The leaking labyrinthine lesion resulting from direct force through the auditory canal: report of five cases

The leaking labyrinthine lesion is treated by conservative methods or surgical procedures. With respect to the stapes, the surgical treatment is controversial. Five cases of middle ear injuries accompanying oval window rupture are reported herein. In each case, direct force through the auditory canal damaged not only the ossicular chain but also the oval window. Initial symptoms were sudden hearing loss with significant conductive disturbance and various degrees of unsteadiness. Spontaneous horizontal nystagmus directed toward the uninvolved ear was observed in each case. Tympanic cavities were promptly explored under general anesthesia and oval window injuries were confirmed. In each case, the damaged stapes was temporally removed from the oval window. Perilymphatic leakage was recognized in each case. Two patients had subluxation of the stapes with a paucity leakage. Three had complete luxation of the stapes with a relatively huge oval window fistula. Disrupted oval windows were repaired with temporalis muscle fascial grafts that were inserted under the middle ear mucosae surrounding the oval windows. The stapes were replaced in the repaired oval windows, and the ossicular chains were reconstructed without artificial grafts. Vestibular dysfunctions disappeared within 7 days, and satisfactory audiologic results were obtained in each case.     

Diagnostic criteria and treatment strategies in traumatic injuries of the ear

The paper presents the results of examination and treatment of patients with different traumatic injuries of ear structures. The most characteristic injuries were detected in different mechanisms of traumas: mechanical (direct, indirect), altitude-induced, and thermal injuries. Major diagnostic signs of traumatic perilymphatic fistulas were revealed. The efficiency of surgical treatment for different injuries was evaluated. The surgical management of traumatic perilymphatic fistulas was comparatively assessed in different periods following injury. Evidence is provided for that it is expedient to close perilymphatic fistulas in ear injuries as early as possible.     

Defensive chronic ear surgery

The surgery for chronic ear disease has been modified in recent years because of the advances that have been made in neuro-otologic surgery including improvement in equipment and surgical techniques. There have been significant advances in the treatment of the acute phase of the inflammatory diseases of the middle ear and mastoid; however, there still remains a significant group of patients that require surgical correction of inflammatory disease of the middle ear and mastoid. A defensive approach to chronic ear surgery has been developed. This includes a proper preoperative evaluation of the patient's middle ear or mastoid problem with office microscopic examination of the ear and proper radiographic and audiologic studies. Surgical techniques include all the aspects of neuro-otologic surgery including an excellent otologic drill and suction irrigation. The point is made that careful defensive chronic ear surgery is best done with blunt instruments to avoid injury to soft tissue structures. A systematic approach to the removal of the disease from the ear is presented including the defensive approach of expecting complications and making preparations to avoid injuries as a result of these complications. This includes positive identification of the facial nerve, identification of labyrinthine fistulas, and cholesteatoma involvement of the posterior and middle fossa. Two cases are presented to illustrate how this defensive approach to chronic ear surgery may allow systemic resolution of very difficult chronic ear problems with preservation of neurologic and labyrinthine function.     

Symposium: Congenital anomalies of the middle ear. III. Congenital anomalies of the middle ear.

Congenital anomalies of the middle ear have been considered rare. The tremendous volume of middle ear surgery performed during the last 15 years has brought attention to numerous anomalies of the facial nerve, ossicles, and middle ear cleft, suggesting that middle ear anomalies are not as rare as once believed. This paper discusses anomalies of the descending and horizontal facial nerve which have been previously reported. The literature of anomalies of the ossicles is reviewed. A very rare anomaly of the carotid artery presenting in the middle ear is described and its surgical treatment outlined. Two anomalies of the middle ear associated with other branchial arch anomalies are reported and their treatment results discussed.     

Lightning causing inner ear damage and intracranial haematoma

Lightning can transmit energy by way of the telephone network to the middle and the inner ear and thus cause pronounced injuries. In the patient mentioned here, the middle ear remained intact, while the inner ear was the seat of widespread damage combined with vascular rupture, the latter causing the formation of an intracranial haematoma. This was originally interpreted wrongly as a neoplasm.     

