The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients / El nuevo abordaje retro-conchal para cirugías del oído medio: nuestra experiencia en 196 pacientes

Background This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact. Methodology A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up. Result The long-term follow-up (22.9 ± 6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001. Conclusion According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up. (AU)

Antecedentes Este estudio tuvo como objetivo describir una nueva propuesta de abordaje retroconchal para la cirugía del oído medio y evaluar sus ventajas e impacto postoperatorio. Metodología Se realizó un estudio retrospectivo de serie de casos en un hospital universitario de tercer nivel desde marzo de 2008 hasta abril de 2022. Se incluyeron 196 pacientes adultos candidatos a cirugía de oído medio por otitis media crónica. El abordaje retroconchal implicó una incisión cutánea en la superficie medial de la concha 1 cm anterior al surco auricular. Permitió la recolección del tamaño requerido de cartílago de la concha y fascia temporal a través de la misma incisión con acceso al oído medio y exposición completa al proceso mastoideo. Evaluamos el uso de este abordaje en la timpanoplastia, incluidas las cirugías de colesteatoma con un seguimiento postoperatorio de al menos un año. Resultado El seguimiento a largo plazo (22,9 ± 6,37 meses) reveló que la mayoría de los casos operados (89%) no desarrollaron secuelas postoperatorias relacionadas con este abordaje. Por otro lado, 22 pacientes (11%) desarrollaron secuelas menores, con diferencia estadísticamente significativa en cuanto a la ocurrencia de secuelas como el valor P < 0,001. Conclusión De acuerdo con nuestra experiencia con un número relativamente grande de pacientes, la técnica retroconchal fue práctica para varias cirugías del oído medio. Permitió un acceso óptimo a diferentes áreas del oído medio y obtener cartílago de la concha y fascia temporal (si es necesario) de gran tamaño a través de la misma incisión sin necesidad de pasos quirúrgicos adicionales. Fue una maniobra segura y sin complicaciones significativas en el seguimiento a largo plazo. (AU)

The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients.

BACKGROUND: This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact. METHODOLOGY: A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up. RESULT: The long-term follow-up (22.9 ±â€¯6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001. CONCLUSION: According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up.

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 del conducto auditivo externo: Experiencia de 5 años Hospital del Salvador / External ear canal cholesteatoma: 5-year experience Hospital del Salvador

Introducción: El colesteatoma del conducto auditivo externo (CCAE) es una estructura quística revestida por epitelio escamoso estratificado queratinizado que tiene la capacidad de invadir y erosionar localmente al hueso temporal. Su incidencia es de 0,19 a 0,3/100.000 habitantes siendo 60 veces menos frecuente que el de oído medio. Objetivo: Describir las características epidemiológicas, clínicas, imagenológicas y tratamiento de los pacientes diagnosticados con CCAE en el Servicio de Otorrinolaringología Hospital del Salvador. Material y Método: Se presenta una serie de ocho casos clínicos recopilados durante el período 2017 y 2021. Se realizó revisión de fichas clínicas, biopsias y tomografías computadas de oídos (TC oídos). Se describen los hallazgos y tratamiento efectuado. Resultados: El promedio de edad fue de 65,6 años, correspondiente a 5 mujeres y 3 hombres con presencia de tabaquismo y diabetes en la mitad de los casos. Los síntomas y signos más frecuentes fueron otalgia e hipoacusia seguido de otorrea. 7 pacientes se presentaron con tímpano íntegro y el compromiso de la pared inferior del conducto se evidenció en 6 de 8 pacientes. La TC oídos mostró erosión ósea del conducto, con o sin compromiso de estructuras adyacentes, en todos los casos y el diagnóstico histológico fue efectuado en el 100% de los pacientes. Se privilegió el tratamiento conservador mediante curaciones óticas periódicas asociado a ácido salicílico al 3% y/o antibióticos tópicos en 6/8 pacientes. Conclusiones: El CCAE es una entidad poco frecuente sin signos ni síntomas patognomónicos por lo que el diagnóstico histológico junto con el estudio imagenológico es perentorio. El tratamiento conservador es una alternativa terapéutica válida que ofrece buenos resultados en pacientes con adecuada adherencia al tratamiento y posibilidad de seguimiento estricto.

