Stabilising total ossicular replacement prosthesis for ossiculoplasty with an absent malleus in canal wall down tympanomastoidectomy - a randomised controlled study.

OBJECTIVES: To compare two titanium total ossicular replacement prosthesis (TORP) stabilisation techniques in canal wall down mastoidectomy presenting with footplate only and absent malleus handle. DESIGN: Prospective, controlled, randomised study. SETTING: Tertiary Otology Department. PARTICIPANTS: Patients operated on with canal wall down mastoidectomy between 1999 and 2009 were randomised into two groups. Two techniques enhancing the TORP stability were compared: Hüttenbrink's method (63 patients, Group 1) and author's (GB) procedure (62 patients, Group 2). Hüttenbrink's technique consists in placing a cartilage shave with a hole in the middle over the footplate. Through this hole, the end of the TORP is accommodated. The author's method involves using a cartilage split in the middle, to lodge the TORP's shaft at one end and to lay the opposite end over the fallopian canal. MAIN OUTCOME MEASURES: Mean postoperative air-bone gap, hearing gain and air-bone gap closure within 20 dB. Auditory outcomes were evaluated at 1 year postoperatively. RESULTS: Postoperative air-bone gap closure within 20 dB (successful outcome) at 1 year was achieved in 59% of patients in Group 1 and 72% in Group 2 (P = 0.03). Mean postoperative air-bone gap was 24.4 ± 10.8 dB for Group 1 and 20.17 ± 9.8 dB for Group 2. The difference is 4.23 dB (95% confidence interval, 0.65-07.81), statistically significant: P = 0.02. Hearing gain was 20.3 ± 9.5 in Group 1 and 25.1 ± 10.2 in Group 2, significantly superior: P = 0.007. CONCLUSION: Better hearing outcomes for author's method could be demonstrated, but our sample size cannot exclude small and possible trivial, group differences.

Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction: creating a window with a drill without use of mucosal flaps.

CONCLUSION: Success and complication rates of endoscopic dacrycystorhinostomy (DCR) creating a window with a drill and without using mucosal flaps are similar to those of external DCR. Moreover, any intranasal or paranasal disease can be treated simultaneously and a superior cosmetic result is achieved. OBJECTIVES: To present success and complication rates of a case series of patients treated with the same technique of endoscopic DCR for acquired nasolacrimal duct obstruction (NLDO). PATIENTS AND METHODS: This was a retrospective case review of 46 patients (25 female, 21 male; mean age 57 years). All patients had acquired NLDO with epiphora. Additionally, chronic dacryocystitis was evident at presentation in five patients. The cause of NLDO was primary acquired NLDO in 35 patients and lacrimal sac mucocele in 11 patients. An endonasal endoscopic approach using a drill was performed. Temporary silicone stenting of the nasolacrimal duct system was applied. In 19 patients additional surgery (11 FESS, 3 septoplasties, 5 FESS and septoplasty) was necessary. Patient follow-up ranged between 3 and 27 months. RESULTS: A successful functional result was obtained in 97.8% of patients. No major complications were observed. Minor complications (acute dacryocystitis or periorbital ecchymosis) occurred in four patients and were treated with antibiotics or resolved spontaneously.

Clinical experience with the Vibrant Soundbridge implant device.

OBJECTIVE: To evaluate the full degree and range of benefits provided by the Vibrant Soundbridge (VSB; Symphonix Devices, Inc., San Jose, CA, U.S.A.) and analyze pre-and postoperative results of audiologic tests. STUDY DESIGN: Single-subject study with each subject serving as his or her own control. SETTING: Multicenter clinical study conducted at 10 centers in Europe. PATIENTS: 47 patients who met the selection criteria for participation in the study. INTERVENTIONS: Implantation of the VSB direct-drive middle ear hearing device. MAIN OUTCOME MEASURES: Average change in unaided thresholds with the patient wearing headphones at each frequency pre-and postsurgery was measured. A mean threshold change less than 5 dB across all frequencies was considered clinically nonsignificant. RESULTS: 47 patients had successful surgery for implantation and fitting with the VSB device. CONCLUSION: The VSB is a new middle ear implant device that can be used safely in the treatment of patients with moderate to severe sensorineural hearing loss.

Multicenter audiometric results with the Vibrant Soundbridge, a semi-implantable hearing device for sensorineural hearing impairment.

The Vibrant Soundbridge, a semi-implantable hearing device for subjects with moderate to severe sensorineural hearing impairment was introduced commercially. First audiologic results are presented on 63 patients from 10 European implant centers. Hearing loss was at 0.5, 1, 2, and 4 kHz varying between 43 and 81 dB HL. The patients used the analogue audio processor, type 302. Measured sound-field gain was compared with NAL-R target values. For most patients an acceptable agreement was found. There was a subgroup of patients, however, with relatively low gain. The results suggest that this was related to the suboptimal positioning and fixation of the transducer to the incus.