先天性外中耳畸形的临床分析

目的：分析外耳畸形与中耳畸形的关系和手术治疗的效果。方法：对52例(62耳)先天性外、中耳畸形患者进行手术治疗，48耳采用经鼓窦乳突径路，14耳采用直入式径路。观察术中所见与外耳畸形的关系。结果：在轻度耳廓畸形者中，鼓室及其内部结构畸形较轻；而在中、重度耳廓畸形者中，中耳畸形情况较严重。术后3个月时平均语频听阈提高15～30dB者占53．2％；提高30dB以上者为40．3％。术后3年则分别为59．7％和25．8％。结论：中耳畸形与耳廓畸形程度相关。治疗效果及畸形程度与是否有并发症的发生有关。     

Temporal bone fractures: three identical cases of lateral middle ear fractures with facial nerve injury and conductive hearing loss

During the past two years at Thomas Jefferson University Hospital the authors have encountered three identical cases of middle ear injuries and their treatment has been so alike that we believe they merit general discussion. These patients illustrate the basic pathology of middle ear fractures in association with skull trauma, and in addition, emphasize the transtympanic approach in the surgical repair. In the past there has been some hesitancy about operating on temporal bone fractures in the acute period. The authors wish to use the following three cases to illustrate the early surgical approach to temporal bone fractures with associated facial nerve injury. It is our belief that the transcanal route is an excellent one for isolated middle ear fractures with concomitant facial nerve palsy when there is normal tearing on the involved side. We also believe that these middle ear fractures should be explored at the earliest possible time, as soon as general status of the patient will allow. We have some hesitancy about performing the standard incus body-to-head transposition for ossicular chain reconstruction because of the close proximity of the exposed facial nerve to the repositioned incus. We worry about pressure of this incus should it become displaced postoperatively onto this bare facial nerve. There is also difficulty experienced with this approach if re-exploration is indicated. The tympano-meatal flap must be elevated off the facial nerve, a procedure not without its own inherent dangers.     

Vestibular ototoxicity following intratympanic applications of chlorhexidine gluconate in the cat

Summary Our previous studies have shown that the disinfectant chlorhexidine gluconate (CH) has an ototoxic effect on the cochlea following its topical application in the middle ear space. The purpose of the present investigation was to demonstrate morphologically if CH also has the potential to injure the vestibular organs in the inner ear and, if so, what structures are most strongly damaged. Nine cats were used for the study. The drug dose of CH and the number of its applications to the middle ear were the same as used in our previous study to produce middle ear injuries. In the 2% CH group of cats pronounced degeneration was found in afferent nerve endings and both types of sensory cells. These nerve terminals showed edematous dilatations and contained degenerated mitochondria. Highly dark-stained degenerated mitochondria were distributed in the sensory cells and the afferent nerve terminals in the 0.05% CH group, but these degenerative changes were much less than in the 2% CH group. No otolithic crystals or synaptic vesicles could be seen in the 2% CH group. The results from this study showed that CH as a disinfectant has an ototoxic effect on the labyrinthine vestibule in which the sensory cell-nerve ending complex is affected as the main target. Even when used in dilute clinical concentrations, vestibular disturbances are a likely complication if the drug solution flows into the middle ear through a perforated eardrum.     

Vestibular ototoxicity following intratympanic applications of chlorhexidine gluconate in the cat

Our previous studies have shown that the disinfectant chlorhexidine gluconate (CH) has an ototoxic effect on the cochlea following its topical application in the middle ear space. The purpose of the present investigation was to demonstrate morphologically if CH also has the potential to injure the vestibular organs in the inner ear and, if so, what structures are most strongly damaged. Nine cats were used for the study. The drug dose of CH and the number of its applications to the middle ear were the same as used in our previous study to produce middle ear injuries. In the 2% CH group of cats pronounced degeneration was found in afferent nerve endings and both types of sensory cells. These nerve terminals showed edematous dilatations and contained degenerated mitochondria. Highly dark-stained degenerated mitochondria were distributed in the sensory cells and the afferent nerve terminals in the 0.05% CH group, but these degenerative changes were much less than in the 2% CH group. No otolithic crystals or synaptic vesicles could be seen in the 2% CH group. The results from this study showed that CH as a disinfectant has an ototoxic effect on the labyrinthine vestibule in which the sensory cell-nerve ending complex is affected as the main target. Even when used in dilute clinical concentrations, vestibular disturbances are a likely complication if the drug solution flows into the middle ear through a perforated eardrum.     

Clinico-audiological characteristics of the patients with acute injury of the ear

Three hundred patients with an acute injury of the ear were examined. It was found that such injuries inflict damage on various structures of the middle and internal ear. Therefore, it is necessary in such cases to conduct a comprehensive audiological examination of hearing for posttraumatic neurosensory hypoacusis to administer early rehabilitation. Audiology is especially indicated if impairment of labyrinthine windows is suspected.     