Introduction: External ear canal cholesteatoma (EECC) is a cystic structure lined by keratinized stratified squamous epithelium that has the ability to locally invade and erode the temporal bone. Its incidence is 0.19 to 0.3 / 100,000 habitants, being 60 times less frequent than that of the middle ear. Aim: To describe the epidemiological, clinical, imaging and treatment characteristics of patients diagnosed with EECC in the Hospital del Salvador ENT department. Material and Methods: A series of eight clinical cases collected during the period 2017 and 2021 is presented. A review of clinical records, biopsies and computed tomography of the ear (ear CT) was carried out. The findings and treatment carried out are described. Results: The average age was 65.6 years corresponding to 5 women and 3 men with the presence of smoking and diabetes in half of the cases. The most frequent symptoms and signs were earache and hearing loss followed by otorrhea. 7 patients presented with an intact eardrum and compromise of the inferior wall of the canal was evidenced in 6 of 8 patients. Ears CT showed bone erosion of the canal with or without compromise of adjacent structures in all cases and the histological diagnosis was made in 100% of the patients. Conservative treatment with periodic ear dressings associated with 3% salicylic acid and / or topical antibiotics was favored in 6/8 patients. Conclusion: EECC is a rare entity without pathognomonic signs or symptoms, therefore the histological diagnosis together with the imaging study is peremptory. Conservative treatment is a valid therapeutic alternative that offers good results in patients with adequate adherence to treatment and the possibility of strict follow-up.

Colesteatoma congénito: revisión de la literatura

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.

Presentación simultánea de quiste epidermoide del ángulo pontocerebeloso y colesteatoma infiltrante del oído medio. Reporte de caso y revisión de literatura / Simultaneous presentation of an epidermoid cyst of the cerebellopontine angle and infiltrating cholesteatoma of the middle ear. Case report and literature review

Introducción: los quistes epidermoides son el tercer tumor más común del ángulo pontocerebeloso (APC). Es infrecuente detectar simultáneamente un colesteatoma infiltrativo del oído medio (OM). Caso clínico: paciente de 51 años acude a urgencias por cefalea hemicraneal intensa, pulsátil secundaria a hidrocefalia aguda, requirió ventriculostomía. En la resonancia magnética nuclear (RMN) cerebral contrastada se reporta una masa en el APC sugestivo de quiste epidermoide y simultáneamente un colesteatoma infiltrativo del OM. La paciente fue intervenida primero con resección de colesteatoma del OM; en un segundo tiempo resección del quiste epidermoide del APC por vía translaberíntica. El posoperatorio la evolución clínica fue satisfactoria. Discusión: los quistes epidermoides del APC son histopatológicamente idénticos al colesteatoma del OM y pueden ser secundarios a estos. Conclusión: se debe individualizar el manejo sin descartar la posibilidad de tener las dos enfermedades de manera simultánea.

Introduction: cysts are the third most common tumor of the cerebellopontine angle (CPA). It is rare to simultaneously detect an infiltrative cholesteatoma of the middle ear (OM). Clinical case: a 51-year-old patient attended the emergency department due to intense throbbing hemicranial headache secondary to acute hydrocephalus, requiring ventriculostomy. Contrast-enhanced cerebral magnetic resonance imaging (MRI) reported a mass in the APC suggestive of an epidermoid cyst and simultaneously an infiltrative cholesteatoma of the OM. The patient underwent first surgery with resection of the OM cholesteatoma; in a second stage, resection of the epidermoid cyst of the APC through a translabyrinthine approach. The postoperative clinical evolution was satisfactory. Discussion: APC epidermoid cysts are histopathologically identical to OM cholesteatoma and may be secondary to them. Conclusion: management must be individualized without ruling out the possibility of having both diseases simultaneously.

Endoscopic transcanal surgery of pars tensa cholesteatoma: Preliminary results.