Surgical treatment of tympanosclerosis.

OBJECTIVE: To report the hearing results of the surgical treatment of tympanosclerosis. STUDY DESIGN: A retrospective review of surgically treated cases of tympanosclerosis. SETTING: A tertiary referral center. PATIENTS: One hundred fifteen patients with middle ear tympanosclerosis operated on between 1987 and 1996, with an average age of 36 years (range 18-59 years). Cases were classified into four groups according to Wielinga and Kerr. Those with an associated cholesteatoma were excluded. INTERVENTION: Depending on the ossicular status, either mobilization of the major ossicles or epitympanic bypass procedure, mobilization of the stapes or stapedectomy. MAIN OUTCOME MEASURES: The postoperative pure-tone average was compared with the preoperative levels by use of conventional audiometry. The air-bone gap was measured. RESULTS: The average postoperative air-bone gap was 18.0+/-10.21 dB in the type II group (attic fixation of the malleus-incus complex with a mobile stapes). 21.8+/-9.5 dB in the type III group (mobile malleus-incus complex, if present, with stapes footplate fixation), and 22.92+/-10.03 dB in the type IV group (fixation of both the stapes footplate and the malleus-incus complex). Patients with a fixed malleus and mobile stapes had significantly better hearing results than those with stapes fixation (p = 0.042, Mann-Whitney U test). CONCLUSION: In ossicular attic fixation, atticotomy and mobilization of ossicles yielded better results than did the epitympanic bypass procedure. The difference, however, did not reach statistical significance. Patients with fixed stapes treated with stapedectomy displayed good hearing results immediately after surgery, but the air-bone gap deteriorated after some time.

Nd:YAG laser-assisted uvulopalatoplasty for snoring.

Uvulopalatopharyngoplasty (UPPP) has been acknowledged as the surgical treatment of choice for snoring. More recently, laser-assisted uvulopalatoplasty (LAUP) has emerged as a reliable, safe, less invasive technique in the surgical treatment of snoring. Our experience includes 90 patients treated by means of Nd:YAG laser-assisted uvulopalatoplasty and the results are presented. The value of different factors (age, sex, snoring loudness, pharynx appearance, Müller manoeuver, presence of apnoeic episodes, overweight) in predicting success or failure of laser surgery has been evaluated. Good results were obtained in 80% of our patients. We found excessive snoring loudness and apnoeic episodes to be statistically associated with failure of LAUP to correct snoring. The other mentioned factors cannot be used in predicting the outcome of Nd:YAG laser-assisted uvulopalatoplasty.

Prognostic factors in tympanoplasty.

OBJECTIVE: To assess the prognostic value of pathologic and technical variables influencing the functional outcome of tympanoplasty. PATIENTS AND STUDY DESIGN: Retrospective review of the records of 544 patients affected by chronic otitis with or without cholesteatoma, operated on by the senior author in a city hospital ENT department. Follow-up was provided systematically by the same institution. INTERVENTIONS: These included tympanoplasty without mastoidectomy in 339 cases, canal wall up technique in 134 cases, and canal wall down in 71 cases. Three hundred twenty-six (60%) were primary, and 218 (40%) were revision procedures. Myringoplasty was performed with autologous temporalis fascia, ossiculoplasty with incus interposition, or partial or total ossicular prostheses. Mean follow-up was 14 months (range, 12-50 months). MAIN OUTCOME MEASURES: Hearing results were defined according to the Committee on Hearing and Equilibrium Guidelines. A one-way analysis of variance was used to determine group differences. Multiple logistic regression analysis was subsequently carried out on the different pathology groups via the hierarchical log linear model. A probability value of p < 0.05 was the level of significance. RESULTS: The status of the mucosal lining, the mastoidectomy, the availability of the malleus handle, and the tympanic membrane perforation were all significantly predictive of the hearing outcome but with differing weight according to the pathologic condition. CONCLUSIONS: Anatomic and technical factors diversely affect the functional outcome of tympanoplasty. A better knowledge of their predictive roles and weights may be useful in both the surgeon's judgment and in the information given to the patient.

Predictive factors in cochlear implants.

Predictive factors in cochlear implants. The clinical records of 32 patients who received a multichannel cochlear implant between 1991 and 1994, were retrospectively reviewed. A Nucleus Mini 22 device was used in 27 cases, a Clarion device in 5 cases. The aim of this study was to identify the predictive role, and hence the influence on the final result of such factors as: the age of patients at implantation and at the onset of deafness, the duration of profound deafness, the aetiology of deafness, sudden or progressive hearing loss, the number of recordable sound frequencies, the promontory test outcome, the length of electrode insertion, the number of active electrodes, the map. A statistically significant negative correlation (p = 0.02) was found between the duration of deafness and patients' performance. The relationship between map and performance, due to the small number of patients, did not reach statistical significance although it was very close to the limit (p = 0.055). The other mentioned factors did not achieve any statistical significance.

