Postoperative Late Hearing Deterioration in Cholesteatoma with Labyrinthine Fistulas.

A labyrinthine fistula is a severe complication of middle ear cholesteatoma that can cause profound sensorineural hearing loss and vertigo. However, there is no consensus regarding the transition to postoperative hearing. Although hearing deteriorates gradually with a delay in some cases of labyrinthine fistula, insufficient consideration has been given to this point. We examined perioperative changes in cases of middle ear cholesteatoma with labyrinthine fistulas. We retrospectively reviewed the medical records of 578 patients with middle ear cholesteatoma who underwent tympanoplasty at our hospital between 2016 and 2021. Patients with labyrinthine fistulas were selected; their perioperative bone-conduction hearing was assessed. Fistula depth was determined following the classification reported by Dornhoffer et al. The hearing was compared preoperatively, early postoperatively (3-6 months), and 1 year postoperatively. Forty-eight patients (8.3%) had labyrinthine fistulas. Regarding depth, 21 cases were type I, 14 were type IIa, 3 were type IIb, and 10 were type III. Preoperative bone-conduction hearing was significantly poor in invasion type IIb or deeper cases. Cases with type IIb or deeper fistulas, multiple fistulas, or vertigo deteriorated postoperatively. Type III cases or those with multiple fistulas deteriorated further from the early postoperative period to 1 year postoperatively. Concerning frequency, 500 and 2000 Hz showed a delayed deterioration. This is a valuable report of delayed hearing loss after surgery in patients with a labyrinthine fistula. This change is associated with the labyrinthine fistula's depth and multiple fistulas-this is important during preoperative counseling of patients undergoing surgery.

Bezold's abscess, an uncommon complication of otitis media and cholesteatoma: a case report.

BACKGROUND: Mastoiditis frequently occurs in children as they are more susceptible to middle ear infections, but infrequently occurs in adults. A rare complication that results from mastoiditis and an obstructing cholesteatoma is a Bezold's abscess, of which there are less than 100 reported cases in literature to date. CASE PRESENTATION: Here, we present a case of a 72-year-old Caucasian man who has had no history of prior ear infections and was found to have a cholesteatoma and advanced acute coalescent mastoiditis complicated by a Bezold's abscess. CONCLUSIONS: Bezold's abscess is a rare entity infrequently encountered in the modern era, likely owing to more prompt treatment of otitis media. Cholesteatoma poses a great risk for both the development of otitis media and further progression to mastoiditis and its associated complications, such as Bezold's abscess. Knowledge of said abscess is crucial; without prompt recognition, further spread of infection can occur with vascular or mediastinal involvement.

Recurrent Cholesteatoma: Why it occurs?

A cholesteatoma is an expansion of keratinizing squamous epithelium that enters the middle ear cleft from the outer layer of the tympanic membrane or ear canal. Choleatomas are always treated surgically. Recurrence of the illness presents another challenge for the patient and the surgeon, though. There have been reports of recurrence rates as high as 30% in adults and as high as 70% in children. Here, we describe a case of persistent recurrent otorrhea following revision surgery, along with acquired recurrent cholesteatoma following canal wall down surgery. A 38-year -male with underlying Diabetes Mellitus and Hypertension presented with left scanty and foul-smelling ear discharge for 2 years and left reduced hearing. He was diagnosed with left chronic active otitis media with cholesteatoma for which he underwent left modified radical mastoidectomy, meatoplasty and tympanoplasty in 2017. Five months post operatively, he presented with left otorrhea. However, he defaulted followed up and presented in April 2018 for similar complaints. Otoscopy examination revealed left tympanic membrane perforation at poster superior quadrant of pars tensa and bluish discoloration behind pars flacida. He was diagnosed as recurrent left cholesteatoma and subsequently he underwent left mastoid exploration under general anesthesia in June 2018. Postsurgery, he developed recurrent ear discharge which was treated with topical antibiotics and ear toileting. We report a case of recurrent Cholesteatoma despite canal wall down procedure requiring a second redo procedure and with persistent recurrent otorrhea after the redo procedure.However, this case demonstrates the need for regular follow ups even after a canal wall down procedure for detecting recurrence of disease. Moreover, this case denotes some of the patient factors and surgeon factors involved in disease recurrence. Furthermore, importance of opting for an imaging study in case of high suspicion of the disease.

Surgical management of secondary acquired cholesteatoma depends on its characteristics.