INTRODUCTION AND OBJECTIVES: The aim of the present study is the assessment of exclusive endoscopic ear surgery for the management of primarily acquired pars tensa cholesteatoma, which is commonly linked to the failure of the Eustachian tube leading to the formation of retraction pockets. MATERIALS AND METHODS: Patients suffering from primarily acquired pars tensa cholesteatoma, who underwent primary surgery in our clinic, between 2014 and 2018 were included in this retrospective study. The disease was classified according to the EAONO/JOS system. Exclusive endoscopic ear surgery was performed for patients without mastoid involvement, while a microscopic-endoscopic tympanoplasty was carried out in case of mastoid extension. We assessed the recidivism rate during the follow-up. RESULTS: Cholesteatomas belonged to stage I in 28% of cases, to stage II in 68% and only one patient was stage III. Only a portion of the pars tensa was involved in 13 instances, the whole pars tensa in 3 and both the tensa and the flaccida in 9. 17 out of 25 patients underwent exclusive endoscopic ear surgery and 8 needed a combined approach. We discovered 1 recurrence and 6 residual diseases. CONCLUSIONS: With only one case of recurrence in our series, we showed how pars tensa cholesteatoma cannot be exclusively explained through Eustachian tube dysfunction, but also through a ventilation blockage between the Eustachian tube and other mesotympanic areas due to the formation of intratympanic folds. Endoscopic ear surgery proved highly effective in the control of recurrences and it should be considered the treatment of choice.

Endoscopic transcanal surgery of pars tensa cholesteatoma: Preliminary results / Cirugía endoscópica transcanal del colesteatoma de la pars tensa: resultados preliminares

Introduction and objectives: The aim of the present study is the assessment of exclusive endoscopic ear surgery for the management of primarily acquired pars tensa cholesteatoma, which is commonly linked to the failure of the Eustachian tube leading to the formation of retraction pockets.Materials and methodsPatients suffering from primarily acquired pars tensa cholesteatoma, who underwent primary surgery in our clinic, between 2014 and 2018 were included in this retrospective study. The disease was classified according to the EAONO/JOS system. Exclusive endoscopic ear surgery was performed for patients without mastoid involvement, while a microscopic–endoscopic tympanoplasty was carried out in case of mastoid extension. We assessed the recidivism rate during the follow-up.ResultsCholesteatomas belonged to stage I in 28% of cases, to stage II in 68% and only one patient was stage III. Only a portion of the pars tensa was involved in 13 instances, the whole pars tensa in 3 and both the tensa and the flaccida in 9. 17 out of 25 patients underwent exclusive endoscopic ear surgery and 8 needed a combined approach. We discovered 1 recurrence and 6 residual diseases.ConclusionsWith only one case of recurrence in our series, we showed how pars tensa cholesteatoma cannot be exclusively explained through Eustachian tube dysfunction, but also through a ventilation blockage between the Eustachian tube and other mesotympanic areas due to the formation of intratympanic folds. Endoscopic ear surgery proved highly effective in the control of recurrences and it should be considered the treatment of choice. (AU)

Introducción y objetivos: El objetivo del presente estudio es la evaluación de la cirugía endoscópica exclusiva del oído para el manejo del colesteatoma de la pars tensa adquirido primario, que comúnmente está relacionado con la falla de la trompa de Eustaquio que conduce a la formación de bolsas de retracción.Materiales y métodosEn este estudio retrospectivo se incluyeron pacientes con colesteatoma de la pars tensa adquirido primario, que se sometieron a cirugía primaria en nuestra clínica, entre 2014 y 2018. La enfermedad se clasificó según el sistema EAONO/JOS. En pacientes sin afectación mastoidea se realizó únicamente cirugía endoscópica de oído, mientras que, en caso de extensión mastoidea, se realizó timpanoplastia microscópica-endoscópica. Se evaluó la tasa de recidiva durante el seguimiento.ResultadosEl 28% de los colesteatomas pertenecían al grado I, el 68% al grado II y solo un paciente estaba en el grado III. Solo una porción de la pars tensa estuvo afectada en 13 casos, toda la pars tensa en tres y tanto la tensa como la fláccida en nueve. Se sometieron a cirugía endoscópica exclusiva del oído 17 de 25 pacientes y ocho necesitaron un abordaje combinado. Descubrimos una recurrencia y seis enfermedades residuales.ConclusionesCon un solo caso de recurrencia en nuestra serie, mostramos cómo el colesteatoma de la pars tensa no puede explicarse exclusivamente por una disfunción de la trompa de Eustaquio, sino también por un bloqueo de la ventilación entre la trompa de Eustaquio y otras áreas mesotimpánicas debido a la formación de pliegues intratimpánicos. La cirugía endoscópica de oído demostró ser altamente eficaz en el control de las recurrencias y debe considerarse el tratamiento de elección. (AU)

