Cochlear implantation via middle fossa approach – a case report

Objective: Cochlear implantation is routinely performed all over the world via the post-auricular, facial recess approach. Our case study describes the middle fossa approach for the management of bilateral profound sensorineural hearing loss in a female child with multiple external, middle and inner ear malformations. The middle fossa approach has been reported sporadically and has been used inconsistently in patients with chronic otitis media and inner ear malformations.

Case study: A 3-year-old female child presented with bilateral profound sensorineural hearing loss, bilateral anotia, right cochlear nerve agenesis, right facial paralysis, bilateral mild inner ear dysplasia and an aberrant left facial nerve covering the left round window. Further tests indicated that she was a suitable candidate for cochlear implantation and was medically cleared for surgery. In view of the multiple malformations and high risk of injury to her only functioning left facial nerve on the side with a cochlear nerve, cochlear implantation via a middle fossa approach was performed.

Conclusion: Middle fossa approach to cochlear implantation is challenging but can be safely performed even in children and offers an option in patients when a routine mastoidectomy, facial recess and round window approach cannot be undertaken.     

Facial Nerve Paralysis in Patients With Chronic Ear Infections: Surgical Outcomes and Radiologic Analysis

Objectives

The purpose of this study was to investigate the clinical features, radiologic findings, and treatment outcomes in patients of facial nerve paralysis with chronic ear infections. And we also aimed to evaluate for radiologic sensitivities on facial canal, labyrinth and cranial fossa dehiscences in middle ear cholesteatomas.

Methods

A total of 13 patients were enrolled in this study. Medical records were retrospectively reviewed for clinical features, radiologic findings, surgical findings, and recovery course. In addition, retrospective review of temporal bone computed tomography (CT) and operative records in 254 middle ear cholesteatoma patients were also performed.

Results

Of the 13 patients, eight had cholesteatomas in the middle ear, while two patients exhibited external auditory canal cholesteatomas. Chronic suppurative otitis media, petrous apex cholesteatoma and tuberculous otitis media were also observed in some patients. The prevalence of facial paralysis in middle ear cholesteatoma patients was 3.5%. The most common involved site of the facial nerve was the tympanic segment. Labyrinthine fistulas and destruction of cranial bases were more frequently observed in facial paralysis patients than nonfacial paralysis patients. The radiologic sensitivity for facial canal dehiscence was 91%. The surgical outcomes for facial paralysis were relatively satisfactory in all patients except in two patients who had petrous apex cholesteatoma and requiring conservative management.

Conclusion

Facial paralyses associated with chronic ear infections were observed in more advanced lesions and the surgical outcomes for facial paralysis were relatively satisfactory. Facial canal dehiscences can be anticipated preoperatively with high resolution CTs.     

Tuberculous mastoiditis.

The prevalence of Mycobacterium tuberculosis is increasing due in part to the rising incidence of immunocompromised hosts. Although Mycobacterium tuberculosis is a well-documented pathogen in otitis media and mastoiditis, its extremely low incidence often precludes consideration when treating these infections. This is especially true when concomitant pulmonary symptoms are absent. We describe two patients who initially presented after prolonged unsuccessful medical and surgical therapy for chronic mastoiditis. In both, the diagnosis of Mycobacterium tuberculosis mastoiditis was made after the onset of complete facial paralysis. On subsequent investigations, one had an asymptomatic pulmonary focus while the other was felt to have primary mastoid disease. Both patients had normal immunological profiles. This report underscores the importance of considering a tuberculous infection in all cases of otitis media and mastoiditis which do not initially respond to conventional antibacterial therapy. This holds true in both immunocompromised and immunocompetent hosts. Early diagnosis with prompt institution of antituberculous therapy is essential to avoid facial nerve paralysis and other grave complications.     