OBJECTIVE: Cholesteatoma secondary to tympanic perforation, known as "secondary acquired cholesteatoma" may progress slower than a retraction pocket cholesteatoma, with less bone destruction and fewer intracranial complications. However, complete surgical removal remains difficult because the pathological epithelium on the marginal side of the extension is not covered by the subepithelial layer of the cholesteatoma matrix, making the boundary with the middle ear mucosa difficult to identify. Therefore, considering the pathophysiology of secondary acquired cholesteatoma, suitable preoperative evaluation and surgical techniques are required. In this study, we aimed to evaluate (i) the extension of secondary acquired cholesteatoma according to the size and location of tympanic membrane perforation; and (ii) the microscopic surgical outcomes, including the rate of residual cholesteatoma, requirement for specialized surgical management, and changes in hearing. METHODS: This retrospective study included data of cases with secondary acquired cholesteatoma (n = 66; 66 ears of 64 patients, 2 patients had bilateral ear involvement), including those who underwent a staged operation (n = 25). RESULTS: The perforation level of the tympanic membrane was associated with the cholesteatoma extension. When the cholesteatoma extended around the stapes, staged operation was chosen. Six cases of spontaneous resolution of stapes lesions at the time of staged surgery were observed. A significant postoperative improvement in hearing was observed; however, five cases experienced sensorineural hearing loss. CONCLUSION: Surgery, including staged surgery of the stapes lesions, along with careful observation of the perforation, is required in secondary acquired cholesteatoma. For lesions that are visible yet challenging to remove, it is imperative to exercise prudent judgment, taking into account the possibility of spontaneous resolution.

Hypertrophic pachymeningitis of the internal auditory canal and cerebellopontine angle from a large recurrent attic cholesteatoma.

OBJECTIVES: To describe a rare complication of cholesteatoma. METHODS: Case report with literature review. RESULTS: We report a case of a 37-year-old male who presented for evaluation of otorrhea, headache, and progressive left sensorineural hearing loss. Clinical and radiologic evaluation demonstrated a large recurrent attic cholesteatoma with erosion into the lateral and superior semicircular canals, and diffuse enhancement of the internal auditory canal and cerebellopontine angle suggestive of hypertrophic pachymeningitis secondary to cholesteatoma. After treatment with a course of antibiotics and canal wall down mastoidectomy surgery for cholesteatoma exteriorization, he experienced improvement of his symptoms and resolution of hypertrophic pachymeningitis. CONCLUSION: Hypertrophic pachymeningitis is a rarely described complication of cholesteatoma. In the context of cholesteatoma, treatment with antibiotics and surgical removal or exteriorization of cholesteatoma are effective treatments for HP.

Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis.

PURPOSE: To investigate the rate of residual disease in the Potsic staging system for congenital cholesteatomas. METHODS: A protocol registration was published on PROSPERO (CRD42022383932), describing residual disease as a primary outcome and hearing improvement as secondary. A systematic search was performed in four databases (PubMed, Embase, Cochrane Library, Web of Science) on December 14, 2022. Articles were included if cholesteatomas were staged according to the Potsic system and follow-up duration was documented. Risk of bias was evaluated using the Quality In Prognosis Studies (QUIPS) tool. In the statistical synthesis a random effects model was used. Between-study heterogeneity was assessed using I2. RESULTS: Thirteen articles were found to be eligible for systematic review and seven were included in the meta-analysis section. All records were retrospective cohort studies with high risk of bias. Regarding the proportions of residual disease, analysis using the χ2 test showed no statistically significant difference between Potsic stages after a follow-up of minimum one year (stage I 0.06 (confidence interval (CI) 0.01-0.33); stage II 0.20 (CI 0.09-0.38); stage III 0.06 (CI 0.00-0.61); stage IV: 0.17 (CI 0.01-0.81)). Postoperative and preoperative hearing outcomes could not be analyzed due to varied reporting. Results on cholesteatoma location and mean age at staging were consistent with those previously published. CONCLUSION: No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system's applicability for outcome prediction could not be proven based on the available data. Targeted studies are needed for a higher level of evidence.

Surgical Treatment for Troublesome Mastoid Cavities: Canal Wall Reconstruction With Bony Obliteration Versus Subtotal Petrosectomy.

INTRODUCTION: A chronically discharging modified radical mastoid cavity may require surgical intervention. We aim to explore two techniques. OBJECTIVE: To compare outcomes of subtotal petrosectomy (STP) and canal wall reconstruction with bony obliteration technique (CWR-BOT). STUDY DESIGN: Retrospective cohort study. SETTING: A tertiary referral center. PATIENTS: All patients with a chronically discharging mastoid cavity surgically treated at the Radboud University Medical Center by STP or CWR-BOT in 2015 to 2020, excluding patients with preoperative cholesteatoma. MAIN OUTCOME MEASURES: Dry ear rate, audiometry, and rehabilitation. SECONDARY OUTCOME MEASURES: Healing time, number of postoperative visits, complications, cholesteatoma, and need for revision surgeries. RESULTS: Thirty-four (58%) patients underwent STP, and 25 (42%) CWR-BOT. A dry ear was established in 100% of patients (STP) and 87% (CWR-BOT). The air-bone gap (ABG) increased by 12 dB in STP, and decreased by 11 dB in CWR-BOT. Postoperative ABG of CWR-BOT patients was better when preoperative computed tomography imaging showed aerated middle ear aeration. ABG improvement was higher when ossicular chain reconstruction took place. Mean follow-up time was 32.5 months (STP) versus 40.5 months (CWR-BOT). Healing time was 1.2 months (STP) versus 4.1 months (CWR-BOT). The number of postoperative visits was 2.5 (STP) versus 5 (CWR-BOT). Cholesteatoma was found in 15% (STP) versus 4% (CWR-BOT) of patients. Complication rate was 18% (STP) and 24% (CWR-BOT) with a need for revision in 21% (STP) and 8% (CWR-BOT), including revisions for cholesteatoma. CONCLUSION: STP and CWR-BOT are excellent treatment options for obtaining a dry ear in patients with a chronically discharging mastoid cavity. This article outlines essential contributing factors in counseling patients when opting for one or the other. Magnetic resonance imaging with diffusion-weighted imaging follow-up should be conducted at 3 and 5 years postoperatively.