Colesteatoma congénito: caso clínico y revisión de literatura

El colesteatoma congénito (CC) es una lesión benigna de epitelio escamoso queratinizado que puede afectar diferentes aéreas del hueso temporal con predominio en el oído medio. El CC es una patología poco frecuente que se presenta en pacientes pediátricos y clínicamente se manifiesta como una lesión blanquecina detrás de un tímpano indemne. La mayoría de los pacientes no presenta historia de hipoacusia, otorrea, infección, perforación o cirugía otológica previa. Se analiza el caso de un prescolar con CC que consultó con trastorno de sueño sin sintomatología otológica, pero con otoscopía alterada como hallazgo clínico. En la resonancia magnética nuclear (RMN) con secuencia de difusión, se evidenciaron hallazgos sugerentes de lesión colesteatomatosa en oído medio. Se realizó tratamiento quirúrgico endoscópico combinado con remoción completa de la lesión compatible histológicamente con CC y reconstrucción funcional con prótesis inactiva con resultado auditivo satisfactorio. El CC requiere alta sospecha diagnóstica por pediatras y otorrinolaringólogos, siendo imprescindible realizar un examen físico acucioso que incluya otoscopía de rutina, aunque el paciente no manifieste síntomas otológicos. El tratamiento es quirúrgico y debe considerar uso de endoscópico para asegurar una extracción completa de la lesión. En algunos casos es requerido realizar una reconstrucción auditiva para asegurar un óptimo resultado funcional.

Congenital cholesteatoma (CC) is a benign lesion of keratinized squamous epithelium that can affect different areas of the temporal bone, predominantly in the middle ear. CC is a rare pathology that occurs in pediatric patients and clinically manifests as a white lesion behind an intact eardrum. Most patients do not have a history of hearing loss, otorrhea, infection, perforation, or previous otologic surgery. The following, is the case of an infant with CC who consulted with a sleep disorder without otological symptoms but with altered otoscopy as a clinical finding. Nuclear magnetic resonance (NMR) with diffusion sequence with findings compatible with a cholesteatomatous lesion in the middle ear. Endoscopic surgical treatment was performed combined with complete removal of the lesion histologically compatible with CC and functional reconstruction with inactive prosthesis with satisfactory hearing results. CC requires high diagnostic suspicion by paediatrics and otorhinolaryngologists, and it is essential to perform a thorough physical examination that includes routine otoscopy even if the patient does not show otological symptoms. Treatment is surgical and endoscopic use should be considered to ensure complete removal of the lesion. In some cases, hearing reconstruction is required to ensure optimal functional results.

Perforación timpánica y colesteatoma, una patología de niños y adultos / Tympanic perforation and cholesteatoma, a pathology of children and adults

