Quality of life after revision mastoidectomy with mastoid obliteration / Calidad de la vida después mastoidectomia de revisión con obliteración mastoidea

Aims To evaluate the postoperative quality of life (QoL) after revision canal wall down mastoidectomy with mastoid obliteration (rCWD). Material and methods A retrospective analysis was conducted on patients treated by rCWD for cholesteatoma between 2016 and 2019. A control group including all patients treated by primary canal wall down with mastoid obliteration (pCWD) for cholesteatoma between 2009 and 2014 was used for the comparison of the postoperative QoL, assessed by the COMQ-12. Results The rCWD and pCWD groups respectively counted 38 and 78 patients with an average follow-up of 30 and 62 months respectively. No significant difference was found in terms of QoL between the two groups. An intra-group analysis among rCWD patients, showed that patients treated by canal wall down (CWD) at the primary surgery had a significantly worse post-revision QoL compared to those initially treated by canal wall up (CWU), specifically in the hearing and balance domains of the questionnaire. Conclusions Revision mastoid obliteration leads to similar QoL results to those obtained after primary CWD with obliteration. Patients who had undergone a CWD as primary surgery complain worse hearing and balance problems compared to those primarily submitted to CWU, even after revision surgery. (AU)

Objetivo Evaluar la calidad de la vida (CdV) post-operatoria después de mastoidectomia de revisión con obliteración mastoidea y timpanoplastia abierta. Materiales y métodos Ha sido efectuada una análisis retrospectiva in pacientes afectados por colesteatoma y tratados con mastoidectomia de revision con obliteración mastoidea entre el 2016 y el 2019. Pacientes afectados por colesteatoma y tratados con timpanoplastia abierta primaria con obliteración mastoidea entre el 2009 y el 2014 representan el grupo de control. La CdV post-operatoria ha sido analizada con el cuestionario COMQ-12. Resultados El grupo de estudio y el grupo control cuentan respectivamente 38 y 78 pacientes con un seguimiento medio de 30 y 62 meses. La CdV no era significativamente diferente entre los dos grupos. Una sub-análisis en el grupo de estudio ha demostrado que la CdV era significativamente peor en pacientes primitivamente tratados con timpanoplastia abierta en comparación con pacientes primitivamente tratados con timpanoplastia serrada, en particular en los dominios de la audición y del equilibrio. Conclusiones La CdV obtenida después de la obliteración mastoidea de revisión es comparable a aquella obtenida con timpanoplastia abierta primaria con obliteración mastoidea. Los pacientes sometidos a cirugía de revisión que habían sido tratados con timpanoplastia abierta primaria presentan una CdV peor de los pacientes precedentemente tratados por timpanoplastia cerrada en los dominios de la audición y del equilibrio. (AU)

Quality of life after revision mastoidectomy with mastoid obliteration.

AIMS: To evaluate the postoperative quality of life (QoL) after revision canal wall down mastoidectomy with mastoid obliteration (rCWD). MATERIAL AND METHODS: A retrospective analysis was conducted on patients treated by rCWD for cholesteatoma between 2016 and 2019. A control group including all patients treated by primary canal wall down with mastoid obliteration (pCWD) for cholesteatoma between 2009 and 2014 was used for the comparison of the postoperative QoL, assessed by the COMQ-12. RESULTS: The rCWD and pCWD groups respectively counted 38 and 78 patients with an average follow-up of 30 and 62 months respectively. No significant difference was found in terms of QoL between the two groups. An intra-group analysis among rCWD patients, showed that patients treated by canal wall down (CWD) at the primary surgery had a significantly worse post-revision QoL compared to those initially treated by canal wall up (CWU), specifically in the hearing and balance domains of the questionnaire. CONCLUSIONS: Revision mastoid obliteration leads to similar QoL results to those obtained after primary CWD with obliteration. Patients who had undergone a CWD as primary surgery complain worse hearing and balance problems compared to those primarily submitted to CWU, even after revision surgery.

Colesteatoma congénito: revisión de la literatura / Congenital cholesteatoma: literature review

El colesteatoma congénito es una entidad clínica única y desafiante, que se caracteriza por acumulación anormal de queratina en el oído medio, medial a la membrana timpánica. Se presenta, mayoritariamente, en el género masculino, con una incidencia estimada de 0.12 por 100.000 habitantes, representando el 4% a 24% de los colesteatomas en población pediátrica y un 2% a 5% del total de colesteatomas. Su origen aún es controversial, siendo la teoría más aceptada, la del arresto epitelial. Su diagnóstico es clínico, variando la sintomatología según severidad del compromiso, presentándose desde hallazgo incidental, hipoacusia de conducción, hasta presentar otalgia y perforación timpánica. Las imágenes se consideran un apoyo complementario preoperatorio. El tratamiento es quirúrgico, con diferentes técnicas disponibles, las cuales se deben definir de manera individual en el caso de cada paciente. Es fundamental su diagnóstico y manejo precoz, para lograr un tratamiento oportuno con menor tasa de complicaciones y compromiso a largo plazo. A continuación, se presenta una revisión de la literatura respecto de esta patología, para difusión en nuestro medio.