Experience in the management of sigmoid sinus thrombophlebitis secondary to middle ear cholesteatoma.

OBJECTIVE: To discuss the management of sigmoid sinus thrombophlebitis secondary to middle ear cholesteatoma. METHODS: We retrospectively analyzed all cases of sigmoid sinus thrombophlebitis caused by middle ear cholesteatoma over a period of 7 years. 7 male and 2 female patients, ranging in age from 9 to 66 years, were diagnosed with sigmoid sinus thrombophlebitis by clinical presentation and radiological examination. By executing a modified mastoidectomy and tympanoplasty (canal wall-down tympanoplasty) to entirely remove the cholesteatoma-like mastoid epithelium, all patients were effectively treated surgically without opening the sigmoid sinus. All patients were treated with broad-spectrum antibiotics, but no anticoagulants were used. RESULTS: 9 patients had otogenic symptoms such as ear pus, tympanic membrane perforation, and hearing loss. In the initial stage of the surgery, modified mastoidectomy and tympanoplasty were performed on 8 of the 9 patients. 1 patient with a brain abscess underwent puncturing (drainage of the abscess) to relieve cranial pressure, and 4 months later, a modified mastoidectomy and tympanoplasty were carried out. Following surgery and medication, the clinical symptoms of every patient improved. After the follow-up of 6 months to 7 years, 3 patients were re-examined for MRV and showed partial sigmoid sinus recovery with recanalization. 4 months following middle ear surgery, the extent of a patient's brain abscess lesions was significantly reduced. 1 patient experienced facial paralysis after surgery and recovered in 3 months. None of the patients had a secondary illness, an infection, or an abscess in a distant organ. CONCLUSION: The key to a better prognosis is an adequate course of perioperative antibiotic medication coupled with surgical treatment. A stable sigmoid sinus thrombus can remain for a long time after middle ear lesions have been removed, and it is less likely to cause infection and abscesses in the distant organs. The restoration of middle ear ventilation is facilitated by tympanoplasty. It is important to work more closely with multidisciplinary teams such as neurology and neurosurgery when deciding whether to perform lateral sinusotomies to remove thrombus or whether to administer anticoagulation.

Diagnosis and treatment of congenital stenosis of external auditory canal with external auditory canal cholesteatoma complicated with exudative effusion in the middle ear and mastoid process.

BACKGROUND: The optimal timing for surgery to promote postoperative recovery in children with congenital stenosis of the external auditory canal with external auditory canal cholesteatoma, who are susceptible to exudative inflammation of middle ear and mastoid process, is still uncertain. OBJECTIVES: To investigate the treatment of congenital stenosis of external auditory canal with external auditory canal cholesteatoma complicated with exudative inflammation. MATERIAL AND METHODS: A retrospective analysis of 45 patients with congenital stenosis of external auditory canal with external auditory canal cholesteatoma complicated with mastoiditis. Based on whether effusion had resolved at the time of surgery, the patients were divided into two groups. Pure-tone audiometry tests were performed before and after surgery for both groups. RESULTS: The average postoperative duration of dry ear was 36.38 days in Group 1 and 47.90 days in Group 2 (p < 0.05). Among patients who underwent hearing reconstruction, the average air conduction threshold decreased by 15-36 dBHL in Group 1 and by 7-22 dBHL in Group 2 (p < 0.05). CONCLUSIONS AND SIGNIFICANCE: The postoperative outcomes of dry ear and hearing improvement can be enhanced by performing operation after effusion resolution in cases of congenital external auditory canal stenosis with external auditory canal cholesteatoma exudative inflammation.

A case report of middle ear cholesteatoma complicated with labyrinthine fistulaand delayed endolymphatic hydrops / 临床耳鼻咽喉头颈外科杂志

Delayed endolymphatic hydrops （DEH） is a rare disease that causes vertigo and is often misdiagnosed as other vertigo diseases. This article reports on a patient with vertigo who was easily misdiagnosed. The patient was a middle ear cholesteatoma complicated by labyrinthine fistula （LF）; however, his vertigo was episodic vertigo, which could not be explained solely by LF causing labyrinthitis. The possibility of endolymphatic hydrops was suspected, which was confirmed by inner ear magnetic resonance gadolinium imaging. This is the first reported case of middle ear cholesteatoma complicated by LF and DEH. The patient underwent surgical resection of the cholesteatoma and three semicircular canal obstructions at the same time. During two years postoperative follow-up, the patient did not experience a recurrence of vertigo. When diagnosing vertigo diseases, a careful history of vertigo is of utmost importance.