Otoacoustic emissions in children with otitis media with effusion

OBJECTIVES: Otoacoustic emissions (OAE) are transmitted from the cochlea to the ear canal via the middle ear and the transmission properties of the middle ear directly influence OAE characteristics. The purpose of this study was to establish the mechanisms of changes occurred in middle ear by tympanometric, audiometric and OAE examination. METHODS: Audiometric and tympanometric examination were performed and otoacoustic emissions were recorded from 22 normal ears and 52 ears with middle ear effusions and repeated 3 months later. RESULTS: Results of the air conduction in study group were significantly different from the control group and we found significant recovery in 3 months. When we analysed the DPOAE evaluation results in our study, some of the DPOAE parameters were found to be different between the control and the study group at low frequencies. Changes in the amplitude, especially at low frequencies, were statistically significant after 3 months. CONCLUSION: The results of this study revealed that measurement of otoacoustic emissions, especially distortion product otoacoustic emissions, is helpful in evaluating the condition of middle ear during the treatment.     

Middle and inner ear barotrauma caused by scubadiving (author's transl)

On the basis of our own experiences and the current literature, the following guidelines were established for the evaluation of scubadivers: 1. The ENT physical examination must include otoscopy and the valsalva manoeuver. The scubadiver should be able to promptly and symmetrically inflate his middle ear spaces. A central perforation is a relative contraindication, while a marginal ear drum perforation is an absolute contraindication for scubadiving. 2. Recommendations to the diver: Ear pressure equalibration should be performed continuously with increasing and decreasing water depth. Ear plugs should never be used. 3. Management of diving injuries: Barotitis should be treated in a manner similar to acute otitis media. Transient vertigo while ascending (alternobaric vertigo) without nystagmus or hearing impairment needs no further vestibular examination. A middle ear exploration is indicated when there is suspicion of a perilymphatic fistula.     

Aggressive papillary middle ear tumour.

A rare middle ear tumour is reported. The clinical presentation was similar to that of a glomus tumour but the pathology that of an aggressive papillary middle ear tumour. This is a recently recognized subgroup of middle ear glandular tumours. Clinical findings, imaging, pathology and treatment are presented.     

中耳胆脂瘤研究进展

中耳胆脂瘤是耳鼻咽喉科较为常见的一种慢性中耳疾病,长期外耳道流脓、鼓膜穿孔、听力下降为其主要特点,它对周围组织具有侵袭性,易引起中耳传音结构的破坏和骨质吸收,进而引起面瘫、迷路炎、耳后骨膜下脓肿及各种颅内外并发症。中耳胆脂瘤的病因及发病机制复杂,治疗方法的疗效争议较多。本文主要将近年来关于中耳胆脂瘤的病因、发病机制及治疗进展进行综述。     

Carcinoid tumor of the middle ear: clinical features, recurrences, and metastases

OBJECTIVE: Present four new cases of carcinoid tumor of the middle ear, two of which developed late recurrences and regional metastases. Review the literature to identify the clinical features, rate of recurrence, and incidence of metastasis of carcinoid tumor of the middle ear. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral hospital. PATIENTS: Eligibility criteria consist of a diagnosis of carcinoid tumor of middle ear. INTERVENTION: Surgical excision of primary and metastatic disease. MAIN OUTCOME MEASURE: Clinical characteristics, rate of recurrence, and incidence of metastasis of carcinoid tumor of the middle ear. RESULTS: Forty-six patients with carcinoid tumor of the middle ear are included in this report, 42 patients were identified from a review of the literature, and 4 new patients are presented. The most common presenting symptom was hearing loss. Surgical excision was the treatment with radical mastoidectomy being the most common procedure. Ten (22%) patients developed locally recurrent disease, and four (9%) developed regional metastases. CONCLUSIONS: Carcinoid tumor of the middle ear is an infrequent cause of a middle ear mass, with only 46 cases published. Despite previous assertions of benignancy, the findings of this study suggest that carcinoid tumor of the middle ear is indeed a potential low-grade malignancy with documented metastatic potential. Almost all middle ear adenomatous tumors ("adenoma" and "carcinoid") show evidence of neuroendocrine differentiation, and so at least some middle ear carcinoids ("adenomas") appear to represent well-differentiated neuroendocrine carcinomas. Presentation and symptoms are consistent with a middle ear mass and rarely include carcinoid syndrome. Surgical treatment is recommended and tailored to the extent of disease. Patients with carcinoid tumor of the middle ear require indefinite follow-up for possible recurrence or metastasis.     

