Endoscopic classification system of pars tensa retractions.

BACKGROUND: Previous classification systems of pars tensa retractions have not consistently incorporated ossicular erosion or the presence of cholesteatoma. OBJECTIVE: This study aimed to illustrate our classification of pars tensa retractions, which is more precise than previous systems, with aided use of the endoscope. METHODS: A retrospective study was carried out on 200 ears of 170 patients whose pars tensa retractions had been documented at a tertiary otological referral centre. RESULTS: A classification system was developed. Pars tensa retractions were divided into the following subcategories: grade 0, grade 1, grade 2a, grade 2b, grade 3a, grade 3b, grade 3c, grade 4a, grade 4b, grade 4c, grade 5a, grade 5b and grade 5c. CONCLUSION: This classification system was able to accommodate all pars tensa retractions. The distribution of grades of pars tensa retractions was based on ossicular status and the presence or absence of cholesteatoma. It is therefore a more applicable, and functionally based system than previous alternatives.

Management of attic retraction pockets.

OBJECTIVE: Attic retraction pockets, classified by degree of invasion and erosion, are reconstructed here as outlined by attic retraction pocket grade. METHOD: Attic retraction pocket grade, surgical management, subsequent conditions of tympanic membrane and middle ear, and improvement of air-bone gap pure tone average were recorded. RESULTS: Our management strategy, based on attic retraction pocket grade, was applied to 200 ears: 44 grade I ears had non-surgical management and 156 grade II-V ears had surgical management. All 200 ears were followed up for 36-240 months, showing only 1 attic retraction pocket reformation and 1 adhesive otitis media (complication rate of 1 per cent), and improved air-bone gaps (p < 0.05). An earlier series of 50 grade IV attic retraction pockets used atticotomy with epitympanic reconstruction. These showed attic retraction pocket recurrence or cholesteatoma onset in 34 ears (68 per cent). When these ears were revised per protocol, there was no evidence of cholesteatoma thereafter. CONCLUSION: Reconstruction of the ossicles and scutal defect according to attic retraction pocket grade shows long-term stability of the tympanic membrane, middle ear and hearing.

A Unified Classification of Middle Ear and Petrous Bone Congenital Cholesteatomas.

BACKGROUND: The aim of this study was to classify congenital cholesteatoma along an entire spectrum of involvement ranging from the middle ear to petrous apex. METHODS: A total of 131 patients (85 adults and 46 children) underwent operations for congenital cholesteatoma over the duration of 27 years. RESULTS: For most cases, middle ear mucosa was normal, the first ossicle eroded by the mass was the stapes, and the mastoid air cell system was well-pneumatized on intraoperative and radiographic views. Totally 34% of patients presented with facial nerve weakness and 45% of these cholesteatomas arose from the supralabyrinthine area (32.8%) and from the petrous apex (12.2%). CONCLUSION: In this unified classification system, the otologist sees congenital cholesteatoma as a continuum, with facial nerve involvement and anacusis as part of the picture. This system of congenital cholesteatoma accommodates the supralabyrinthine and petrous bone locations of the disease.

The Thickness of the facial Nerve Sheath Consistently Varies by Region in Its Intra-Tympanic Course on Cadaveric Study.

OBJECTIVES: Iatrogenic removal of intra-temporal disease processes, such as cholesteatoma and keratosis obturans, can be challenging when the facial nerve (FN) is involved. Despite this concern about possible FN injury during these procedures, our clinical observation has been that the diseased growth can be cleaned quite easily from the vertical FN epineurium. Therefore, we designed a cadaveric protocol to measure thickness of the FN sheath (epineurium) in horizontal, second genu and vertical FN segments and to correlate these measurements with surgical management of FN disorders. METHODS: Fifty non-fixated (wet) cadaveric temporal bones were dissected over 1 year's time. The intra-temporal FN sheath epineurium was harvested from the mid-horizontal, second genu, and mid-vertical segments. Using a digital micrometric technique, the thickness of each sample was measured. Data analysis was performed using student's two-tailed, dependent t-test. RESULTS: Epineurial nerve sheath thickness was the least in the horizontal segment (mean 0.9 mm, range 0.040-0.140 mm), greater at the second genu (mean 0.19 mm, range 0.010-0.280 mm), and greatest in the vertical segment (mean 0.29 mm, range 0.170-0.570 mm). These differences were statistically significant. CONCLUSION: In cases of cholesteatoma and keratosis obturans involving the vertical FN, the disease process can be separated from the FN sheath because of the sheath thickness in this region. Disease in the horizontal segment involves a thinner sheath and separating the disease process from the nerve is more difficult in this area.

Unmitigated negative nasopharyngeal pressure is associated with attic retraction pocket formation: LaPlace's law in action.

BACKGROUND: Decades of clinical observation have led our subspecialty team to suspect that negative nasopharyngeal pressure is associated with attic retraction pocket formation. Furthermore, LaPlace's law, which states that the pressure within a sphere varies with the inverse of the radius, provides the dynamic explanation for why the attic area of the tympanic membrane tends to retract more frequently than the pars tensa. METHODS: The attic retraction pockets of 154 patients were classified into grades of severity (grades I-V). Impedance audiometry of middle-ear pressure was measured in the resting state, and after sniffing, swallowing and the Valsalva manoeuvre. RESULTS: Negative nasopharyngeal pressure (sniffing) caused a diminution of middle-ear pressure of -5 daPa on average in normal ears, and of -24 daPa to -45 daPa for tympanic membranes with attic retraction pockets of grade I to grade V. CONCLUSION: Attic retraction pockets are associated with greater collapse of middle-ear volume when negative pressure is created in the nasopharynx. LaPlace's law, and the composition of the pars flaccida, suggests an explanation for why the attic region retracts more than the pars tensa.

Facial Nerve Decompression After Temporal Bone Fracture-The Bangalore Protocol.

Background: Our tertiary otology center treats facial weakness and paralysis after motor vehicle crashes. We evaluate these patients with physical exam, audiogram, Schirmer's test, and CT scan. Our protocol for management of the facial weakness provides good results for our patients. Methods: Our protocol begins with oral steroids, and serial evaluations. Indications for decompression and our unique transcanal approach to identify the sites for decompression are described. A retrospective review of the medical record presents our patients treated between 1998 and 2017. Results: One hundred and forty one patients with grade 4 or more weakness underwent decompression. Mean pre-operative and post-operative House-Brackmann (HB) scores were HB5 and HB2, respectively. Fourteen of 104 patients (13%) presenting with HB5 and 6 still had HB5 or HB6 after decompression. Eighty-three of thee 104 patients (80%) achieved HB1 or HB2 at 6 months. Post-operative bone levels were unchanged. Post-operative air levels were improved in cases of perigeniculate fractures (84%). Conclusion: This Bangalore protocol facilitates advantageous improvement in facial function and conductive hearing loss after traumatic facial nerve crush injuries. The surgical technique, albeit challenging, helps identify the fracture lines, facilitates reconstruction of disrupted ossicles, and avoids craniotomy.

Effective Inexpensive Management of Necrotizing Otitis Externa Is Possible in Resource-Poor Settings.

INTRODUCTION: Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well. MATERIALS AND METHODS: Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention. RESULTS: Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression. CONCLUSION: Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.