Clues for facial canal dehiscence in chronic otitis media

Introduction and objectives: The goal of this study was to determine the impact of external and middle ear findings in the incidence of facial canal dehiscence (FCD) during mastoidectomy for chronic otitis media.Material and methodsWe examined the operative details of 186 patients who underwent primary tympanomastoidectomy for chronic otitis media between January 2015 and January 2020 retrospectively.In this study we only evaluated the second portion of the facial nerve canal.ResultsThe global prevalence of FCD was 22.6% (42/186 patients) with a higher incidence, of 38.7% (36/93), in patients with chronic otitis media with cholesteatoma (C-COM).Associations were found between facial canal dehiscence, labyrinthine fistula (p˂ .001) and facial nerve paralysis (p˂ .001).Ossicular erosions were observed at a significant level in patients with facial canal dehiscence, the incidence of FCD was significantly higher (p=.005, Odds ratio 5.489) when malleus and incus were eroded, incus plus stapes were eroded (p=.014; OR 4.059) and malleus, incus, and stapes together were eroded (p=.002; OR 4.929).ConclusionsThis study revealed an incidence of facial canal dehiscence of 22.6%. It also revealed that the presence of lateral semicircular canal fistula is associated with a higher prevalence of facial canal dehiscence.The same was noted in the case of some ossicular erosions, especially the combinations of eroded malleus and incus, incus and stapes, and all 3 ossicles. (AU)

Introducción y objetivos: El objetivo de este estudio fue determinar el impacto de los hallazgos del oído externo y medio en la incidencia de dehiscencia del canal facial (DCF) durante la mastoidectomía por otitis media crónica.Material y métodosExaminamos los detalles quirúrgicos de 186 pacientes intervenidos de timpanomastoidectomía primaria por otitis media crónica entre enero de 2015 y enero de 2020 de forma retrospectiva.En este estudio solo evaluamos la segunda porción del canal del nervio facial.ResultadosLa prevalencia global de DCF fue del 22,6% (42/186 pacientes) con una incidencia mayor, del 38,7% (36/93), en pacientes con otitis media crónica con colesteatoma (C-COM).Se encontraron asociaciones entre DCF, fístula laberíntica (p ˂ 0,001) y parálisis del nervio facial (p ˂ 0,001).Se observaron erosiones osiculares significativas en pacientes con DCF. La incidencia de DCF fue significativamente mayor (p=0,005; odds ratio 5.489) cuando el martillo y el yunque estaban erosionados, el yunque y el estribo erosionados (p=0,014; OR 4,059) y erosiones del martillo, yunque y estribo juntos (p=0,002; OR 4,929).ConclusionesEste estudio reveló una incidencia de DCF del 22,6%. También reveló que la presencia de fístula del canal semicircular lateral se asocia con una mayor prevalencia de DCF.Lo mismo se observó en el caso de algunas erosiones osiculares, especialmente las combinaciones de martillo y yunque, yunque y estribo, y los 3 huesecillos erosionados. (AU)

Association between facial nerve second genu angle and facial canal dehiscence in patients with cholesteatoma: evaluation with temporal multidetector computed tomography and surgical findings / Associação entre o ângulo do segundo joelho do nervo facial e deiscência do canal facial em pacientes com colesteatoma: avaliac¸ão do osso temporal por tomografia com multidetectores e pelos achados cirúrgicos

Abstract Introduction: Otitis media, mastoiditis or the pressure effect of tumorous lesions such as cholesteatoma can be the cause of facial canal dehiscence and facial nerve paralysis. The most common segment involved in dehiscence is the tympanic segment and the second most common is the lateral aspect of the facial canal in the oval window area. Objective: To determine the prevalence of the facial canal dehiscence and the relationship between the angle at the second genu of the facial nerve and facial canal dehiscence. Methods: We evaluated the surgical findings in 113 patients who underwent surgery for cholesteatoma. Facial canal dehiscence was detected in 62 of the 113 patients. Patients were divided into two groups: Group 1, with dehiscence of the facial canal and Group 2, without dehiscence of the facial canal. Results: The mean angles at the second genu of the facial nerve in Groups 1 and 2 were 117.8º ± 9.63º and 114º ± 9.9º, respectively. There was a statistically significant difference between the mean angles at the second genu for the two groups (p = 0.04). Conclusion: In patients with dehiscence of the facial canal, the angle at the second genu was found to be wider than those without dehiscence.