Congenital cholesteatoma (CC) is a unique and challenging clinical entity characterized by abnormal accumulation of keratin in the middle ear, medial to the tympanic membrane, being more frequent in the male gender, with an estimated incidence of 0.12 per 100,000 inhabitants. It represents 4% to 24% of cholesteatomas in the pediatric population and 2% to 5% of all cholesteatomas. Its cause is still controversial, the most accepted theory being epithelial arrest. The diagnosis is clinical, varying the symptoms according to the severity of the compromise, from incidental finding, through conduction hearing loss, to presenting otalgia and tympanic perforation. Images are considered additional preoperative support. Treatment is predominantly surgical, with different techniques available, which must be defined individually. Its early discovery and management are essential to achieve proper treatment with a lower rate of complications and long-term commitment. We present a review of the literature regarding CC to provide information relevant to our area of expertise.

Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap.

OBJECTIVE: Unstable cavities are defined as cavities with cerumen accumulation that need frequent cavity cleaning in the out-patient clinic, cavities that are intolerant to water due to risk of infection or that are subject to frequent infection and otorrhoea. The objective of this study is to address the problem of troublesome mastoid cavities, with the performance of secondary mastoid obliteration and canal wall reconstruction, using a novel posterior auricular artery (PAA) fascia-periosteum flap. MATERIALS AND METHODS: A prospective study was designed, only secondary obliterations were included. Unstable mastoid cavities were defined as Merchant grade 2 or 3 and were included for surgery. RESULTS: At 12 months of follow up, a complete external auditory canal (EAC) and a self-cleaning ear were achieved in all 23 patients. Completely dry ears were achieved in 21 patients (91.3%). An air-bone gap improvement of 5dB was achieved. CONCLUSION: Mastoid obliteration and EAC reconstruction are effective procedures to treat troublesome post canal wall down mastoid cavities. They improve quality of life and enable patients to overcome ear discharge. A standard EAC size enables the utilization of conventional hearing aids, it also reduces the need for constant mastoid cleaning and decreases healthcare expenses. The PAA flap seems to be an effective procedure to achieve all these features, as it is used to obliterate the mastoid and becomes a structural component of the neo-EAC.

Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap

Objective: Unstable cavities are defined as cavities with cerumen accumulation that need frequent cavity cleaning in the out-patient clinic, cavities that are intolerant to water due to risk of infection or that are subject to frequent infection and otorrhoea. The objective of this study is to address the problem of troublesome mastoid cavities, with the performance of secondary mastoid obliteration and canal wall reconstruction, using a novel posterior auricular artery (PAA) fascia-periosteum flap.Materials and methodsA prospective study was designed, only secondary obliterations were included. Unstable mastoid cavities were defined as Merchant grade 2 or 3 and were included for surgery.ResultsAt 12 months of follow up, a complete external auditory canal (EAC) and a self-cleaning ear were achieved in all 23 patients. Completely dry ears were achieved in 21 patients (91.3%). An air-bone gap improvement of 5dB was achieved.ConclusionMastoid obliteration and EAC reconstruction are effective procedures to treat troublesome post canal wall down mastoid cavities. They improve quality of life and enable patients to overcome ear discharge. A standard EAC size enables the utilization of conventional hearing aids, it also reduces the need for constant mastoid cleaning and decreases healthcare expenses. The PAA flap seems to be an effective procedure to achieve all these features, as it is used to obliterate the mastoid and becomes a structural component of the neo-EAC. (AU)

Objetivo: Las cavidades inestables se definen como cavidades que presentan acumulación de cerumen que requieren limpieza en la consulta de manera frecuente, son cavidades intolerantes al agua por su elevado riesgo de infección o tienen frecuentes infecciones y otorrea. El objetivo de este estudio es abordar el problema de las cavidades mastoideas problemáticas con una obliteración mastoidea secundaria y reconstrucción del conducto auditivo externo (CAE) usando un colgajo fascio-perióstico de la arteria auricular posterior.Materiales y métodosSe diseñó y realizó un estudio prospectivo, solo se incluyeron obliteraciones secundarias. Las mastoides inestables fueron definidas según la clasificación de Merchant como grado 2 o 3 y fueron incluidas para la cirugía.ResultadosA los 12 meses de seguimiento, se consiguió un CAE completo y autolimpiable en los 23 pacientes. Se lograron oídos completamente secos en 21 casos (91,3%). Se obtuvo una mejoría media en la brecha aire-hueso de 5dB.ConclusiónLa obliteración mastoidea y la reconstrucción del CAE son procedimientos eficaces para tratar mastoides problemáticas posmastoidectomías abiertas. Mejoran la calidad de vida de los pacientes y son efectivas para solventar la otorrea recurrente. La obtención de un CAE de tamaño estándar es importante para permitir que el paciente pueda utilizar una audioprótesis estándar, además de reducir la necesidad de limpieza de la cavidad de manera constante y la dependencia del paciente a los controles en la consulta, disminuyendo así el gasto en sanidad. El colgajo de arteria auricular posterior parece ser una herramienta útil para lograr todas estas características, y también es usado para obliterar las mastoides y se convierte en un componente estructural del neo-CAE. (AU)