INTRODUCCIÓN. La patología de oído es una enfermedad frecuente en nuestro medio, asociada a infecciones a repetición del oído, con la presencia de perforación timpánica y colesteatoma, que determinará la presencia de lesiones mucho más acentuadas en cuanto a la evolución auditiva o complicaciones locales o sistémicas. OBJETIVO. Determinar la asociación existente entre la presencia de colesteatoma y perforación timpánica en pacientes con otitis media crónica. MATERIALES Y MÉTODOS. Estudio epidemiológico analítico retrospectivo. Población de 4 733 y muestra de 75 pacientes para casos y 75 para controles basados en historias clínicas tomadas del sistema informático AS 400, que acudieron a la consulta externa de torrinolaringología del Hospital de Especialidades Carlos Andrade Marín en el periodo de enero de 2018 a diciembre de 2019; Criterios de inclusión para grupo de casos: Hombres y mujeres de 20 a 65 años de edad, diagnóstico de otitis media crónica, diagnóstico de colesteatoma ótico. Criterios de inclusión para grupo controles: Hombres y mujeres de 20 a 65 años de edad, no presentar diagnóstico de colesteatoma. RESULTADOS. Se observó una relación fuerte entre el poseer perforación timpánica y el desarrollo de colesteatoma con un valor de OR 33,14 con un IC al 95% de 31,94 ­ 34,34, con lo que se comprobó la hipótesis del estudio. Se determinó que la perforación timpánica es un factor de riesgo asociado con el desarrollo de colesteatoma en pacientes con otitis media crónica, la prevalencia de colesteatoma en relación a la edad estuvo en un 72% en pacientes de 41 a 65 años, con mayor predominancia en mujeres en un 57,3%. DISCUSIÓN. La presencia de perforación timpánica de acuerdo a lo observado es un factor de riesgo para el desarrollo de colesteatoma, ligado en su mayoría a cuadros de Otitis Media Crónica. CONCLUSIONES. Se confirmó que la perforación timpánica, es un factor de riesgo en el desarrollo del colesteatoma en los pacientes que tienen otitis media crónica, lo que demuestra la necesidad de manejo actualizado y continuo en pacientes con esta patología de oído. Se requieren estudios con muestras más amplias para determinar otros factores de riesgo como sexo, nivel de educación y edad que podrían influir en el desarrollo de colesteatoma.

INTRODUCTION. Ear pathology is a frequent disease in our environment, associated with repeated ear infections, with the presence of tympanic perforation and cholesteatoma, which will determine the presence of much more accentuated lesions in terms of auditory evolution or local or systemic complications. OBJECTIVE. To determine the association between the presence of cholesteatoma and tympanic perforation in patients with chronic otitis media. MATERIALS AND METHODS. Retrospective analytical epidemiological study. Population of 4 733 and sample of 75 patients for cases and 75 for controls based on clinical histories taken from the AS 400 computer system, who attended the Otorhinolaryngology outpatient clinic of the Carlos Andrade Marín Specialties Hospital in the period from January 2018 to December 2019; Inclusion criteria for case group: Men and women aged 20 to 65 years, diagnosis of chronic otitis media, diagnosis of otic cholesteatoma. Inclusion criteria for controls group: men and women aged 20 to 65 years, no diagnosis of cholesteatoma. RESULTS. A strong relationship was observed between having tympanic perforation and the development of cholesteatoma with an OR value of 33,14 with a 95% CI of 31,94 - 34,34, thus proving the study hypothesis. It was determined that tympanic perforation is a risk factor associated with the development of cholesteatoma in patients with chronic otitis media, the prevalence of cholesteatoma in relation to age was 72% in patients aged 41 to 65 years, with greater predominance in women in 57,3%. DISCUSSION. The presence of tympanic perforation according to what was observed is a risk factor for the development of cholesteatoma, mostly linked to Chronic Otitis Media. CONCLUSIONS. It was confirmed that tympanic perforation is a risk factor in the development of cholesteatoma in patients with chronic otitis media, which demonstrates the need for updated and continuous management in patients with this ear pathology. Studies with larger samples are required to determine other risk factors such as sex, education level and age that could influence the development of cholesteatoma.

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.

Implante coclear en otitis media crónica: Revisión de literatura

La otitis media crónica (OMC) activa y colesteatomatosa se consideraban una contraindicación para el uso de implante coclear (IC) en el pasado. Actualmente, se han propuesto múltiples opciones quirúrgicas para el IC, de acuerdo con las características clínicas del paciente y el tipo de patología otológica prexistente. La cirugía del IC se puede realizar en un tiempo o en etapas, siendo fundamental intervenir un oído seco y estable previo a la instalación definitiva del electrodo para reducir complicaciones y obtener resultados auditivos satisfactorios. El IC es un tratamiento seguro y eficaz en pacientes con OMC. Múltiples reportes internacionales han evidenciado baja tasa de complicaciones mayores y óptimos resultados auditivos funcionales en pacientes con hipoacusia y OMC.

