A technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy

Objective

To present a simple technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy, and to assess the efficacy and the surgical results of this technique.

Methods

Retrospective clinical study of a consecutive series of procedures from 2004 to 2008. One hundred thirteen patients undergone canal wall down mastoidectomy with tympanoplasty and concurrent procedure of mastoid obliteration and meatoplasty that uses an anteriorly based musculoperiosteal flap and a horizontal skin incision on the concha were included. Preoperative diagnoses were classified into cholesteatoma, adhesive otitis media, and chronic suppurative otitis media. The mean duration of follow-up was 38 months, with a range of 12–75 months. We analyzed control of suppuration and creation of a dry mastoid cavity according to the Merchant's grading system for evaluation of the efficacy of this technique, and hearing outcome. We evaluated postoperative complications including development of recurrent or residual cholesteatomas and duration of the mastoid cavity achieving a complete healing.

Results

Seventy-two patients had cholesteatoma, whereas 27 patients had adhesive otitis media and 14 patients had chronic suppurative otitis media. Eighty-three percent of all patients, in 86% of patients with cholesteatoma, in 78% of patients with adhesive otitis media, and in 78% of patients with chronic suppurative otitis media were achieved a dry and self-cleaning mastoid and complete control of infection. Duration of the mastoid cavity achieving a dry and self-cleaning mastoid ranged from 4 weeks to 24 weeks and the mean time of the complete epithelialization was 11.1 ± 4.6 weeks. The average ABGs were 32.4 ± 13.8 dB preoperatively and 23 ± 13.2 dB postoperatively. There were 5 patients with failure of control of infection postoperatively and 3 patients of recidivistic cholesteatoma.

Conclusion

The efficacy of our technique to make a dry and healthy mastoid cavity after a canal wall down mastoidectomy is satisfactory, and the rate of complication is acceptably low. We believe that our technique could be a convenient method to prevent cavity problems after canal wall down mastoidectomy.     

Acquired middle ear cholesteatoma in children with cleft palate: Experience from 18 surgical cases

Objectives

To review an institutional experience with the surgical management of middle ear cholesteatoma in children with cleft palate.

Materials and methods

We analyzed retrospectively 18 children diagnosed with cleft palate who underwent surgery for acquired middle ear cholesteatoma between 2000 and 2007. The following data were recorded: age, sex, history of ventilation tube insertion, status of the contralateral ear, cholesteatoma location and extension, and surgical technique involved. Cholesteatoma recidivism, stable mastoid cavity and hearing levels were the main outcomes measured.

Results

Follow-up ranged from 5 to 12 years (mean 8 years). Twelve children underwent planned staged canal wall up mastoidectomy: a residual cholesteatoma was found and removed during the second-look procedure in 2 ears (16.6%); two children (16.6%) showed a recurrent cholesteatoma and required conversion to canal wall down mastoidectomy. A modified Bondy technique was chosen in two children with an epitympanic cholesteatoma with an intact tympano-ossicular system, while in the remaining four subjects a canal wall down mastoidectomy was performed because of an irreparable erosion of the postero-superior canal wall: no cases of recurrent cholesteatoma were observed in these 6 children; revision mastoidectomy was needed in one patient for cavity granulation. A postoperative air-bone gap result of 0–20 dB was achieved in 11 children (61.1%); in 5 cases (27.7%) postoperative air-bone gap was between 21 and 30 dB, while in 2 (11.1%) was >30 dB. Bone conduction thresholds remained unaffected in all cases.

Conclusions

Our results indicate that most cleft palate children with cholesteatoma can be managed with a canal wall up mastoidectomy with low complication rates. In extensive disease with large erosion of the canal wall as well in presence of a retraction pocket in the contralateral ear, a canal wall down mastoidectomy should be considered. In epitympanic cholesteatomas with an intact tympano-ossicular system and mesotympanum free of disease, the modified Bondy procedure is an effective surgical option. As in the general pediatric population, improvement or preservation of hearing can be obtained in most patients.     

Mastoid obliteration using calcium phosphate bone paste with an artificial dermis soaked with basic fibroblast growth factor: preliminary clinical report

Objectives

To describe mastoid obliteration using a calcium phosphate paste with an artificial dermis soaked with basic fibroblast growth factor (b-FGF) and the usefulness of this procedure.

Methods

Ten ears that underwent a canal wall-down mastoidectomy were treated with calcium phosphate paste. The cases consisted of four patients with mastoid cavity problem, four with middle ear cholesteatoma, one with adhesive otitis media, and one with external auditory canal cholesteatoma. The post-operative follow-up period was 19.9 months on average (ranging from 13 to 23 months). First, the canal wall-down mastoidectomy was performed. Then, the calcium phosphate paste was used to fill up to the facial ridge posteriorly and the horizontal segment of the facial canal superiorly. The surface of the paste was covered with an artificial dermis soaked with b-FGF.