Modelos de simulación para entrenamiento en cirugía de hueso temporal

El fresado de hueso temporal (HT) es un desafío para los otorrinolaringólogos. Este procedimiento requiere un conocimiento detallado de esta zona anatómicamente compleja y un dominio de la técnica quirúrgica. La exposición a una mastoidectomía simple o mastoidectomía radical varía entre residentes y distintos programas de especialidad y, frecuentemente, no se cumple el número requerido para la curva de aprendizaje durante la formación. Por lo anterior, surge la necesidad de realizar simulación quirúrgica de fresado de HT. El gold standard para su entrenamiento son los modelos cadavéricos, sin embargo, su costo y baja disponibilidad representan una limitación importante. Los modelos de simulación no cadavéricos podrían jugar un rol importante en el entrenamiento de esta cirugía. Se realizó una revisión exhaustiva de la literatura sobre los modelos de simulación disponibles en fresado de HT. Se encontraron estudios sobre modelos cadavéricos, basados en impresión 3D, realidad virtual y de bajo costo. Los modelos de impresión 3D y realidad virtual han sido evaluados favorablemente en cuanto a adquisición de habilidades, aprendizaje de anatomía, similitud con modelos cadavéricos y sensación táctil. Los modelos de impresión 3D presentan mayor fidelidad anatómica y física, pero tienen un mayor costo. En suma, se han desarrollado modelos de fresado de HT no cadavéricos que cuentan, principalmente, con validez de apariencia y contenido, y solo algunos con validez de constructo. Se necesitan más estudios para evaluar su validez predictiva y transferencia de habilidades al paciente real.

Temporal bone (TB) dissection is a challenging procedure for otolaryngologists. It requires a detailed knowledge of this anatomically complex area and mastery of the surgical technique. Exposure to a simple or radical mastoidectomy may vary among residents and specialty programs, frequently not complying with the required number of surgeries to complete the learning curve during residency. Hence, TB dissection simulation is of great importance. The gold standard for simulated training are cadaveric models, nevertheless, the associated high cost and low availability represent a major limitation for this modality. Non-cadaveric simulation models could play a key role in simulated training for this surgery. A comprehensive review of the literature regarding the available simulation models for TB dissection was conducted. Articles for cadaveric, 3D-printed, virtual reality and low-cost models were identified. 3D-printed and virtual reality models have been favorably evaluated in terms of skill acquisition, anatomy learning, similarity to cadaveric models, and tactile sensation. 3D-printed models present superior anatomic and physical fidelity, but are more expensive. In sum, the current non-cadaveric models for TB dissection mostly present face and content validity, while few models count with construct validity. Further studies are required to assess predictive validity and skill transfer to the real patient.

Concordancia entre hallazgos radiológicos y quirúrgicos en pacientes sometidos a mastoidectomía

Introducción: Existe gran controversia acerca de los signos radiológicos de la patología de oído medio y su relación con la extensión real de la patología que nos sugiera decidir un comportamiento determinado. Objetivo: establecer la concordancia entre los hallazgos radiológicos y quirúrgicos encontrados en pacientes sometidos a mastoidectomía. Material y Método: Diseño observacional descriptivo de corte transversal de prueba diagnóstica. Se revisó fichas clínicas y se especificó el tipo de cirugía junto con los hallazgos intra-quirúrgicos. Resultados: se observó erosión de la cadena osicular intraoperatoria en 75 pacientes, 63 predichos correctamente por tomografía computada (TC), con sensibilidad del 84% y especificidad del 94% (k = 0,625). Se detectó erosión del tegmen tympani en nueve pacientes por TC de los 10, con un VPP = 90% y un VPN = 95% (k = 0,809). Hubo sospecha de erosión del canal semicircular lateral en cinco pacientes y se encontró dehiscencias intraoperatorias en 12, sin falsos positivos (k = 0,554). La TC detectó dehiscencia del canal del nervio facial con sensibilidad del 55% y especificidad del 98% (k = 0,636). Conclusión: Los resultados sugieren que la TC preoperatoria con evidencia radiológica de erosión osicular tiene una buena a muy buena concordancia con los hallazgos intraoperatorios.

Introduction: There is a great controversy about the radiological signs of middle ear pathology and its relation with the real extension of the pathology that suggests us to decide a certain medical choice. Aim: To establish concordance between radiological and surgical findings in patients submitted to mastoidectomy. Material and Method: An observational and descriptive design of retrospective cross-sectional diagnostic test. Clinical records were reviewed to specify the type of surgery and intraoperative findings. Results: Intraoperative ossicular chain erosion was observed in 75 patients, 63 were correctly predicted by computed tomography (CT), with a sensitivity of 84% and specificity of 94% (k = 0.625). Tegmen tympani erosion was detected by CT in 9 patients out of 10, with a PPV = 90% and NPV = 95% (k = 0.809). There was suspected lateral semicircular canal erosion in 5 patients and intraoperative dehiscence was found in 12, with no false positives (k = 0.554). CT detected facial nerve canal dehiscence with sensitivity of 55% and specificity of 98% (k = 0.636). Conclusion: The results suggest that preoperative CT with radiological evidence of ossicular erosion has good to very good agreement with intraoperative findings.

Cholesteatoma: Influence of surgical technique and EAONO/JOS stage on audiological results.