Resumo Introdução: Otite média, mastoidite ou a compressão por lesões tumorais como o colesteatoma podem ser a causa da deiscência do canal facial e paralisia do nervo facial. A deiscência ocorre mais frequentemente no segmento timpânico, seguido do aspecto lateral do canal facial na área da janela oval. Objetivo: Determinar a prevalência da deiscência do canal facial e sua relação com o ângulo no segundo joelho do nervo facial. Método: Avaliamos os achados cirúrgicos para detecção de deiscência do canal facial em 113 pacientes submetidos à cirurgia de colesteatoma. A deiscência do canal facial foi observada em 62. Os pacientes foram divididos em dois grupos: Grupo 1, com deiscência do canal facial, e Grupo 2, sem deiscência do canal facial. Resultados: Os ângulos médios no segundo joelho do nervo facial nos grupos 1 e 2 foram 117,8º ± 9,63º e 114º ± 9,9º, respectivamente. Houve diferença estatisticamente significante entre os ângulos médios no segundo joelho para os dois grupos (p = 0,04). Conclusão: Em pacientes com deiscência no canal facial, foi observado que o ângulo do segundo joelho era maior do que naqueles sem deiscência.

Cholesteatoma labyrinthine fistula: prevalence and impact / Fístula labiríntica por colesteatoma: prevalência e impacto

Abstract Introduction: Labyrinthine fistula is one of the most common complications associated with cholesteatoma. It represents an erosive loss of the endochondral bone overlying the labyrinth. Reasons for cholesteatoma-induced labyrinthine fistula are still poorly understood. Objective: Evaluate patients with cholesteatoma, in order to identify possible risk factors or clinical findings associated with labyrinthine fistula. Secondary objectives were to determine the prevalence of labyrinthine fistula in the study cohort, to analyze the role of computed tomography and to describe the hearing results after surgery. Methods: This retrospective cohort study included patients with an acquired middle ear cholesteatoma in at least one ear with no prior surgery, who underwent audiometry and tomographic examination of the ears or surgery at our institution. Hearing results after surgery were analyzed according to the labyrinthine fistula classification and the employed technique. Results: We analyzed a total of 333 patients, of which 9 (2.7%) had labyrinthine fistula in the lateral semicircular canal. In 8 patients, the fistula was first identified on image studies and confirmed at surgery. In patients with posterior epitympanic and two-route cholesteatomas, the prevalence was 5.0%; and in cases with remaining cholesteatoma growth patterns, the prevalence was 0.6% (p = 0.16). In addition, the prevalence ratio for labyrinthine fistula between patients with and without vertigo was 2.1. Of patients without sensorineural hearing loss before surgery, 80.0% remained with the same bone conduction thresholds, whereas 20.0% progressed to profound hearing loss. Of patients with sensorineural hearing loss before surgery, 33.33% remained with the same hearing impairment, whereas 33.33% showed improvement of the bone conduction thresholds' Pure Tone Average. Conclusion: Labyrinthine fistula must be ruled out prior to ear surgery, particularly in cases of posterior epitympanic or two-route cholesteatoma. Computed tomography is a good diagnostic modality for lateral semicircular canal fistula. Sensorineural hearing loss can occur post-surgically, even in previously unaffected patients despite the technique employed.

Resumo Introdução: A fístula labiríntica é uma das complicações mais comuns associadas ao colesteatoma. Representa uma perda erosiva do osso endocondral que recobre o labirinto. As razões para a ocorrência da fístula labiríntica induzida pelo colesteatoma ainda são mal compreendidas. Objetivo: Avaliar pacientes com colesteatoma, a fim de identificar possíveis fatores de risco ou achados clínicos associados à fístula labiríntica. Os objetivos secundários foram determinar a prevalência de fístula labiríntica no estudo de coorte, analisar o papel da tomografia computadorizada e descrever os resultados auditivos após a cirurgia. Método: Este foi um estudo de coorte retrospectivo. Foram incluídos pacientes com colesteatoma adquirido de orelha média em pelo menos um lado sem cirurgia prévia que haviam sido submetidos à audiometria e tomografia computadorizada de orelha ou cirurgia em nossa instituição. Os resultados auditivos após a cirurgia foram analisados de acordo com a classificação de fístula labiríntica e da técnica empregada. Resultados: Analisamos um total de 333 pacientes, dos quais 9 (2,7%) apresentavam fístula labiríntica no canal semicircular lateral. Em 8 pacientes, a fístula foi identificada na tomografia computadorizada e confirmada durante a cirurgia. Em pacientes com colesteatomas epitimpânicos posteriores e de via dupla, a prevalência foi de 5,0%; e nos casos com padrão de crescimento de colesteatoma remanescente, a prevalência foi de 0,6% (p = 0,16). Além disso, a taxa de prevalência de fístula labiríntica entre pacientes com e sem vertigem foi de 2,1. Dos pacientes sem perda auditiva neurossensorial antes da cirurgia, 80,0% permaneceram com os mesmos limiares de condução óssea, enquanto 20,0% progrediram para perda auditiva profunda. Dos pacientes com perda auditiva neurossensorial antes da cirurgia, 33,33% permaneceram com a mesma deficiência auditiva, enquanto 33,33% apresentaram melhora da média de dos limiares de condução óssea aos tons puros. Conclusão: A fístula labiríntica deve ser descartada antes do procedimento cirúrgico, particularmente nos casos de colesteatomas epitimpânicos posteriores e de dupla via. A tomografia computadorizada é uma boa modalidade diagnóstica para a fístula do canal semicircular lateral. A perda auditiva neurossensorial pode ocorrer pós-cirurgicamente, mesmo em pacientes previamente não afetados, a despeito da técnica empregada.