Supurative and cholesteatomatous chronic otitis media (COM) were considered a contraindication to cochlear implant (CI) use in the past. Currently, multiple surgical options have been proposed for CI according to the clinical characteristics of the patient and the type of pre-existing otological pathology. Cochlear implant surgery can be performed in a single time or in stages, being essential to intervene a dry and stable ear prior to the definitive installation of the electrode to reduce complications and obtain satisfactory hearing results. CI is a safe and effective treatment in patients with COM. Multiple international reports have shown a low rate of major complications and optimal functional hearing results in patients with hearing loss and COM.

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 METHODS: We 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. RESULTS: The 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). CONCLUSIONS: This 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. These findings raise awareness about the usefulness of middle ear findings in predicting FCD, thus providing valuable information for the otological surgeon to avoid iatrogenic injuries.

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)

Particularidades del abordaje transcanal endoscópico de los tumores benignos de oído medio en adultos / Nuances in transcanal endoscopic approach to benign middle ear tumours in adult patients

Antecedentes y objetivo: La cirugía mínimamente invasiva de tumores benignos del oído medio es posible mediante el uso del endoscopio. La mejor iluminación y la visión más amplia que ofrece permiten el abordaje transcanal de estos raros tumores. El objetivo del presente trabajo es sintetizar los puntos clave de su diagnóstico y tratamiento, a través de una serie propia de casos.Materiales y métodosEstudio retrospectivo de tumores benignos de oído medio intervenidos exclusivamente por vía transcanal endoscópica en un hospital universitario de tercer nivel, de adultos, entre junio de 2018 y junio de 2020. El seguimiento postoperatorio se realizó mediante otoendoscopia y audiometría.ResultadosFueron intervenidos durante el periodo de estudio 6 pacientes; 5 fueron mujeres y uno fue hombre, con una edad media de 57,8 años (± 21,9). Cuatro tumores estaban en el oído izquierdo y 2 en el oído derecho. Estos incluían 4paragangliomas timpánicos (3 de tipo I y uno de tipo II), un neurinoma de cuerda de tímpano y un colesteatoma congénito. No hubo complicaciones postoperatorias graves. En el momento actual no se ha constatado recidiva tumoral en ninguno de los casos, con un seguimiento mínimo de 7 meses.ConclusionesEl presente estudio añade evidencia sobre la seguridad y eficacia de la cirugía transcanal endoscópica de oído, como técnica mínimamente invasiva, para el tratamiento de tumores benignos de oído medio confinados en la cavidad timpánica. (AU)

Background and objective: Minimally invasive surgery of benign middle ear tumours is possible by using the endoscope. The optimal lighting and the broadest vision it offers, allow a transcanal approach to these rare tumours. The objective of this work is to summarize its key points through a case series.Materials and methodsRetrospective study of benign middle ear tumours that underwent exclusive endoscopic surgery in a third-level adult university hospital between June 2018 and June 2020. Postoperative follow-up was performed by otoendoscopy and audiometry.ResultsSix patients underwent surgery during the study period. Five patients were female and one male, with an average age of 57.8 years (± 21.9). Four tumours were in the left ear and 2 in the right ear. These included 4tympanic paragangliomas (3 type I and one type II), a chorda tympani neuroma, and a congenital cholesteatoma. There were no serious postoperative complications. At present, no tumour recurrence has been found in either case, with a minimum follow-up of 7 months.ConclusionsThe present study adds evidence on the safety and efficacy of endoscopic transcanal ear surgery, as a minimally invasive technique, for the treatment of benign middle ear tumours confined to the tympanic cavity. (AU)

Nuances in transcanal endoscopic approach to benign middle ear tumours in adult patients.

BACKGROUND AND OBJECTIVE: Minimally invasive surgery of benign middle ear tumours is possible by using the endoscope. The optimal lighting and the broadest vision it offers, allow a transcanal approach to these rare tumours. The objective of this work is to summarise its key points through a case series. MATERIALS AND METHODS: Retrospective study of benign middle ear tumours that underwent exclusive endoscopic surgery in a third-level adult university hospital between June 2018 and June 2020. Postoperative follow-up was performed by otoendoscopy and audiometry. RESULTS: Six patients underwent surgery during the study period. Five patients were female and one male, with an average age of 57.8 years (±21.9). Four tumours were in the left ear and 2 in the right ear. These included four tympanic paragangliomas (three type I and one type II), a chorda tympani neuroma, and a congenital cholesteatoma. There were no serious postoperative complications. At present, no tumour recurrence has been found in either case, with a minimum follow-up of 7 months. CONCLUSIONS: The present study adds evidence on the safety and efficacy of endoscopic transcanal ear surgery, as a minimally invasive technique, for the treatment of benign middle ear tumours confined to the tympanic cavity.