Tuberculous otitis media –series of 10 cases

BackgroundTuberculosis (TB) of the middle ear cleft (MEC) is a rare extra-pulmonary manifestation. Signs and symptoms of tuberculous otitis media are indistinguishable from that of non-tuberculous otitis media making early diagnosis difficult.ObjectivesTo study the clinical presentations, complications and effective diagnostic modalities in tuberculosis of middle ear cleft.MethodsWe retrospectively studied 10 patients diagnosed with chronic otitis media, unresponsive to 2 months conventional treatment. Pure tone audiogram, High resolution computed tomography (HRCT) of temporal bone, and AFB staining of ear discharge were done. All patients underwent mastoid surgery. AFB staining and histopathological examination of granulation tissue removed from the middle ear and mastoid were also done.ResultsClinical findings were mastoid swelling, facial palsy and post-aural fistula 3,4 & 2 patients respectively. All patients had persistent ear discharge and three had vertigo. Hearing loss was of moderate conductive type in five, sensorineural type in three and mixed type in two. HRCT of temporal bone revealed soft tissue density in MEC in 9 and evidence of bone destruction in 6 cases. Diagnosis of TB was confirmed either by (a) demonstration of AFB in ear discharge (4 patients)/tissue removed during surgery (4 patients) or (b) by demonstration of tuberculous granulomas with necrosis on histopathological examination of tissue from MEC (8 patients).ConclusionTuberculosis should be suspected in all cases of chronic otitis media unresponsive to conventional treatment particularly in endemic areas. Histopathological examination and AFB staining of tissue removed during mastoid surgery are reliable diagnostic methods.     

Facial nerve paralysis secondary to chronic otitis media without cholesteatoma.

Numerous papers have been written on facial nerve paralysis caused by chronic suppurative otitis media. However the authors found none documenting the results of therapy in a series of patients in whom facial nerve dysfunction was caused by chronic otitis media without cholesteatoma. Thus, there is little factual information available to help select a specific therapeutic plan for such cases. Over the past decade, the senior author has managed five cases (6 ears) of chronic suppurative otitis media without cholesteatoma in which facial paresis (4 ears) or paralysis (2 ears) developed 10 days or less before surgery. The chronic otitis media involved the mastoid and middle ear in five cases; and the mastoid, middle ear, and petrous apex in one case. Modified radical mastoidectomy was performed in four ears, tympanomastoidectomy with facial recess exposure in one ear, and complete mastoidectomy with middle cranial fossa petrous apicectomy in one ear. Five patients had complete recovery of facial nerve function (House grade I), and one patient had 90 percent recovery (House grade II). The results provide support for semi-emergent surgery in the management of chronic suppurative otitis media when facial nerve paralysis supervenes.     

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data

ObjectivesReview of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century.Material and methodsSearch of the Medline, Cochrane and Embase databases for the period 2000–2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data.ResultsIn total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P = 0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively.ConclusionAural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.     

Facial nerve canal dehiscence in chronic otitis media without cholesteatoma

The information on incidence of the facial nerve canal dehiscence in chronic otitis media is important for surgeons. The purpose of this study is to disclose the histopathologic findings of facial nerve canal dehiscence in human temporal bones with chronic otitis media. We divided the human temporal bones into two groups (age 4 years, and under 4 years of age). We evaluated the incidence and the area of the facial nerve canal dehiscence in chronic otitis media under light microscopy. Age-matched normal control temporal bones were also examined. In the age group of 4 years, 68.9 % of temporal bones with chronic otitis media and 71.9 % of controls had the facial nerve canal dehiscence. There was no significant difference between them (P = 0.61). The area of the dehiscence in temporal bones with chronic otitis media was not statistically different from controls (P = 0.53). In the age group under 4 years, 88.2 % of temporal bones with chronic otitis media and 76.5 % of controls had the dehiscence. No significant difference was found between them (P = 0.66). The area of the dehiscence in temporal bones with chronic otitis media was not statistically different from controls in the age group under 4 years (P = 0.43). In chronic otitis media, the incidence of facial nerve canal dehiscence was high and was not statistically different from controls. These results suggest that there is no association between chronic otitis media and the presence of facial nerve canal dehiscence.     

Clues for facial canal dehiscence in chronic otitis media

Introduction and objectivesThe 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.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.     

Nonspecific necrotizing petrositis: an unusual complication of otitis in children

Three cases of an unusual form of suppurative chronic otitis media in children 2 and 3 years old are presented. The clinical feature common to all cases was otorrhea, beginning at the first months of life, with a silent evolution to a complete peripheral facial paralysis. In one case the facial paralysis was bilateral. The treatment applied was surgical: subtotal petrosectomy. The surgical findings were bloody granulation tissue, sequestering completely the otic capsule. The facial nerve was destroyed almost the total length of the Fallopian canal in all cases. The histopathologic examination revealed a destructive and nonspecific chronic inflammatory process. The culture showed Gram-negative organisms, such as Pseudomonas aeruginosa and Proteus mirabilis. Etiologic aspects involved in the process are discussed and the name non-specific necrotizing petrositis is suggested to individualize this rare form of otitis which, with morbidity, leads to severe complications such as facial paralysis and deafness.     

