in 51% of cases. There was no case of postoperative sensorineural hearing loss. One case of extrusion of the prosthesis was seen (1%). CONCLUSION: Stabilizing the total ossicular replacement prosthesis with the Silastic banding technique when performing ossicular reconstruction is a safe, effective method when the stapes supra-structure is present and the malleus absent.