INTRODUCTION AND OBJECTIVE: The treatment of cholesteatoma is surgical in most cases. When it is indicated, it is preferable to choose a reconstructive surgical technique with the dual purpose of eradicating the disease and preserving or improving the patient's hearing. In 2017, the European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS) published a new cholesteatoma classification. The aims of this study were to determine the influence of the surgical technique used and this classification on patient's hearing outcomes. METHODS: A retrospective study that included patients who underwent reconstructive surgery of cholesteatoma between 2012 and 2017 was carried out. Based on pre-surgical computed tomography (CT) images, disease was staged according to the EAONO/JOS classification. Hearing outcomes obtained by pre and postoperative pure tone audiometry were analysed according to the surgical technique used and according to the stage of the disease. RESULTS: 143 patients with no statistically significant differences in hearing thresholds before surgery were included. One year after surgery, all the patients' (P = .01 and P = .001) airpure tone average (PTA) and mean differential auditory threshold had improved significantly. Those patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy presented better postsurgical air PTA and postsurgical mean differential auditory threshold outcomes (P = .007 and P = .014) than those patients who underwent tympanoplasty with canal wall down mastoidectomy. Moreover, the patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy had improved air PTA and mean differential auditory threshold one year after the surgery with statistical significance (P = .001, P = .013). The mean differential auditory threshold was also better (P = .008) in the patients who underwent tympanoplasty with canal wall down mastoidectomy one year after the procedure. CONCLUSIONS: Reconstructive surgical techniques improve hearing one year after surgery. In our study, this improvement was significantly greater with tympanoplasty with two-stage canal wall up mastoidectomy.

Colesteatoma: influencia de la técnica quirúrgica y el estadio EAONO/JOS en los resultados audiológicos / Cholesteatoma: Influence of surgical technique and EAONO/JOS stage on audiological results

Antecedentes y objetivo: El tratamiento del colesteatoma es quirúrgico en la mayoría de los casos. Cuando está indicado, es preferible optar por una técnica quirúrgica reconstructiva con el doble propósito de eliminar la enfermedad y preservar o mejorar la audición del paciente. En 2017 se publicó una nueva clasificación del colesteatoma por parte de la European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS). El objetivo de este estudio es determinar la influencia que tanto la técnica quirúrgica empleada como la clasificación de la enfermedad tienen en los resultados auditivos de los pacientes. Materiales y métodos: Se realiza un estudio retrospectivo que incluye pacientes intervenidos de colesteatoma mediante una técnica reconstructiva entre 2012 y 2017. A partir de la tomografía computarizada (TC) prequirúrgica de cada paciente se estadifica la enfermedad según la clasificación de la EAONO/JOS. Los datos audiológicos obtenidos mediante audiometría tonal liminar (ATL) pre y postoperatoria son analizados en función de la técnica quirúrgica empleada y según el estadio de la enfermedad. Resultados: Se incluyen 143 pacientes con umbrales auditivos sin diferencias significativas antes de la cirugía. Al año de la intervención, el umbral medio auditivo (pure tone average [PTA]) aéreo y el umbral diferencial auditivo (UDA) medio mejoran significativamente (p=0,01 y p=0,001) en toda la muestra. Los pacientes intervenidos con técnica cerrada en dos tiempos presentan mejores resultados en el PTA aéreo postoperatorio y UDA medio posquirúrgico que los operados mediante técnica abierta (p=0,007 y p=0,014). El PTA aéreo postoperatorio y el UDA medio postoperatorio mejoran en los pacientes intervenidos con técnica cerrada en dos tiempos quirúrgicos (p=0,001 y p=0,013), en comparación con la audición previa que presentaban. El UDA medio postoperatorio también mejora significativamente en los pacientes operados mediante técnica abierta (p=0,008). Conclusiones: Todas las técnicas quirúrgicas reconstructivas producen una mejora significativa de la audición al año de la intervención. En nuestro estudio esta mejora es significativamente superior con una timpanoplastia con mastoidectomía cerrada en dos tiempos quirúrgicos.(AU)

Introduction and objective: The treatment of cholesteatoma is surgical in most cases. When it is indicated, it is preferable to choose a reconstructive surgical technique with the dual purpose of eradicating the disease and preserving or improving the patient's hearing. In 2017, the European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS) published a new cholesteatoma classification. The aims of this study are to determine the influence of the surgical technique use and this classification on patient's hearing outcomes. Methods: A retrospective study that include patients who underwent reconstructive surgery of cholesteatoma between 2012 and 2017 is carried out. Based on pre-surgical computed tomography (CT) images, disease is staged according to the EAONO/JOS classification. Hearing outcomes obtained by pre and postoperative pure tone audiometry are analysed according to the surgical technique used and according to the stage of the disease. Results: 143 patients with no statistically significant differences in hearing thresholds before surgery are included. One year after surgery, all the patients’ airbone pure tone average (PTA) and mean differential auditory threshold have improved significantly (P = .01 and P = .001). Those patients who undergo tympanoplasty with two-stage canal wall up mastoidectomy presente better postsurgical air PTA and postsurgical mean differential auditory threshold outcomes (P=.007 and P=.014) than those patients who underwent tympanoplasty with canal wall down mastoidectomy. Moreover, the patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy had improved airbone PTA and mean differential auditory threshold one year after the surgery with statistical significance (P=.001 and P=.013). The mean differential auditory threshold is also better (P=.008) in the patients who undergo tympanoplasty with canal wall down mastoidectomy one year after the procedure. Conclusions: Reconstructive surgical techniques improve hearing one year after surgery. In our study, this improvement is significantly greater with tympanoplasty with two-stage canal wall up mastoidectomy.(AU)