Rheumatoid nodule of the temporal bone

A 69-year-old woman with severe rheumatoid arthritis presented with a history of chronic otitis and a facial nerve paralysis. She was found to have a rheumatoid nodule involving the mastoid and mesotympanum. This is believed to be the first reported case of a rheumatoid nodule involving the temporal bone.     

Wegener’s granulomatosis presenting with bilateral facial nerve palsy

Primary manifestation of Wegener’s granulomatosis in the mucosa of the middle ear is rather rare, and has been reported as presenting with serous otitis media, chronic otitis media, sensorineural hearing loss, and, in rare instances, unilateral facial palsy. Bilateral facial palsy has never been reported. This last fact constitutes the interest in our report of a 23-year-old female patient who presented with symptoms of recurrent bilateral otitis media, eventually developing sensorineural hearing loss and bilateral facial palsy. Soon thereafter neurological symptoms appeared and lung extension was noted. Histological examination of repeated biopsies taken from the nasal and middle ear mucosa was not conclusive for the suspected disease, and c-ANCA titers were also initially repeatedly negative. Eventually, positive lung biopsy and elevated c-ANCA titers when the patient had developed pulmonary granulomas confirmed the diagnosis of Wegener’s granulomatosis. Mastoid surgery with facial nerve decompression of the most severely afflicted side did not result in the recovery of facial nerve function. Medical therapy with corticosteroids and cyclophosphamide improved the clinical picture but were ineffective in improving the bilateral sensorineural hearing loss and the facial paralysis on the operated side. We would contribute to the literature a unique case of bilateral facial nerve palsy due to Wegener’s granulomatosis. Received: 13 December 2000 / Accepted: 5 February 2001     

Gradenigo's syndrome: Is fusobacterium different? Two cases and review of the literature

Gradenigo's syndrome is a rare but life threatening complication of acute otitis media (AOM), which includes a classic triad of otitis media, deep facial pain and ipsilateral abducens nerve paralysis. The incidence of Fusobacterium necrophorum infections has increased in recent years. We describe two cases of Gradenigo's syndrome caused by F. necrophorum. Additional four cases were identified in a review of the literature. Gradenigo's syndrome as well as other neurologic complications should be considered in cases of complicated acute otitis media. F. necrophorum should be empirically treated while awaiting culture results.     

Glial heterotopia of the middle ear

IntroductionGlial heterotopia is defined as the presence of normal glial tissue in an abnormal site.Case reportWe report the case of a 63-year-old man who presented with right hearing loss and tinnitus. ENT examination, computed tomography and magnetic resonance imaging showed signs of chronic otitis media. Right mastoidectomy demonstrated a solid mass of the right mastoid and middle ear with no associated dehiscence of the tegmen tympani. Histological examination of the mass revealed normal glial tissue.DiscussionGlial heterotopia is a rare entity, which must be distinguished from encephalocele. It is usually an incidental surgical finding when the surgeon observes a mass of the mastoid and middle ear not communicating with the central nervous system. Histological examination confirms the diagnosis by revealing normal glial tissue in the ear.     

Tuberculosis of the inner ear

Tuberculosis of the middle ear is a rare, but not a nonexistent disease. It is well reported in literature that the typical features of this disease have been changing over the years, what can lead to delay in proper diagnosis and cause irreversible complications. Presented two cases of tuberculous otitis media confirm the opinion that historically classical triad of features: painless otorrhea, multiple perforations of the tympanic membrane and concomitant peripheral facial paralysis is often absent in the clinical picture of this disease.     

Tuberculous chronic otitis media. A clinical case

Tuberculous otitis media is a rare cause of chronic suppurative infection of the middle ear and mastoid. Patients typically have chronic tympanic membrane perforation and ear discharge associated with progressive, profound hearing loss, and resistance to antibiotic treatment. Diagnosis is often delayed by a low clinical suspicion, thus leading to complications such as irreversible hearing loss and facial nerve paralysis. Histological examination of a biopsy specimen reveals tuberculous changes. The disease is treated with antituberculosis agents.     

