Four-Hour-Delayed Gadolinium 3D REAL IR and SPACE FLAIR MRI Correlated to Meniere Disease Histology.

Objectives: This study aims to showcase the complementary nature of utilizing both histopathology and magnetic resonance imaging (MRI) in understanding the otologic pathophysiology of Meniere disease. In addition, it seeks to raise awareness of the value of preserving and curating historical temporal bone collections which continue to inform our understanding of otologic diseases. Methods: The essential anatomical feature of Meniere disease-the distended membranous labyrinth-is explored through a comparison of early temporal bone studies with contemporary MRI techniques. The histopathologic photomicrographs are of inner ear specimens from deceased patients with symptoms consistent with Meniere disease. The MRI sequences from living patients exhibiting classic Meniere disease symptoms during life are captured 4 hours post-administration of gadolinium. Results: Both histopathologic examination and MRI imaging reveal consistent distention of the saccule, utricle, and scala media in patients with Meniere disease. The study shows the histologic photomicrographs of actual Meniere patients compared to the MRIs and successfully demonstrates the correlation between postmortem histological findings and MRI evidence of distension in living patients. Conclusions: A corresponding distension of the membranous labyrinth is seen in both the histologic specimens and the Meniere MRIs. This correlation suggests the potential utility of utilizing MRI to aid in diagnosing atypical Meniere disease and distinguishing it from other disease processes, such as migraine equivalent vertigo. The integration of historical temporal bone studies with modern MRI techniques offers valuable insights into the pathophysiology of otologic diseases. In addition, it emphasizes the importance of preserving and curating historical temporal bone collections for continued research and medical education purposes. Previous studies of delayed MRIs did not use Meniere disease temporal bone histopathology images.

Endoscopic classification system of pars tensa retractions.

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

Management of attic retraction pockets.

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

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

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

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

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

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

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

Prevalence of Hearing Loss, and Middle Ear Disease in 1351 School Age Children in Mekelle, Ethiopia.

OBJECTIVES: The objective of this study was to begin to measure the prevalence of elevated hearing thresholds in Ethiopia, with audiometric equipment, including bone oscillators and tympanometers. To that end Ethiopian nationals were trained in audiometric techniques to obtain sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) rates in school age children. METHODS: Five mainstreamed public grade schools in northern Ethiopia were the sites for audiometry campaigns examining 1351 children and testing them with behavioral audiometry. RESULTS: Seven percent of students had SNHL > 20 dB in at least 1 frequency in at least 1 ear, and 0.6% of ears had SNHL > 50 dB. Eighteen percent8% of students had CHL > 20 dB in 1 or both ears. The frequency with the highest incidence of elevated pure tone thresholds was at 8000 Hz. Seven percent of students had an air bone gap at 2000 and/or 4000 Hz of at least 15 dB. Air bone gap is not obtained at 8000 Hz. There were 22 perforated tympanic membranes in 17 children (0.8% of tympanic membranes, 1% of students). CONCLUSION: This study gives a baseline for the prevalence of hearing loss in school age children in mainstreamed northern Ethiopian schools. It is the first of its kind and perhaps can help in estimated hearing health needs there. LEVEL OF EVIDENCE: 2.

Assessing the Impact of a Training Initiative for Nasopharyngeal and Oropharyngeal Swabbing for COVID-19 Testing.