O uso do retalho de fáscia parietotemporal no tratamento do colesteatoma recidivado: caso clínico / The use of parietotemporal fascia flap in the treatment of recurrent cholesteatoma: clinical case

O colesteatoma consiste em um processo inflamatório que resulta na migração do epitélio escamoso queratinizado para o ouvido médio. Embora considerada uma entidade histopatologicamente benigna, pode se comportar de forma bastante agressiva sendo uma importante causa de surdez em todos os países. Descarga, dor, ruptura do tímpano com extensão para o ouvido interno levando à surdez e vertigem, são as manifestações clínicas mais comuns. O tratamento consiste na excisão cirúrgica de todo o epitélio estranho da orelha média. As recorrências podem chegar a 50% e são um desafio para os médicos de ouvido, nariz e garganta. Neste relato de caso descrevemos um caso de colesteatoma recorrente adquirido em um hospital terciário em Portugal, tratado com ablação radical de ouvido médio e cavidade mastóide pelos médicos otorrinolaringologistas. A opção reconstrutiva escolhida foi a obliteração do espaço morto com retalho fascial temporo-parietal pelo Serviço de Cirurgia Plástica.

Cholesteatoma consists of an inflmmatory process that results in the migration of squamous keratinized epithelium into the middle ear. Although regarded as a histopathologically benign entity it can behave quite aggressively being an important cause of deafness in all countries. Ear discharge, pain, ear drum rupture with extension into the inner ear leading to deafness and vertigo, are the most common clinical manifestations. Treatment consists of surgically excising all the foreign epithelium from the middle ear. Recurrences can be as high as 50% and are a challenge to Ear, Nose and Throat doctors. In this case report we describe a case of an acquired recurrent cholesteatoma in a tertiary hospital in Portugal, treated with radical ablation of middle ear and mastoid cavity by the otolaryngologists. The chosen reconstructive option was obliteration of the dead space using a temporo-parietal fascial flap by the Plastic Surgery Department

Radiological evaluation of the postsurgical middle ear.

OBJECTIVE: The radiological evaluation of the postsurgical middle ear is complex due to the intricate anatomy of this region and the wide variety of procedures and materials used iin middle ear surgery. Knowledge of these factors will enable normal postsurgical changes to be differentiated from complications. This article describes the most common surgical procedures in the middle ear, their indications, and the normal radiological appearance after these procedures. It reviews the most common causes of failure in stapes surgery, in surgery for chronic otitis media, and in surgery for cholesteatoma, suggesting the best imaging method to assess the middle ear in each case. CONCLUSION: Computed tomography enables the evaluation of prostheses and the aeration of the cavities, whereas magnetic resonance imaging makes it possible to characterize the possible occupation of the cavities and is the technique of choice for the follow-up of closed mastoidectomy for cholesteatomas.

Cholesteatoma: Influence of surgical technique and EAONO/JOS stage on audiological results. / Colesteatoma: influencia de la técnica quirúrgica y el estadio EAONO/JOS en los resultados audiológicos.

INTRODUCTION AND OBJECTIVE: The treatment of cholesteatoma is surgical in most cases. When it is indicated, it is preferable to choose a reconstructive surgical technique with the dual purpose of eradicating the disease and preserving or improving the patient's hearing. In 2017, the European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS) published a new cholesteatoma classification. The aims of this study are to determine the influence of the surgical technique use and this classification on patient's hearing outcomes. METHODS: A retrospective study that include patients who underwent reconstructive surgery of cholesteatoma between 2012 and 2017 is carried out. Based on pre-surgical computed tomography (CT) images, disease is staged according to the EAONO/JOS classification. Hearing outcomes obtained by pre and postoperative pure tone audiometry are analysed according to the surgical technique used and according to the stage of the disease. RESULTS: 143 patients with no statistically significant differences in hearing thresholds before surgery are included. One year after surgery, all the patients' airbone pure tone average (PTA) and mean differential auditory threshold have improved significantly (P = .01 and P = .001). Those patients who undergo tympanoplasty with two-stage canal wall up mastoidectomy presente better postsurgical air PTA and postsurgical mean differential auditory threshold outcomes (P=.007 and P=.014) than those patients who underwent tympanoplasty with canal wall down mastoidectomy. Moreover, the patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy had improved airbone PTA and mean differential auditory threshold one year after the surgery with statistical significance (P=.001 and P=.013). The mean differential auditory threshold is also better (P=.008) in the patients who undergo tympanoplasty with canal wall down mastoidectomy one year after the procedure. CONCLUSIONS: Reconstructive surgical techniques improve hearing one year after surgery. In our study, this improvement is significantly greater with tympanoplasty with two-stage canal wall up mastoidectomy.