Results

Following calcium phosphate paste treatment, all open cavities were decreased in volume and epithelized within 2 months.

Conclusion

Calcium phosphate paste appears effective for mastoid obliteration. Using an artificial dermis soaked with b-FGF appears to prevent exposure of the paste to the skin of the external auditory meatus. However, the number of the patients is too small to draw any conclusion.     

Closure of minor tracheoesophageal fistulae with calcium hydroxlapatite

Objective

To demonstrate a novel technique for the closure of a pinhole tracheoesophageal fistula using Radiesse (calcium hydroxylapatite).

Methods

Two patients underwent closure of a persistent tracheoesophageal fistula with four quadrant injections of Radiesse around the fistulous tract.

Results

Both patients had their fistulas successful closed. The first patient died after 3 months due to lung metastasis. The second patient required a further attempt at closure with Radiesse injection and has been without a leak for 18 months at his last follow up appointment.

Conclusion

We feel this is an acceptable minimally invasive method to close a persistent pinhole tracheoesophageal fistula after failed management with chemical cautery.     

Revision surgery for chronic otitis media: Characteristics and outcomes in comparison with primary surgery

Objectives

To analyze the characteristics and outcomes of revision surgery for chronic otitis media (COM) with or without cholesteatoma, and to compare with those of primary surgery.

Methods

A retrospective chart review was performed on 208 patients who underwent revision surgery for COM over an 8-year period (1997–2004) and 51 patients who underwent a primary canal wall down mastoidectomy (CWDM), and were followed for more than 12 months.

Results

Recurrent or residual cholesteatoma was found in 49.5% of cases. The mastoid tip and perisinal air cells were the most frequent sites of residual air cells. As a result of revision surgery, a dry and safe ear was achieved in 88.5% of patients. A residual air–bone gap (ABG) of ≤30 dB was achieved in 70.1% of cases with a revision CWDM with ossiculoplasty. In comparison with 51 patients who underwent primary CWDM, the disease control rate was not different. However, postoperative hearing result after ossiculoplasty was worse and longer healing time was required after revision surgery.

Conclusion

The characteristics and surgical outcome of recurrent COM must be fully understood for complete control of the disease.     

Effectiveness of MESNA on the success of cholesteatoma surgery

Importance

It is important that chronic otitis media with cholesteatoma be treated successfully in patients to protect them from having repeated surgeries with related surgical co-morbidities and hearing loss.

Objective

To evaluate the effectiveness of MESNA usage on the residual cholesteatoma rates of the patients who underwent surgery due to chronic otitis media with cholesteatoma.

Design

Retrospective single-institution study of a prospectively collected database.

Setting

Tertiary University Hospital.

Participants

Nine hundred and thirty-four patients underwent surgery due to chronic otitis media between September 2000 and March 2012 by the same surgeon. One hundred and forty-one cases out of 934 patients were selected who had cholesteatoma for the study. These randomly selected 141 cases were divided into two groups as follows: I. Forty-six cases were applied MESNA (Sodium 2-mercaptoethanesulfonate) intraoperatively, and II. Ninety-five cases were not applied MESNA intraoperatively. The cases that were followed-up at least one year were included in this study.

Intervention

MESNA (Ureomitexan, MESNA, Baxter oncology, Germany) was diluted with saline (20% MESNA and 80% saline) that was applied, and then a waiting period of approximately 5 min followed to start to dissect cholesteatoma matrix.

Main outcomes and measures

Residual cholesteatoma rates between intraoperative MESNA, a disulfide bond breaking chemical agent, applied and MESNA non-applied cases in the postoperative follow-up period were compared for the success of the surgery.

Results

MESNA was used in 46 patients out of 141 cases intraoperatively. Twenty-four of these patients underwent CWD (canal wall down), and twenty-two patients underwent CWU (canal wall up) mastoidectomy. For the other 95 subjects, 56 patients with CWD and 39 with CWU mastoidectomy, MESNA was not applied. Residual cholesteatoma rates were found to be significantly higher in MESNA non-applied group than MESNA applied group (p < 0.05). Residual cholesteatoma rates between CWD and CWU mastoidectomy procedures were not statistically significant (p > 0.05).

Conclusions and relevance

MESNA application that breaks disulfide bonds in the structure of the matrix in cholesteatoma surgery may assist the elimination of the disease, and increase surgical success by facilitating the elevation of the epithelium. Thereby, it causes a decrease in the possibility of remaining residual epithelium after surgery, which decreases the need for second-look surgery.

Trial registration

The retrospective research protocol was approved by the Inonu University Clinical Research Ethics Committee. Registration number:………     

Management of acquired cholesteatoma in children: A 15 year review in ENT service of CHNU de FANN Dakar

Objectives

To analyze the epidemiology, diagnosis, management and the prognosis of cholesteatoma of the middle ear in children.