Paralysies faciales périphériques d'origine choléstéatomateuse : diagnostic et traitement

But :discuter les modalités diagnostiques et thérapeutiques des paralysies faciales périphériques d'origine choléstéatomateuse.Matériel et méthodes :étude rétrospective sur une période de 20 ans (1994- 2013). Mille quatre cent vinght trois patients ont été opérés pour otite moyenne choléstéatomateuse. Sept cas compliqués d'une paralysie faciale périphérique ont fait l'objet de ce travail.Résultats :L'incidence de la paralysie faciale était de 0,5%. La paralysie faciale était d'installation brutale chez quatre patients et progressive dans trois cas. Elle était partielle dans cinq cas et complète chez deux patients. En per opératoire, le canal facial était intact dans 4 cas. La matrice de cholésteatome était disséquée sans ouverture de la gaine du nerf dénudé et en respectant le canal facial indemne. L'évolution était favorable dans les cas où le canal facial était intact. Conclusion : La paralysie faciale d'origine choléstéatomateuse est une urgence chirurgicale. Plusieurs facteurs conditionnent le pronostic, dominés par l'intégrité du canal facial osseux

Hearing loss assessment in primary and secondary acquired cholesteatoma, / Potenciais evocados auditivos de longa latência com verbais e não verbais

ABSTRACT INTRODUCTION: Acquired middle ear cholesteatoma can be classified as primary or secondary. Although both can result in hearing loss, it is still controversial whether there is an association between the type of cholesteatoma and the degree of hearing loss. OBJECTIVE: To analyze the association between hearing loss and the type of acquired cholesteatoma, and the status of the ossicular chain. METHODS: This was a cross-sectional historical cohort study involving patients diagnosed with acquired cholesteatoma who were surgically treated. Air and bone conduction thresholds, air-bone gaps and the status of the ossicular chain were analyzed for both types of cholesteatoma. RESULTS: Eighty patients aged 5-57 were included in the study. Fifty-one patients had primary cholesteatoma and 29 had secondary cholesteatoma. Both types of cholesteatoma determined greater air-bone gaps at 0.5 kHz. Secondary cholesteatoma determined greater hearing loss in all analyzed frequencies and higher air conduction and air-bone gap means. CONCLUSION: There was association between hearing loss and the type of cholesteatoma. Secondary cholesteatoma resulted in greater hearing impairment.

RESUMO INTRODUÇÃO: O colesteatoma adquirido de orelha média pode ser classificado como primário e secundário. Ambos podem ocasionar perda de audição, mas ainda há controvérsia quanto à relação dos tipos de colesteatoma com a perda auditiva. OBJETIVO: Analisar a relação dos tipos de colesteatoma e da erosão da cadeia ossicular com a perda auditiva. MÉTODO: Estudo de coorte histórica com corte transversal, envolvendo pacientes que receberam o diagnóstico de colesteatoma adquirido e foram submetidos à cirurgia otológica. Foram analisados os limiares ósseos, aéreos e a diferença aéreo-óssea, e suas associações com os tipos de colesteatoma e com a presença de erosão na cadeia ossicular. RESULTADOS: No estudo foram incluídos oitenta pacientes, com idade entre 5 e 57 anos, sendo 51 com colesteatoma primário e 29 com colesteatoma secundário. Ambos os tipos de colesteatoma determinaram maior diferença aéreo-óssea na frequência de 0,5 kHz. O colesteatoma secundário determinou uma perda auditiva maior em todas as frequências analisadas, e maiores médias do limiar aéreo e da diferença aéreo-óssea. CONCLUSÃO: Houve associação entre o tipo de colesteatoma e a perda de audição. O colesteatoma secundário determinou maior comprometimento da audição.