Colesteatoma complicado en un niño con síndrome de Down: un caso clínico / Complicated cholesteatoma in a child with Down syndrome: a case report

El colesteatoma adquirido en niños es una enfermedad agresiva debido a su rápido crecimiento y la alta tasa de recurrencia. Las complicaciones se dividen en dos grandes grupos: las relacionadas con el hueso temporal (dentro o fuera de él) y las complicaciones intracraneales. El absceso subperióstico es la complicación extratemporal más común y es más frecuente en los niños más pequeños. Los pacientes que padecen síndrome de Down tienen una prevalencia elevada (superior al 80 %) de otitis media con efusión, que puede estar determinada anatómicamente por la hipoplasia mediofacial con una nasofaringe estrecha y adenoides hipertrófica, junto a trastornos funcionales y mecánicos de la trompa auditiva. Se presenta un niño de 8 años con síndrome de Down que desarrolló un absceso subperióstico como complicación de un colesteatoma que requirió abordaje quirúrgico inmediato para su resolución.

Acquired cholesteatoma in children is an aggressive disease due to its rapid growth and high recurrence rate. The complications are divided into intra-and extratemporal complications or intracranial complication. Subperiosteal abscess is the most common extratemporal complication. It is most frequent in young children. However, there are also other associated complications described in the literature. Down syndrome patients have anatomical and functional predisposing factors that contribute to chronic cholesteatomatous otitis media. The prevalence is greater than 80 %. In this report, we present a case of subperiosteal abscess in an 8-year-old child with Down's syndrome. This abscess presented as a complication of an extended cholesteatoma and required inmediate surgery for resolution.

Actinomicosis en el hueso temporal. Reporte de un caso pediátrico / Actinomycosis in temporal bone. A pediatric case report

La actinomicosis es una infección causada por un bacilo anaerobio Gram-positivo, filamentoso, ramificado, no esporulado. Integra la flora habitual de la orofaringe y coloniza transitoriamente el tracto gastrointestinal, genital femenino y el árbol bronquial. Es poco frecuente en el hueso temporal. Por su semejanza a un hongo, es difícil su reconocimiento, lo que hace necesaria la sospecha clínica para obtener los cultivos apropiados en condiciones anaeróbicas en forma prolongada. Los hallazgos microscópicos típicos incluyen necrosis con gránulos de azufre amarillento y la presencia de filamentos que se asemejan a infecciones fúngicas. El tratamiento requiere de elevadas y prolongadas dosis de antibiótico con penicilina o amoxicilina, entre 6 y 12 meses. La duración de la terapia antimicrobiana podría ser reducida en pacientes que han sido operados quirúrgicamente. Se presenta, a continuación, un caso clínico de actinomicosis en el hueso temporal en un paciente pediátrico que requirió tratamiento quirúrgico para su resolución.

Actinomycosis is an infection caused by a Gram-positive, filamentous anaerobic bacillus. Mainly belonging to the human commensal flora of the oropharynx, it normally colonizes the human digestive and genital tracts and the bronchial tree. It is slightly frequent in the temporal bone. Bacterial cultures and pathology are the cornerstone of diagnosis, but particular conditions are required in order to get the correct diagnosis. Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium and typical microscopic findings include necrosis with yellowish sulfur granules and filamentous Gram-positive fungal-like pathogens. Patients with actinomycosis require prolonged (6- to 12-month) high doses of penicillin G or amoxicillin, but the duration of antimicrobial therapy could probably be shortened in patients in whom optimal surgical resection of infected tissues has been performed. A pediatric patient with actinomycosis in temporal bone who needed surgery resolution is reported.

Therapeutic approach to pediatric acute mastoiditis - an update / Abordagem terapêutica da mastoidite aguda pediátrica - uma atualização

Abstract Introduction: Acute mastoiditis remains the most common complication of acute otitis media. It may rarely appear also in cochlear implant patients. However, the treatment recommendations for this disease are not precisely defined or employed, and in the current literature the differences regarding both the diagnosis and management are relatively substantial. Objective: The aim of this study was to determine a standard and safe procedure to be applied in case of pediatric acute mastoiditis. Methods: A retrospective chart review of 73 patients with 83 episodes of acute mastoiditis hospitalized at our tertiary-care center between 2001 and 2016 was conducted. Bacteriology, methods of treatment, hospital course, complications, and otologic history were analyzed. Based on our experience and literature data, a protocol was established in order to standardize management of pediatric acute mastoiditis. Results: All the patients treated for acute mastoiditis were submitted to an intravenous antibiotic regimen. In the analyzed group pharmacological treatment only was applied in 11% of children, in 12% myringotomy/tympanostomy was added, and in the vast majority of patients (77%) mastoidectomy was performed. In our study recurrent mastoiditis was noted in 8% of the patients. We also experienced acute mastoiditis in a cochlear implant child, and in this case, a minimal surgical procedure, in order to protect the device, was recommended. Conclusions: The main points of the management protocol are: initiate a broad-spectrum intravenous antibiotic treatment; mastoidectomy should be performed if the infection fails to be controlled after 48 h of administering intravenous antibiotic therapy. We believe that early mastoidectomy prevents serious complications, and our initial observation is that by performing broad mastoidectomy with posterior attic and facial recess exposure, recurrence of acute mastoiditis can be prevented.