OBJECTIVE: The accuracy and reliability of COVID-19 testing are critical to limit transmission. After observing variability in testing techniques, we otolaryngologists at a tertiary medical center initiated and evaluated the impact of nasopharyngeal and oropharyngeal swabbing training, including video instruction, to standardize sampling techniques and ensure high-quality specimens. METHODS: Participants in the training were employees (N = 40). Training consisted of an instructional video on how to perform nasopharyngeal and oropharyngeal swabs and a live demonstration. Participants completed pre- and posttraining surveys assessing their knowledge and confidence in performing nasopharyngeal and oropharyngeal swabs. They then performed swabbing on partners, which was graded per a standardized checklist. RESULTS: Mean scores for knowledge-based questions and confidence in swabbing were significantly higher after the training session (both P < .001). All participants scored ≥6 of 8 on the posttraining checklist. Ninety-five percent rated the video as very or extremely useful. DISCUSSION: Specialized instruction for nasopharyngeal swabbing improved participants' knowledge-specifically, the appropriate head position and minimum swab time in nasopharynx-and their confidence. After the training, their swabbing execution scores were high. IMPLICATIONS FOR PRACTICE: Video-assisted hands-on instruction for nasopharyngeal swab sampling can be used to standardize teaching. When prompt and accurate testing is paramount, this instruction can optimize procedural technique and should be used early and often. In addition, there may be a professional responsibility of otolaryngologists to participate in such initiatives.

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

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

The effect of surgeon experience on tympanic membrane closure.

OBJECTIVE: Review of the English language literature finds little documentation of the relation of otology or otolaryngology outcomes to a surgeon's age, years in practice, or numbers of cases previously performed. Because of one surgeon's adoption of a new tympanoplasty technique for uncomplicated tympanic membrane perforations, our institution was situated to report an example of a surgical learning curve with its outcome. Experience versus outcome is worth establishing objectively because these relationships reflect on training and certification. DESIGN: This retrospective review of the medical records tallied preoperative risk factors and perforation sizes for four consecutive 100-blocks of double-layer tympanoplasties. SETTING: An otology specialty care facility in Addis Ababa, Ethiopia. PARTICIPANTS: Participants were 359 patients with tympanic membrane perforations without ossicular discontinuity or erosion who underwent 400 primary simple tympanoplasties. INTERVENTION: A double-layer tympanoplasty was performed in each operation using an endaural approach. OUTCOME MEASURES: The outcomes were closure of the perforation and change in hearing. RESULTS: There were no statistically significant differences between the four 100-block case cohorts in preoperative risk factors and perforation sizes. Preoperative, postoperative, and change of hearing were also the same between the four groups; and statistically there was no significant difference between the four 100-block cohorts. Perforation closure for each successive 100-block increased from 74% to 98%. The closure rates of the second, third, and fourth 100-block were each statistically significantly different from the first 100-block, but not from each other. CONCLUSION: This simple study demonstrates the surgical learning curve with increased surgeon experience, and is one of very few such documentations. With each additional 100 cases, the outcomes improved, and sheds light on the numbers of cases necessary for competency. LEVEL OF EVIDENCE: 3.

Diagnostic Protocol for Detecting Otosclerosis on High-Resolution Temporal Bone CT.

OBJECTIVES: To present a systematic checklist to improve diagnosing otosclerosis (OS) on high-resolution computed tomography (HRCT) of the temporal bones and review this protocol's efficacy in diagnosing OS on HRCT. METHODS: A retrospective case series was performed at a University Referral Hospital in urban Chicago, Illinois. High-resolution computed tomographies of the temporal bone were reviewed including 17 ears in the test group with surgically confirmed OS and 21 ears in the control group surgically confirmed to not have OS. Preoperative HRCTs were evaluated by a single neuroradiologist using a systematic protocol created to assist in diagnosing OS. This looked for radiolucency at the fissula ante fenestram and pericochlear region, and new bone formation around the oval and round windows. RESULTS: The radiologist accurately diagnosed OS in all 17 test group ears and ruled out OS in all 21 control group ears using the protocol. All 17 test ears were read to have lucency at the fissula ante fenestram, 9 (53.0%) to have new bone formation, and 8 (47.1%) to have cochlear lucency. The radiologist was more confident in diagnosing OS when cochlear lucency was present with the fissula ante fenestram lucency. CONCLUSIONS: This HRCT checklist is a highly accurate tool for evaluating the presence of OS when images are reviewed in the systematic fashion described. Imaging prior to surgery aids in counseling patients, preparing surgically, and excluding other pathologies.

