Anatomical variations and relations of large blood vessels to the tympanic cavity.

PURPOSE: The aim of this study was to assess the protrusion of the upper bulb of the internal jugular vein (UBJV) and the internal carotid artery (ICA) into the cavum tympani, the thickness and the structure of the bone wall that separates these blood vessels from the middle ear cavity, as well as the bone wall absence between these blood vessels and the cavum tympani. METHODS: The study included a total of 150 samples of temporal bones of elderly people, both sexes. The methods used in the study were anatomic and histologic, while analyses were done by a surgical microscope. RESULTS: In 38 (25.3%) of the 150 studied temporal bones, the UBJV protruded into the cavum tympani, elevating its bottom. In 3 (7.8%) of the samples the bulb had a high position, thus filling the hypotympanum, and closing the lower half of the fenestra rotunda. The most frequent thickness of the bone wall that separates the ICA and the Eustachian tube was 2 mm (48.2%), less frequently it was 2-4 mm (29.6%), while least frequently it was of paper consistency (22.2%). CONCLUSION: High jugular bulb, aberrant ICA and anomalies of their wall structures are a pitfall and risk for middle ear surgery. Awareness of this variation is very important in the presurgical evaluation of the temporal bone to avoid vascular injury.

Recurrent malignant otitis externa with multiple cranial nerve involvement: A case report.

Introduction: Necrotizing otitis externa is a rare but conditionally fatal infection of external auditory canal with extension to deep soft tissue and bones, resulting in necrosis and osteomyelitis of the temporal bone and scull base. This condition is also known as malignant otitis due to an aggressive behavior and poor treatment response. Early diagnosis of malignant otitis is a difficult challenge. We present an illustrative case of necrotizing otitis externa and suggest some strategies to avoid diagnostic and treatment pitfalls. Case Outline: A 70-year-old patient presented with signs of malignant otitis externa, complicated by peripheral facial palsy. Adequate diagnostic and treatment procedures were performed with clinical signs of resolution. The recurrence of malignant infection had presented three months after previous infection with multiple cranial nerve neuropathies and signs of jugular vein and lateral sinus thrombosis. An aggressive antibiotic treatment and surgery were carried out, followed by substantial recovery of the patient and complete restoration of cranial nerves' functions. Conclusion: Necrotizing otitis externa is a serious condition with uncertain prognosis. The suspicion of malignant external otitis should be raised in cases of resistance to topical treatment, especially in patient with predisposing factors. Evidence-based guideline for necrotizing otitis externa still doesn't exist and treatment protocol should be adjusted to individual presentation of each patient.

Bilateral congenital cholesteatoma of the temporal bone in Crouzon syndrome.

INTRODUCTION: Crouzon syndrome is an autosomal dominant genetic disease characterized by bicoronal craniosynostosis, exorbitism with hypertelorism, and maxillary hypoplasia with mandibular prognathism. CASE OUTLINE: We present the first reported case of Crouzon syndrome associated with a bilateral con- genital cholesteatoma of the temporal bone and discuss about the potential pathogenesis. CONCLUSION: Early diagnosis and management are crucial to prevent complications and an otologist should be an integral part of the multidisciplinary team.

Tick on the tympanic membrane.

INTRODUCTION: Different foreign bodies can reach the lumen of the external auditory canal. Clinical presence of the foreign bodies depends on the nature of the foreign body, localization, morphological features, and the presence of pathological process. CASE REPORT: This study gives a report on a rare foreign body--a tick on the eardrum, which is a very rare localization in European countries. CONCLUSION: Identification, determination of the nature of the foreign body and the way of extracting it depend on the application of adequate diagnostic and therapeutic approaches.

External ear canal cholesteatoma after ventilation tube insertion and mastoidectomy.

INTRODUCTION: Etiopathogenetically, there are two types of chollesteatomas: congenital, and acquired. Numerous theories in the literature try to explain the nature of the disease, however, the question about cholesteatomas remain still unanswered. The aim of the study was to present a case of external ear canal cholesteatoma (EEC) developed following microsurgery (ventilation tube insertion and mastoidectomy), as well as to point ant possible mechanisms if its development. CASE REPORT: A 16-year-old boy presented a 4-month sense of fullness in the ear and otalgia on the left side. A year before, mastoidectomy and posterior atticotomy were performed with ventilation tube placement due to acute purulent mastoiditis. Diagnosis was based on otoscopy examination, audiology and computed tomography (CT) findings. CT showed an obliterative soft-tissue mass completely filled the external ear canal with associated erosion of subjacent the bone. There were squamous epithelial links between the canal cholesteatoma and lateral tympanic membrane surface. They originated from the margins of tympanic membrane incision made for a ventilation tube (VT) insertion. The position of VT was good as well as the aeration of the middle ear cavity. The tympanic membrane was intact and of normal appearance without middle ear extension or mastoid involvement of cholesteatoma. Cholesteatoma and ventilation tube were both removed. The patient recovered without complications and shortly audiology revealed hearing improving. Follow-up 2 years later, however, showed no signs of the disease. CONCLUSION: There could be more than one potential delicate mechanism of developing EEC in the ear with VT insertion and mastoidectomy. It is necessary to perform routine otologic surveillance in all patients with tubes. Affected ear CT scan is very helpful in showing the extent of cholesteatoma and bony defects, which could not be assessed by otoscopic examination alone.