[Considerations on the rehabilitation of the hearing in cochlear implant patients]. / Considerazioni sulla riabilitazione della funzione uditiva nei pazienti con impianto cocleare.

In this study, the Cochlear Implant Programme of the ENT Department of Ospedale Civile di Venezia, is presented. Between 1989 and 1994, after a rigorous selection process, 36 patients were selected to be implanted with a cochlear prostheses: 28 with the multichannel Nucleus 22 device, 5 with the Clarion implant and 3 with the single channel Med-E1 BTE device. The distribution of the patients according to age, etiology, duration of auditory deprivation, age at onset of deafness, is presented. The different speech-coding strategies of the Nucleus system (Wearable Speech Processing, Multipeak speech processing and Spectral Maximum Sound processor) and the stimulation mode (common ground, bipolar, bipolar + 1) as well as the Clarion speech coding strategy (Continuous Interleaved Samples and Compressed Analog) are briefly discussed. The rehabilitation programme, the specific speech recognition assessment test batteries-Consonant Confusion Test, Vocal Confusion Test, Speech Tracking, MAC battery-as they are employed in our department, are presented. As we have analyzed our results, certain factors appear as predicting a favourable outcome: - age of onset of deafness; postlingual patients, who have developed communication skills compare favourably to the perilingual group. - durations of auditory deprivation, as it is related to surviving cells in the cochlea: the shorter the period of deafness, the better the results. - length of electrode insertion, as it is determined by ossification of the cochlea. - high dynamic range of the MAP. - percent of activated electrodes: a number of 10 active electrodes or less predicts a poor outcome. - for simplification reasons, a new variable is introduced-Auditory Deprivation Index- and its positive correlation to the performance presented. - the time period of experience with the device, length and quality of rehabilitation and family support have to be mentioned.

[Selective vestibular neurectomy: a comparison of techniques]. / Neurotomia vestibolare selettiva: tecniche a confronto.

The surgical treatment of patients suffering from incapacitating peripheral vertigo is still controversial. In the ENT Department of the Civil Hospital of Venice 43 patients with disabling menieric vertigo spells underwent a selective vestibular nerve section employing either a retrosigmoid (25 cases) or a retrolabyrinthine approach (18 cases) between 1991 and 1993. The two approaches are compared with regard to surgical technique, pre- and postoperative complications and i.e. functional results, i.e. vertigo control and hearing preservation. Functional results, classified according to the guidelines reported by the Committee on Hearing and Equilibrium of the AAO-HNS in 1985 did not show substantial differences. We obtained complete vertigo control in 95% of the patients and hearing was conserved at the preoperative level in almost all of the cases. The retrosigmoid approach demonstrated distinct advantages with regard to the surgical technique employed; it was faster, offered a wider surgical field in the cerebello-pontine angle and brought about fewer peri- and postoperative complications.

[Problems in cochlear implant surgery]. / Problemi nella chirurgia dell'impianto cocleare.

In cochlear implant surgery, major complications, requiring revision procedures, do not exceed 5% of cases reported. Less frequent are problems that call for specific technical solutions. In 44 multichannel implantations (out of 54 cases) adverse conditions occurred and were successfully resolved in 6 patients: 1) delayed wound breakdown (one case); 2) chronic otitis media (three cases); 3) cochlear obliteration (two cases). Problem 1 was managed with the excision of an ellipse of skin including the devitalized areas under local anesthesia. The electronic package was left untouched, and the freshly cutaneous edges were mobilized and layer-sutured. Problem 2 was solved through a two-stage procedure. The chronic ear was dealt with as usual (myringoplasty, tympanoplasty, revision of a radical mastoidectomy). In the second stage the cochleotomy and device implantation were carried out. Problem 3 is a major issue for the surgeon. Following the Lehnhardt technique we drilled along the basal cochlear turn using the sharp line between the yellowish otic bone and the white newly formed bone as a landmark, until a patent s.tympani was found at the ascending part of the 1st or at the beginning of the 2nd turn.

[Speech perception test in Italian language for profoundly deaf children]. / Test di misura della percezione verbale nei bambini sordi profondi.