Methods

This was a retrospective study of 15 years (from 01 January 1995 to 31 December 2009) for patients aged 0–15 years admitted in ENT ward of FANN hospital for chronic otitis media complicated with cholesteatoma The parameters studied were epidemiology, clinical presentation, disease progression and management.

Results

Sixty-six participants were included. We noted a slight male predominance with a sex ratio of 1.44. The average mean age was 10 years. Most patients presented with signs of complications (69.7%) and mastoiditis was the most common complication (63.6%). The otorrhea was noted in almost all patients: n = 64 (97%) and deafness in 49 patients (74, 2%). There was a slight predominance of cholesteatoma on the right side (51.5%). Schuller's view of the mastoid cells was done in 21.2% of patients (n = 14) and showed sclerotic mastoid air cells for all them. Eighty-two percent (82%) of patients presented with conductive hearing loss. A radical mastoidectomy was performed in 66.7% and modified radical mastoidectomy in 33.3% of cases. Mean follow-up was 6 months. Recurrence of cholesteatoma was noted in 13% of cases.

Conclusions

ENT ward of Hospital Fann is one of the two centers in Senegal where cholesteatoma of the middle ear are treated. This low number of cholesteatoma in children in a developing country is in relation to the fact that patients only present when complications develop: 70% of cases. The reason for this in our setting include insufficient human and manpower resources necessary for prompt management of the disease and also lack of awareness among the populace. In these settings we advocate canal wall down mastoidectomy (radical or modified radical) as the treatment of choice.     

Bioglass reconstruction of posterior meatal wall after canal wall down mastoidectomy

Background

Canal wall down (CWD) mastoidectomy has many drawbacks including chronic otorrhea, granulations, dizziness on exposure to cold or hot water and tendency of debris accumulation in the mastoid cavity demanding periodic cleaning. Many of these problems can be solved by reconstruction of the posterior meatal wall (PMW).

Clinical analysis of secondary acquired cholesteatoma

Objective

This study aimed to analyze the clinical features of patients who underwent surgery for secondary acquired cholesteatoma (SAC).

Materials and methods

The subjects were 30 patients who underwent surgery for SAC in 30 ears. We investigated the age distribution, sex, tympanic membrane (TM) findings, temporal bone pneumatization, morphology of TM epidermis invasion, extent of cholesteatoma invasion, ossicular erosion, surgical methods and surgical results.

Results

There were 10 males (33.3%) and 20 females (66.6%), with a mean age 54.9 years. The TM perforation was medium-sized or larger in 27 ears (90%). Temporal bone pneumatization was poor or bad in 90% (18/20) of the evaluated ears. The cholesteatoma invaded from the malleus manubrium to the promontory in 23 ears (76.7%). There were no patients in whom the cholesteatoma invaded the antrum or mastoid. The ossicles were affected in 19 ears (63.3%). Ossiculoplasty with a columella on the stapes was the most frequent procedure, performed for 16 ears (53.3%). There were no hearing results with a postoperative air-bone gap of more than 31 dB.

Conclusions

Although SAC is rare, it is important for the clinician to keep this type of cholesteatoma in mind.     

Surgical management of labyrinthine fistula in chronic otitis media with cholesteatoma

Objective

To present the surgical outcomes of complete removal of the matrix of labyrinthine fistulas in a large series of middle ear cholesteatomas.

Patients and methods

This is a retrospective study. We analyzed 38 of 778 patients who were operated on for cholesteatoma and were proved to have labyrinthine fistula from 1991 to 2007. For this study, a more aggressive strategy was adopted that compromised immediate total removal of the matrix, regardless of size. To evaluate the safety and efficacy of the procedure, pre and postoperative pure-tone audiometry were compared and the recurrence rate was analyzed. Relevant data from the literature using a wide array of strategies were compared with our results.

Results

Only two patients suffered from postoperative hearing deterioration of bone conduction of more than 10 dB HL. There was no relationship between the size of labyrinthine fistulas and postoperative hearing deterioration. Recurrence of labyrinthine fistulas was not found.

Conclusions

Total removal of the cholesteatoma matrix in one step is a safe and effective method for the treatment of labyrinthine fistulas.     

Postauricular cutaneous mastoid fistula

Postauricular cutaneous mastoid fistula is a rare condition. The cutaneous mastoid fistula is a very rare complication of chronic suppurative otitis media. The fistula tracts are typically difficult to manage because of the surrounding necrotic skin edges. We describe an unusual case of a postauricular cutaneous mastoid fistula and outline the surgical technique used for closure.     

Acquired cholesteatoma in children: Clinical features and surgical outcome

Objective

In general, cholesteatoma tends to recur more frequently in children than in adults. This has been suggested to be due to immature Eustachian tube function, underdeveloped mastoid air cells, and subsequent repetitive otitis media in children. This study was undertaken to determine the characteristics of acquired cholesteatoma in children by comparison with that in adults.