Avaliação da expressão gênica de metaloproteinases de matriz e seus inibidores em colesteatomas por amplificação de ácidos nucleicos / Cholesteatoma gene expression of matrix metalloproteinases and their inhibitors by RT-PCR

O colesteatoma adquirido da orelha média é uma lesão epitelial escamosa queratinizante e hiperproliferativa benigna que pode resultar na destruição das estruturas ósseas circunvizinhas do osso temporal. Estudos recentes demonstram que alterações na produção celular de metaloproteinases de matriz (MMPs) e seus inibidores específicos (TIMPs) contribuem para a fisiopatologia do colesteatoma. OBJETIVO: Verificar a aplicabilidade da amplificação de RNA para avaliação da expressão de isoformas de MMPs e TIMPS em colesteatomas para correlação com a agressividade da doença. MATERIAIS E MÉTODOS: Estudo prospectivo. Dezenove casos de colesteatomas em diferentes estágios de evolução foram selecionados. RNA extraído das biópsias foi submetido à transcrição reversa - reação da polimerase em cadeia (RT-PCR) para amplificação semiquantitativa de MMP2, MMP3, MMP9, MMP13 e TIMP1. Resultados: Seis colesteatomas apresentaram reação positiva para pelo menos um dos genes estudados. Quatro amostras amplificaram apenas um gene (MMP2 ou MM13) e duas amostras amplificaram três genes (MMP2, TIMP1 e MMP3 ou MMP13). Nenhuma amostra amplificou MMP9. CONCLUSÃO: A avaliação da expressão gênica de MMPs e TIMPs em colesteatomas pode ser realizada por RT-PCR, apesar de dificuldades técnicas. Não foi possível realizar associação entre o perfil de expressão gênica e a agressividade da doença.

Acquired middle ear cholesteatoma is a benign keratinizing hyperproliferative squamous epithelial lesion that may result in the destruction of the bone structures surrounding the temporal bone. Recent studies show that variations in cellular production of matrix metalloproteinases (MMPs) and their specific inhibitors (TIMPs) contribute to the pathophysiology of cholesteatoma. OBJECTIVE: This study aims to analyze the use of RNA amplification tests to evaluate the expression of MMP and TIMP isoforms in cholesteatomas and their correlation with disease severity. MATERIALS AND METHODS: This is a prospective study. Nineteen cholesteatoma cases at different stages were selected. RNA collected from biopsy specimens was submitted to reverse transcription polymerase chain reaction (RT-PCR) for semiquantitative amplification of MMP2, MMP3, MMP9, MMP13 and TIMP1. RESULTS: Six cholesteatomas were positive for at least one of the studied genes. Four samples amplified a single gene (MMP2 or MMP13) and two samples amplified three genes (MMP2, TIMP1 and MMP3 or MMP13). No sample amplified MMP9. CONCLUSION: RT-PCR can be used to assess MMP and TIMP gene expression in cholesteatomas despite technical difficulties. Gene expression profiles could not be related to disease severity.

El osteoma en la mastoides, ¿un hallazgo incidental? / The mastoid osteoma, an incidental feature?

Los osteomas mastoideos son tumores óseos benignos que excepcionalmente aparecen en la mastoides, habiendo sido descritos 137 casos en la literatura actual. Suelen presentarse de un modo asintomático, aunque no siempre es así. Presentamos 3 casos de osteomas mastoideos: un osteoma pediculado con base de implantación en el antro mastoideo y con extensión hacia el canal ático antral, que coexistía con una otitis media colesteatomatosa, un osteoma mastoideo superficial asintomático y un osteoma sesil dependiente de la tabla interna de la escama del hueso temporal, en una paciente con un cuadro vertiginoso. Hacemos una revisión de esta rara entidad, y planteamos una posible asociación entre el osteoma mastoideo, el síndrome vertiginoso y la otitis media colesteatomatosa (AU)

Osteoma in the mastoid is a rare benign osteogenic tumour that has been described in literature in only 137 cases. It usually appears in asymptomatic patients, although a few cases are described associated with clinical manifestations. We report three cases of mastoid osteoma: a pedunculated osteoma in the aditus ad antrum (associated with a cholesteatoma), a superficial osteoma of the mastoid surface and a sessile osteoma that progressed to the temporal lobe (associated with vertigo). A brief review of this rare entity is presented and a possible association between mastoid osteoma, cholesteatoma otitis and vertigo is posed (AU)

Gustatory alteration evaluation in patients with chronic otitis media / Avaliação de alteração gustatória em pacientes com otite média crônica

Many studies have shown the consequent gustatory alteration caused by ear surgeries. However, few have reported this alteration in patients with chronic otitis media (COM), prior to surgical treatment. AIM: to identify gustatory alterations due to chorda tympani nerve involvement in patients with COM without prior surgery. METHODS: Clinical essay, with tests based on "taste strips" with different concentrations of salt, sweet, bitter, and sour, was performed in 45 patients with unilateral cholesteatomatous or suppurated COM not previously submitted to otological surgery, using the disease-free ear on the contralateral side as control. The score ranged between 0 and 16. RESULTS: A total of 25 patients presented cholesteatoma and 20 had non-cholesteatomatous disease. The mean score was 6.65 for the affected side and 9.93 for the half of the tongue on the side of the healthy ear (p<0.001). No patients had complained of gustatory alterations before the examination. Among the 24 patients with unilateral hypogeusia, eight cases of unilateral ageusia were found on the affected side. There was an association between cholesteatoma (p=0.055), disease duration (p=0.07) and worsening in gustatory sensitivity. CONCLUSION: Patients with COM can have gustatory alterations, even in the absence of complaints.