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)

Fibrous dysplasia: rare manifestation in the temporal bone / Displasia fibrosa: manifestação rara no osso temporal

Abstract Introduction: Fibrous dysplasia is a benign disorder, in which normal bone is replaced by fibrosis and immature bone trabeculae, showing a similar distribution between the genders, and being more prevalent in the earlier decades of life. Fibrous dysplasia of the temporal bone is a rare condition, and there is no consensus as to whether it is more common in monostotic or polyostotic forms. External auditory meatus stenosis and conductive dysacusis are the most common manifestations, with cholesteatoma being a common complication, whereas the involvement of the otic capsule is an unusual one. Surgical treatment is indicated to control pain or dysacusis, otorrhea, cholesteatoma, and deformity. Objectives: To describe the clinical experience of a tertiary referral hospital with cases of fibrous dysplasia of the temporal bone. Methods: Sampling of patients diagnosed with fibrous dysplasia of the temporal bone, confirmed by tomography, treated at the pediatric otology and otorhinolaryngology outpatient clinics, between 2015 and 2018. The assessed variables were age, gender, laterality, external auditory meatus stenosis, deformity, hearing loss, presence of secondary cholesteatoma of the external auditory meatus, lesion extension and management. Results: Five patients were included, four females and one male, with age ranging from 13 to 34 years. Three had the polyostotic form and two the monostotic form of fibrous dysplasia of the temporal bone. Four patients had local deformity and external auditory meatus stenosis, two of which progressed to cholesteatoma. All patients showed some degree of hearing impairment. All had preserved otic capsule at the tomography. Two patients are currently undergoing clinical observation; two were submitted to tympanomastoidectomy due to secondary cholesteatoma; one was submitted to lesion resection, aiming to control the dysacusis progression. Conclusion: Five cases of fibrous dysplasia of the temporal bone were described, a rare disorder of which the otologist should be aware.

Resumo Introdução: Displasia fibrosa é uma desordem benigna, na qual o osso é substituído por fibrose e trabeculado ósseo imaturo, com distribuição semelhante entre sexos, mais comum nas primeiras décadas de vida. O acometimento do osso temporal pela displasia fibrosa é raro, não há consenso se é mais comum nas formas monostóticas ou poliostóticas. Estenose do meato acústico externo e disacusia condutiva são as manifestações mais comuns. Colesteatoma é também uma complicação comum e o acometimento da cápsula ótica incomum. O tratamento cirúrgico está indicado para controle de dor ou disacusia, otorreia, colesteatoma, deformidade. Objetivos: Descrever a experiência clínica de hospital terciário de referência com casos de displasia fibrosa do osso temporal. Método: Amostragem dos pacientes com diagnóstico de displasia fibrosa do osso temporal, confirmado pela tomografia, atendidos nos ambulatórios de otologia e otorrinolaringologia pediátrica, entre 2015 e 2018. As variáveis avaliadas foram idade, gênero, lateralidade, estenose do meato acústico externo, deformidade, perda auditiva, presença de colesteatoma secundário de meato acústico externo, extensão da lesão e conduta adotada. Resultados: Foram incluídos cinco pacientes, quatro do sexo feminino e um masculino, de 13-34 anos. Três apresentaram a forma poliostótica da displasia fibrosa do osso temporal e dois a forma monostótica. Quatro apresentaram deformidade local e estenose do meato acústico externo, dois desses evoluíram com colesteatoma. Todos manifestaram algum grau de comprometimento auditivo. Todos apresentaram cápsula ótica preservada na tomografia. Duas pacientes estão em observação clínica; duas foram submetidas a timpanomastoidectomia devido a colesteatoma secundário; um foi submetido a ressecção da lesão para controle de progressão da disacusia. Conclusão: Foram descritos cinco casos de displasia fibrosa do osso temporal, desordem rara para a qual o otologista deve estar atento.