Current Considerations in Neck Dissection

Conclusions. High resolution CT imaging can provide useful information about the pathological exposure of the mastoid portion of the facial nerve before mastoid surgery and can assess the injury site of the facial nerve after operation. Objectives. To evaluate the diagnostic value of high resolution CT scanning of pathological exposure of the mastoid portion of facial nerve and provide valuable information for otologic surgery, and to analyse the cause of facial nerve paralysis after operation. Materials and methods. Routine CT scanning was used to examine patients with chronic suppurative otitis media and external auditory canal cholesteatoma preoperatively by axial-transverse and coronal views. If there was any pathological exposure of the mastoid portion of the facial nerve on CT imaging, then this was compared with intraoperative findings. In addition, one patient who had suffered postoperative facial nerve paralysis was also examined by CT scanning to determine whether any pre-existing pathological exposure of facial nerve could be found. Results. Through routine CT scanning six patients with chronic suppurative otitis media and three patients with external auditory canal cholesteatoma were found to have pathological exposure of the mastoid portion of the facial nerve. Coronal views could more clearly show the size and the position of the exposure; the corresponding surgical findings (pathological exposure) for the facial nerve could be confirmed in all nine patients. CT imaging could also show that the patient who had suffered postoperative facial nerve paralysis did indeed have pre-existing pathological exposure of the mastoid portion of the facial nerve.     

Mesenchymal stem cells in iatrogenic facial nerve paralysis: a possible role in the future

Iatrogenic facial nerve paralysis is one of the major and drastic complications of ear surgery. We report a case of a 20-year-old female patient with simple chronic otitis media who underwent mastoidectomy and tympanoplasty. During the mastoidectomy process the facial nerve was unintentionally destroyed, leaving a gap of 8–10 mm in the third segment of the intratemporal facial nerve. The nerve was repaired with a nerve cable graft obtained from the vicinity. On the 42nd day, autologous mesenchymal stem cell transplantation was performed after facial nerve trauma. The patient’s facial nerve paralysis has recovered from House-Brackmann grade VI to IV within a week and then to III in the fifth month. The rapid, postoperative progress, and the early follow-up results are discussed. This case represents the first bone marrow stem cell application in a peripheral nerve, namely the facial nerve.This case was presented at the XXXth World Congress of the International Society of Hematology, Istanbul, 28 September–2 October 2005.     

岩尖胆脂瘤的诊断与治疗

目的：讨论岩尖胆脂瘤的诊断与治疗。方法：总结了４例岩尖胆脂瘤的回顾性资料。结果：４例均有重度耳聋、眩晕、面瘫及慢性中耳炎病史，颞骨ＣＴ扫描作出诊断，并经迷路———耳蜗径路全部切除岩尖胆脂瘤。结论：认为颞骨ＣＴ扫描及ＭＲＩ对临床诊断及手术径路的选择有重要作用。经迷路———耳蜗径路为彻底清除胆脂瘤，处理面神经及脑脊液漏提供了最直接的通道     

Tuberculous otitis media developing as a complication of tympanostomy tube insertion

Primary tuberculous otitis media of which infection focus cannot be found elsewhere in the body is a rare disease. Route of the infection has been hypothesized as Eustachian tube or external auditory canal with tympanic membrane perforation but it is hard to ascertain in the patient. We present a case of an 8-year-old child who suffered chronic otorrhea after tympanostomy tube insertion. The radiological and histopathological findings revealed tuberculous otitis media, which occurred as a complication of tympanostomy tube insertion.     

Primary papillary adenocarcinoma confined to the middle ear and mastoid

Primary adenocarcinoma is a rare tumor of the middle ear and temporal bone; its most frequent symptoms are hearing loss, otalgia, and facial paralysis. Otoscopic examination of a 27-year-old man revealed purulent discharge in the ear canal, diffuse edema, and hypertrophy of the right tympanic membrane. He presented with a grade III (House-Brachman) facial paralysis and right conductive hearing loss with a history of aural discharge for 6 months, otalgia, and facial weakness for 2 days. Computed tomography of the temporal bone showed an opacity filling the tympanic cavity, antrum, and aditus. Tympanotomy revealed diffuse edema of the middle ear mucosa, and granulation tissue was encountered during mastoidectomy filling the antrum and periantral cells and eroding the fallopian canal at the level of the oval window. After the histopathological examination revealed papillary adenocarcinoma, a subtotal temporal bone resection, facial nerve segmenter resection, and end-to-end anastomosis of the facial with the hypoglossal nerves were performed. The importance of histopathological examination in all cases of chronic otitis media with granulation tissue is stressed. Received: 9 February 2000 / Accepted: 5 September 2000