In vitro reconstruction of a three-dimensional middle ear mucosal organ and its in vivo transplantation

CONCLUSIONS: These experimental findings suggest the feasibility of artificial middle ear mucosa grafting as an effective treatment for achieving mucosal regeneration after middle ear surgery. OBJECTIVES: Postoperative mucosal regeneration of tympanic cavity and mastoid cavity is of great importance after middle ear surgery. We reconstructed in vitro a three-dimensional middle ear mucosal organ, and assessed its feasibility for regenerative medicine of middle ear-related diseases. MATERIALS AND METHODS: Epithelial cells and fibroblasts were isolated from the middle ear mucosa of rats and propagated by subculturing. An artificial middle ear mucosal organ was reconstructed by overlaying the middle ear epithelial cells on three-dimensional lattices of a collagen gel that had been repopulated with the fibroblasts. In addition, the artificial organ was implanted in the middle ear cavity of rats. RESULTS: The artificial middle ear mucosa consisted of the single layer of epithelial cells, the basal membrane, and the underlying connective tissue. Electron microscopy revealed the presence of tight junctions and adherence junctions on the apical side, and adhesion complexes made of desmosomes. The reconstituted mucosa expressed genes of mucin, strongly suggesting that the artificial middle ear mucosa was capable of secreting mucus proteins. The DiI-labeled artificial middle ear mucosa implanted into the middle ear cavity was well engrafted and associated with host tissues.     

Diving-related inner ear injuries

Diving-related inner ear barotrauma (IEB) and inner ear decompression sickness (IEDS) most often result in permanent severe cochleovestibular deficits, unless immediate diagnosis is reached and the correct treatment is commenced early. Nine cases of sport-diving-induced inner ear injuries that were referred to the Israeli Naval Hyperbaric Institute between October 1987 and September 1989 are presented with regard to evaluation, treatment, and follow-up. The diagnosis was IEB in five divers and IEDS in four. Explorative tympanotomy was carried out with remarkable results in two patients with IEB, while the remaining three were relieved by bed rest alone. Three of the four IEDS patients were recompressed according to the extended US Navy Table 6 with good short-term results. The role of complete otoneurological evaluation in the decision-making process leading to the correct diagnosis and treatment is emphasized.     

Autoimmunity in otology

Experimental and clinical studies over the past ten years have confirmed that immune-mediated disease can involve the external, middle, and/or inner ear. Autoimmune inner ear dysfunction can result from systemic or localized disease. The pathogenesis of autoimmunity and the responsible antigen(s) of the inner ear is not known at present. The clinical course, laboratory test results, and treatment response often follow a consistent pattern but in some cases may be highly variable. Empirical treatment of autoimmune inner ear disease has produced encouraging preliminary results, and further research should provide better understanding of these otoimmune disorders.     

Local application of CpG oligodeoxynucleotide enhances nontypeable Haemophilus influenzae-specific mucosal IgA responses in the middle ear

CONCLUSIONS: Nasal vaccination with P6 protein of nontypeable Haemophilus influenzae (NTHi) and CpG oligodeoxynucleotide (ODN) may be effective for the induction of NTHi-specific protective immunity in the middle ear and middle ear application of CpG ODN may possibly be a new treatment strategy for otitis media (OM). OBJECTIVES: Owing to the increased prevalence of antibiotic-resistant bacteria in recent years, treatment for OM often fails. In the interest of developing an alternative treatment that does not require antibiotics, the efficacy of middle ear application of CpG ODN was examined. MATERIALS AND METHODS: Mice were immunized intranasally with P6 and CpG ODN, and CpG ODN was then inoculated into the middle ear. P6-specific antibody titers were determined by enzyme-linked immunosorbent assay (ELISA) and the numbers of P6-specific antibody-producing cells were determined by enzyme-linked immunospot (ELISPOT) assay. RESULTS: P6-specific IgA in ear wash and serum IgG titers were elevated after nasal immunization. The number of specific IgA-producing cells was markedly increased in the middle ear mucosa. Interestingly, middle ear application of CpG ODN enhanced IgA levels in the middle ear.