Resumo Introdução: A mastoidite aguda continua a ser a complicação mais comum da otite média aguda. Pode ocorrer também, embora raramente, em pacientes com implante coclear. Entretanto, as recomendações de tratamento para essa doença não são bem definidas ou usadas e, na literatura corrente, as diferenças em relação ao diagnóstico e ao manejo são relativamente significativas. Objetivo: O objetivo deste estudo foi determinar um procedimento padrão e seguro a ser aplicado em caso de mastoidite aguda pediátrica. Método: Foi realizada uma revisão retrospectiva de prontuários de 73 pacientes com 83 episó-dios de mastoidite aguda hospitalizados em nosso centro terciário entre os anos de 2001 a 2016. Foram analisados a bacteriologia, métodos de tratamento, evolução hospitalar, complicações e histórico otológico. Com base em nossa experiência e dados da literatura, foi estabelecido um protocolo para padronizar o tratamento da mastoidite aguda pediátrica. Resultados: Todos os pacientes tratados para mastoidite aguda foram submetidos a antibioticoterapia endovenosa. No grupo analisado, o tratamento farmacológico só foi aplicado em 11% das crianças, em 12% a miringotomia/timpanostomia foi adicionada e na maior parte dos pacientes (77%) foi feita a mastoidectomia. Em nosso estudo, mastoidite recorrente foi observada em 8% dos pacientes. Também observamos mastoidite aguda em criança usuária de implante coclear e, nesse caso, foi recomendada a minimização de procedimentos cirúrgicos, a fim de proteger o dispositivo. Conclusões: Os principais pontos do protocolo de conduta são: iniciar um tratamento antibiótico endovenoso de amplo espectro; a mastoidectomia deve ser feita caso a infecção não seja controlada após 48 horas da administração de antibioticoterapia intravenosa. Acreditamos que a mastoidectomia precoce previne complicações graves e nossa observação inicial é que, com uma mastoidectomia ampla com exposição do ático posterior e do recesso facial, a recorrência de mastoidite aguda pode ser evitada.

Resultados de la mastoidectomía radical modificada en pacientes con otitis media crónica supurada / Results of modified radical mastoidectomy in patients with chronic suppurative media otitis

RESUMEN Fundamento: la otitis media crónica es causa importante de morbilidad, deterioro auditivo e ingresos hospitalarios debido a recurrencias y complicaciones, donde la mastoidectomía radical modificada la técnica adecuada para lograr resultados anatómicos y funcionales. Objetivo: describir los resultados de la mastoidectomía radical modificada en pacientes con otitis media crónica supurada. Métodos: se realizó un estudio descriptivo retrospectivo, longitudinal en 54 pacientes con otitis media crónica, a los que se les realizó mastoidectomía radical modificada. Las variables objeto de estudio fueron de caracterización clínica y epidemiológica y los resultados se evaluaron en excelente, bueno, regular y malo. Los datos fueron procesados utilizando la estadística descriptiva para distribución de frecuencias absolutas y relativas, y se reflejaron en tablas. Resultados: el mayor número de operados fue del sexo masculino, entre la tercera y cuarta década de la vida; la hipoacusia, otorrea y perforación timpánica fueron las manifestaciones más frecuentes. La imagen tumoral e hipoacusia conductiva y la Pseudomona aeruginosa, se hallaron con mayor frecuencia. La mastoidectomía con timpanoplastia tipo III por lisis de los huesecillos, cavidades limpias, amplias, muros bajos e injerto íntegro, permitió que la mayoría de los pacientes tuvieran buenos resultados anatómicos y funcionales, y las complicaciones fueron escasas. Conclusiones: la técnica utilizada fue la mastoidectomía radical modificada, asociada a timpanoplastia tipo III y predominaron los resultados excelentes, buenos y regulares en los enfermos operados.

ABSTRACT Background: chronic media otitis is an important cause of morbidity, hearing impairment and hospital admissions due to recurrences and complications, with modified radical mastoidectomy being the appropriate technique to achieve anatomical and functional results. Objective: to describe the results of the modified radical mastoidectomy in patients with suppurative chronic media otitis. Methods: a retrospective, longitudinal descriptive study in 54 patients with chronic media otitis, who underwent modified radical mastoidectomy. The variables under study were of clinical and epidemiological characterization and the results were evaluated as excellent, good, fair and bad. The data were processed using descriptive statistics for distribution of absolute and relative frequencies, and were reflected in tables. Results: the largest number of patients was male, between the third and fourth decade of life; hearing loss, otorrhea and tympanic perforation were the most frequent manifestations. The tumor image and conductive hearing loss and Pseudomonas aeruginosa were found more frequently. The mastoidectomy with tympanoplasty type III by lysis of the ossicles, clean, wide cavities, low walls and intact graft, allowed the majority of patients to have good anatomical and functional results, and complications were scarce. Conclusions: the technique used was modified radical mastoidectomy, associated with tympanoplasty type III and excellent, good and regular results prevailed in the operated patients.