Langerhans' cell histiocytosis of the temporal bone in an adult with central diabetes insipidus.

We present a case of Langerhans' cell histiocytosis in a 40-year-old woman presenting with central diabetes insipidus and right ear pain. As this disease process is often clinically challenging, the presence of certain imaging findings should raise the possibility of this diagnosis. We review the pertinent imaging and correlate with histology and immunohistochemistry leading to the diagnosis.

Stapedectomy Is Rewarding: But How to Prove It?

OBJECTIVE: To demonstrate that neurotologists enjoy performing stapedectomies. SUBJECTS: A group of survey recipients consisting of 174 neurotologists who perform stapedectomy, a nonoverlapping control group of 145 head/neck oncologists who perform parotidectomy, and a second nonoverlapping control group of 365 pediatric otolaryngologists who perform tonsillectomy. OUTCOME MEASURES: Responses to surveys distributed by electronic mail to the 3 nonoverlapping recipient groups during nonoverlapping 4-week periods. RESULTS: During the 4-week survey periods, 84 of 174 neurotologists (48%) responded, while 33 of 145 oncologists (23%) and 87 of 365 pediatric otolaryngologists (24%) responded. Most neurotologists performed stapedectomy (80/84; 95% of survey responders), while 33 of 33 (100% of survey responders) oncologists performed parotidectomy and 87 of 87 (100% of survey responders) pediatric otolaryngologists performed tonsillectomy. Seventy-six of the 80 neurotologists who performed stapedectomies (95%) enjoyed performing it, slightly more than the 30 of the 33 oncologists who performed parotidectomies (91%) and appreciably more than the 67 of 87 pediatric otolaryngologists who performed tonsillectomies (77%). Twenty-three neurotologists (30%) would sacrifice vacation time to perform additional stapedectomies, slightly more than 8 oncologists (27%) for additional parotidectomies and more than the 7 pediatric otolaryngologists (10%) for additional tonsillectomies. Ten (13%) of the neurotologists, 3 (9%) of the oncologists, and 1 (2%) of the pediatric otolaryngologists would sacrifice 5 or more vacation days to perform more of the procedures. CONCLUSIONS: Our data suggest that neurotologists enjoy performing stapedectomy.

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

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

Double-Layer Tympanic Membrane Graft in Type I Tympanoplasty.

BACKGROUND: Some discussion remains among otologists regarding the best grafts for tympanic membrane closure. It is unclear whether double-layer grafts are superior to single-layer and whether single-layer cartilage is superior to fascia or perichondrium alone. The objective of the current study was to examine the relative efficacy of single-layer versus double-layer tympanic membrane grafting techniques. MATERIALS AND METHODS: A retrospective review of the medical records was used to address the objective of the study. Patients operated on in an over/under technique by the same surgeon underwent single-layer perichondrium or single-layer perichondrium with a cartilage island, or a double-layer of perichondrium combined with periochondrium with a cartilage island. The outcomes assessed were tympanic membrane reperforation and hearing improvement. RESULTS: A total of 135/177 (76%) perichondrium grafts had no reperforation, and 43/55 (78%) perichondrium with cartilage island grafts had no reperforation; 352/390 (90%) of the double-layer closures had no reperforation. There was no statistically significant difference in reperforation rates between the 2 single-layer techniques (P = .926). The difference in reperforation rates after the double-layer closure versus the perichondrium single-layer closure was statistically significant (P = .001), as was the difference in reperforation rates after the double-layer closure versus the cartilage island single-layer closure (P = .02). All 3 groups showed statistically significant hearing improvement postoperatively (P < .0001). Preoperative hearing levels (P = .179), postoperative hearing (P = .857), and decibels of hearing improvement (P = .356) were the same for all 3 groups. CONCLUSION: Double-layer closure gives lower tympanic membrane reperforation rates than does single-layer closure, as well as similar hearing outcomes.