Muitos estudos mostraram a consequente alteração do paladar após cirurgia otológica. Entretanto, poucos reportaram essa alteração como uma queixa de pacientes com otite média crônica (OMC) previamente à cirurgia. OBJETIVO: Avaliar alterações na função gustatória na área inervada pelo nervo corda do tímpano em pacientes com OMC ainda não submetidos à cirurgia. MATERIAL E MÉTODOS: O ensaio clínico, com teste gustatório baseado em "tiras gustativas" com diferentes concentrações de sal, doce, amargo e azedo, foi realizado em 45 pacientes com OMC colesteatomatosa e não-colesteatomatosa unilateral, nunca antes submetidos à cirurgia otológica, utilizando a metade da língua do lado livre de doença otológica como controle. As notas variavam de 0 a 16. RESULTADOS: 25 pacientes apresentavam colesteatoma e o restante OMC não-colesteatomatosa. A pontuação média foi de 6,65 para o lado afetado e 9,93 para a metade da língua do lado sadio (p<0,001). Nenhum paciente se queixava de alteração do paladar antes do exame. Encontramos 24 casos de hipogeusia do lado afetado, sendo 8 (17,7 por cento) casos de ageusia. Houve uma relação entre tempo de doença (p=0,07) e colesteatoma (p=0,055) com piora da sensibilidade gustativa. CONCLUSÃO: Pacientes com OMC podem apresentar alteração gustativa, mesmo na ausência de queixas.

Miringoplastias primarias. Resultados a los 2 años de seguimiento / Primary myringoplasties. Results after a 2 year follow-up period

Introducción y objetivos: La miringoplastia tiene como finalidad el cierre de la perforación timpánica y mejorar la audición, con resultados variables en la literatura. Nuestro objetivo fue saber cuál es la realidad de esta cirugía en nuestro centro y compararla con la publicada. Métodos: Análisis retrospectivo de 217 miringoplastias primarias efectuadas en el Servicio de Otorrinolaringología del Hospital Universitario Ramón y Cajal entre los años 1998 y 2003, con descripción de las características de perforación, técnica quirúrgica y resultados postoperatorios (cierre de la perforación y mejoría de la audición). Resultados: En su mayoría eran adultos y la etiología principal fue la secuela otorreica (91 %). Predominaron perforaciones menores a subtotal en tamaño (64 %) que no afectaban al anillo timpánico (79 %). La técnica de colocación del injerto respecto al resto timpánico fue lateral (45 %), mixta (29 %) y medial (26 %); se utilizó el abordaje retroauricular (66 %) y endoaural (34 %). La fascia de músculo temporal fue el injerto más utilizado (87 %). El cierre de la perforación se consiguió entre un 78 y un 91 % de los casos a lo largo de los 24 meses de seguimiento, con un valor final del 78 % a los 2 años de seguimiento. La mejora de la audición, reflejada como un umbral diferencial audiométrico menor de 20dB, se observó en aproximadamente el 56 % de los casos. Conclusiones: La miringoplastia en nuestro centro alcanza cifras de éxito anatómico (78 %) y funcional (56 %) comparables con las de la literatura. Consideramos fundamental el seguimiento a medio plazo de los pacientes por el fenómeno de reperforación, que puede ocurrir hasta pasados 2 años o más (AU)

Introduction and goals: The goals of myringoplasty are closure of the perforation in the tympanic membrane and improvement in hearing levels, with varying results in the published literature. Our aim was to determine the results of this procedure at our centre and compare them with the literature. Methods: Retrospective analysis of 217 primary myringoplasties carried out in the Otorhinolaryngology Department of the Ramón y Cajal University Hospital between 1998 and 2003, describing the characteristics of the perforations, surgical technique and post-operative results (perforation closure and hearing improvement). Results: The majority were adults with perforations secondary to recurrent middle ear infections (91 %). Most were less than sub-total (64 %) and did not involve the tympanic annulus (79 %). Grafts were inserted using lateral (45 %), mixed (29 %) and medial (26 %) techniques, using retroauricular (66 %) and endaural (34 %) approaches. Temporal muscle fascia was the graft most frequently used (87 %). Perforation closure was achieved in between 78 % and 91 % of cases throughout the 24-month follow-up period, with an overall closure value of 78 % after 2years of follow-up. Hearing improvement, established as an air bone gap difference of less than 20dB, was seen in proximately 56 % of cases. Conclusions: At our centre, myringoplasty achieves anatomical (78 %) and functional (56 %) success comparable to the results described in the literature. We consider medium-term follow-up to be of the utmost importance because of reperforation phenomena, which may occur as much as 2 years or more after surgery (AU)