Impacto de la mastoidectomía en la reparación de la perforación timpánica en pacientes con otitis media crónica no colesteatomatosa con hueso mastoideo esclerótico / Impact of mastoidectomy in the repair of tympanic perforation in patients with chronic non-cholesteatomatous otitis media with sclerotic mastoid bone

Objetivo: describir las características clínicas y resultados obtenidos en pacientes a los cuales se les realizó reparación de perforación timpánica secundaria a otitis media crónica no colesteatomatosa con hueso mastoideo esclerótico, con y sin mastoidectomía. Materiales y métodos: estudio de tipo trasversal comparativo, con un muestreo no probabilístico por serie consecutiva de casos. Se revisaron los expedientes de pacientes que cumplan con los criterios de inclusión en el periodo comprendido enero del 2015 a mayo 2016. Se tomarón datos como; edad, sexo, estado de procedencia,a la otoscopia, presencia de otorrea transoperatoria y postoperatoria, estado de la mucosa, presencia de timpanoesclerosis o miringoesclerosis, perforación o retracción del injerto. Resultados: un total de 48 pacientes fueron seleccionados; 31 del sexo femenino y 17 del sexo masculino, con edad promedio de 43,25 años, el seguimiento fue de 3 meses. Al comparar al grupo de paciente con mastoidectomía y sin esta, no se encontró diferencia estadísticamente significativa en cuanto a éxito de la cirugía (perforación de injerto RR 1,2, p 1, otorrea posoperatoria RR 2,26, p 0;68 y retracción del injerto RR 0;76, p 1). Se encontró que las características durante y previa a la cirugía no influyeron en el resultado final, presentando un promedio global del 94% de integración del injerto. Conclusión: la mastoidectomía no muestra beneficio adicional en la reparación de la membrana timpánica, las características durante y previa a la cirugía no influyeron en el resultado final..(AU)

Objective: to describe the clinical characteristics and results obtained in patients who underwent repair of tympanic perforation secondary to chronic non-cholesteatomatous otitis media with sclerotic mastoid bone, with and without mastoidectomy. Material and methods: comparative cross-sectional study, with a non-probabilistic sampling by consecutive series of cases. We reviewed the files of patients who meet the inclusion criteria in the period from January 2015 to May 2016. Data was collected such as; age, sex, state of origin, history of smoking, cause of perforation, duration of dry ear, data to otoscopy, presence of transoperative and postoperative otorrhea, state of the mucosa, presence of tympanosclerosis or miringoesclerosis, perforation or retraction of the graft. Results: a total of 48 patients were selected; 31 of the female sex and 17 of the male sex, with an average age of 43.25 years, the follow-up was 3 months. When comparing the group of patients with and without mastoidectomy, no statistically significant difference was found in the success of the surgery (graft perforation RR 1.2, p 1, postoperative otorrhea RR 2.26, p 0.68 and graft retraction RR 0.76, p 1). We found that the characteristics during and before surgery did not influence the final result, presenting an overall average of 94% of graft integration. Conclusions: the mastoidectomy shows no additional benefit in tympanic membrane repair, the characteristics during and prior to surgery did not influence the final result..(AU)

Therapeutic approach to pediatric acute mastoiditis - an update.

INTRODUCTION: Acute mastoiditis remains the most common complication of acute otitis media. It may rarely appear also in cochlear implant patients. However, the treatment recommendations for this disease are not precisely defined or employed, and in the current literature the differences regarding both the diagnosis and management are relatively substantial. OBJECTIVE: The aim of this study was to determine a standard and safe procedure to be applied in case of pediatric acute mastoiditis. METHODS: A retrospective chart review of 73 patients with 83 episodes of acute mastoiditis hospitalized at our tertiary-care center between 2001 and 2016 was conducted. Bacteriology, methods of treatment, hospital course, complications, and otologic history were analyzed. Based on our experience and literature data, a protocol was established in order to standardize management of pediatric acute mastoiditis. RESULTS: All the patients treated for acute mastoiditis were submitted to an intravenous antibiotic regimen. In the analyzed group pharmacological treatment only was applied in 11% of children, in 12% myringotomy/tympanostomy was added, and in the vast majority of patients (77%) mastoidectomy was performed. In our study recurrent mastoiditis was noted in 8% of the patients. We also experienced acute mastoiditis in a cochlear implant child, and in this case, a minimal surgical procedure, in order to protect the device, was recommended. CONCLUSIONS: The main points of the management protocol are: initiate a broad-spectrum intravenous antibiotic treatment; mastoidectomy should be performed if the infection fails to be controlled after 48h of administering intravenous antibiotic therapy. We believe that early mastoidectomy prevents serious complications, and our initial observation is that by performing broad mastoidectomy with posterior attic and facial recess exposure, recurrence of acute mastoiditis can be prevented.

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.

[Combined approach for the treatment of spontaneous temporal encephaloceles: transmastoid plus temporal minicraniotomy]. / Abordaje combinado para el tratamiento de los encefaloceles temporales espontáneos: mastoidectomía + minicraneotomía.

Spontaneous encephaloceles are defined as brain herniations with no apparent cause. The aim of this paper is to describe the surgical technique performed in our department. We reviewed the last 3 cases treated with combined approach (transmastoid plus minicraniotomy) with 2-layer closure. In all cases the bone defects were located and successfully sealed. We had no postoperative complications. There were no relapses in our follow-up period. The transmastoid approach has the advantage over the open approach with middle fossa craniotomy in that it locates the bone defect with no brain retraction. Nevertheless, it is not useful in large-sized, multiple or anterior defects. Due to those drawbacks, we think that the combined approach with temporal minicraniotomy is the best choice for this entity.