Speech perception tests are an important part of procedures for diagnosing pre-verbal hearing loss. Merely establishing a child's hearing threshold with and without a hearing aid is not sufficient to ensure an adequate evaluation with a view to selecting cases suitable for cochlear implants because it fails to indicate the real benefit obtained from using a conventional hearing aid reliably. Speech perception tests have proved useful not only for patient selection, but also for subsequent evaluation of the efficacy of new hearing aids, such as tactile devices and cochlear implants. In clinical practice, the tests most commonly adopted with small children are: The Auditory Comprehension Test (ACT), Discrimination after Training (DAT), Monosyllable, Trochee, Spondee tests (MTS), Glendonald Auditory Screening Priocedure (GASP), Early Speech Perception Test (ESP), Rather than considering specific results achieved in individual cases, reference is generally made to the four speech perception classes proposed by Moog and Geers of the CID of St. Louis. The purpose of this classification, made on the results obtained with suitably differentiated tests according to the child's age and language ability, is to detect differences in perception of a spoken message in ideal listening conditions. To date, no italian language speech perception test has been designed to establish the assessment of speech perception level in children with profound hearing impairment. We attempted, therefore, to adapt the existing English tests to the Italian language taking into consideration the differences between the two languages. Our attention focused on the ESP test since it can be applied to even very small children (2 years old). The ESP is proposed in a standard version for hearing-impaired children over the age of 6 years and in a simplified version for younger children. The rationale we used for selecting Italian words reflect the rationale established for the original version, but the choice of single words follows different criteria from the original version. In fact, the two languages differ in important linguistic features so that the test can not be not adapted to the Italian language by simply translating the words involved. As currently there is no children's language dictionary in Italian arranged according to age bracket, we chose words used in children and in pre-school reading material.

Early management of the paralyzed upper eyelid using a gold implant.

One main goal in the management of a peripheral facial paralysis is to provide the patient with adequate protection to the cornea in order to avoid keratitis. Medical treatment, (ophthalmic drops, ointments, taping, etc.), often fails and surgery has to be considered. The various methods hitherto described, e.g. tarsorraphy, plastic strips, magnetic implants and wire springs, are associated with drawbacks such as infection, poor cosmetic outcome or need for a revision procedure. Between 1990 and 1992, 12 patients, suffering from an upper eyelid paralysis, as a consequence of a peripheral impairment of the homolateral facial nerve function, were operated on in our Department with the implant of a gold weight within the upper eyelid itself. This procedure yielded, in all cases, an excellent lid closure, corneal protection as well as a good cosmesis. The surgical technique is simple, if performed under local anesthesia, and the patient leaves the hospital on the same day of surgery. Should the natural eye function return, the implant can be easily removed.

[Multichannel cochlear implant: personal experience]. / L'impianto cocleare multicanale. Nostra esperienza.

Cochlear Implantation is a recognized procedure for acoustical rehabilitation of the profoundly or totally deaf unable to effectively use a traditional hearing aid. Since 1989, 30 patients (27 postlingual and 3 perilingual) have been operated on by the senior Author with the implantation of a multichannel device: Med-El (3 cases), Clarion (3 case) and Nucleus Mini-22 (24 cases). The first 24 Nucleus cases, with a multipeak speechcoding strategy, are the object of this retrospective report. Selection of patients was performed according to an international protocol which includes PTA and Speech Audiometry, CT and/or MRI imaging of the ear, the Promontorial Test, an evaluation of lip reading ability, a psychological evaluation, a trial with two recent and currently available aids. The operation was carried out under general anesthesia. An extended endaural approach was adopted. The internal package of the device was firmly seated onto the temporalis squama and the electrode array was introduced into the tympanic cleft via a posterior tympanotomy. The electrode system was inserted into the scala tympani through a cochleotomy drilled out at the anteroinferior border of the round window. The whole system was fixed to the bony walls of the mastoid and squama using an ionomeric bone bonding agent. Starting at the second postoperative month and up to the 24th month of utilization of the device, each patient was evaluated with regard to his or her ability to recognize environmental sounds, to detect prosody transitions and to understand speech with and without visual cues. Selected tests, either close or open set, were used from the MAC and the Iowa Cochlear Implant Battery, as well as the Helen test. Telephone conversation was also evaluated. Results were very encouraging in all cases, showing that the multichannel cochlear device provides the properly selected patient a substantial auditory rehabilitation allowing him or her to understand speech in most instances without any visual cue.

[Introduction to the surgery of the middle ear: general principles]. / Introducción a la cirugía del oído medio. Principios generales.

We study the basic guidelines of the middle ear surgery, having as target the recuperation of the anatomic functional integrity of ear. There are different important elements in the quality/quantity of the functional results as follows: The surgery technical method used. The actual pathology in the middle ear. The quality of eustachian tube function. The surgeon's experience and ability and several factors. We review the concept introduced by Wullstein called it tympanoplasty from 1952 till nowadays. Finally, we described the most frequent surgery procedures used in the daily practice.