Methods

We retrospectively evaluated 42 children with acquired cholesteatoma (males, 38; females, 4; age range, 3–15 years) using medical records from January 1999 to December 2009 at the Department of Otolaryngology, Niigata University Hospital. The extent of disease was classified according to the Classification and Staging of cholesteatoma proposed by the Japan Otological Society in 2010.

Results

No major differences in stage classification were observed between children and adults. In children with pars flaccida-type cholesteatoma, the epithelium tended to invade from the attic to the mastoid cavity and mesotympanum. In contrast, adult patients with invasion to the mesotympanum were fewer. The rate of disappearance of the stapes superstructure was almost the same in children and in adults. The destruction of the superstructure of the stapes was more common in pars tensa type than pars flaccida type; so it was dependent on the pathology. Postoperative hearing levels were better in children, even in those with widespread lesions. However, the recurrence rate was significantly higher in children.

Conclusions

Acquired cholesteatoma in children showed a wider invasion, and the recurrence rates were higher than that in adults. For patients with a widespread lesion and severe destruction of the ossicles, a two-stage surgery is recommended.     

Obliteration of Radical Cavities and Total Reconstruction Procedure Without Staging After Canal Wall Down Mastoidectomy: Long-term Results

Objectives

We evaluate the long-term surgical and hearing results using a canal wall down mastoidectomy technique followed by cavities obliteration, canal wall reconstruction and ossiculoplasty without staging.

Methods

A total of 44 patients between January 2002 and October 2009 were selected and 27 of them were revision cases. Preoperative and postoperative pure tone average (PTA) and air-bone gap (ABG) were assessed and compared 1 and 4 years after surgery.

Results

The middle ear was well healed and aerated in 40 patients (90.9%) and the tympanic membrane was intact in 42 patients (95.5%). Recurrent cholesteatoma was found on postoperative follow-up in two of the revision patients (7.4%) but none in the primary patients. Seven patients were found to have partial canal bone absorption, but revision surgery was not required. Over 86.4% of all cases were water resistant. Long-lasting improvement and/or preservation of hearing, with maintenance of PTA-ABG closure in 63.7% of all cases within 20 dB, were obtained.

Conclusion

The efficacy of our technique after a canal wall down mastoidectomy is satisfactory, and the rate of complication is acceptably low. We believe that our technique could be a convenient method in disease control and providing an excellent basis for hearing restoration simultaneously.     

The learning curve in revision cholesteatoma surgery

Objective

To review the results of revision surgery for cholesteatoma.

Study design

Retrospective review of patient's records.

Setting

Tertiary referral center.

Patients

A retrospective study of patients operated for acquired middle ear cholesteatoma during the period 1990–2002 was performed. A total of 758 patients were divided into two groups according to surgical experience, and followed during short-term and long-term period. The cholesteatoma was divided according to location, age of patients, status of auditory ossicles, and bilaterality of disease.

Interventions

The patients were treated with single canal wall up or wall down, according to the propagation of disease and condition of middle ear. The indications for the reoperations were: recurrent or residual cholesteatoma, resuppuration, and AB gap more than 20 dB.

Main outcome measures

Type of surgical therapy, localization of cholesteatoma, age of patients, revisions, bilaterality of disease, damage of auditory ossicles and learning curve were analyzed.

Results

The number of revision operations was reduced in the second period (from totally 24.3% to 16.4%). Closed technique gave a significantly lower rate of failure. For attic cholesteatoma, adults, bilateral disease, and ossicular damage the rate of revisions was significantly lower with surgical experience.

Conclusion

Surgical experience was important for reduction of reoperation rate for attic and sinus cholesteatoma, adults, bilateral cholesteatoma, and when closed technique is used.     

Canal wall reconstruction and preservation in the surgical management of cholesteatoma in children with Down's syndrome

Introduction

Down's syndrome is associated with poor Eustachian tube function, and an increased incidence of cholesteatoma. The only previously published case series suggests that ‘canal wall preserving’ procedures are only rarely suitable for the management of cholesteatoma in this population.

Methods

We conducted a retrospective review of the hospital's clinical records database to identify patients with Down's syndrome and cholesteatoma. These patients’ notes were then reviewed.

Results

We identified nine patients with Down's syndrome who had undergone surgical management of cholesteatoma over a twelve year period. Three patients had bilateral disease, meaning twelve ears were treated. Seven ears were initially treated with ‘canal wall down’ procedures. Four out of five of the remaining ears were successfully treated using ‘canal wall preservation’ or ‘canal wall reconstruction’, with one ear requiring subsequent conversion to a ‘canal wall down’ approach.

Conclusion

Canal wall preservation/reconstruction is feasible in patients with Down's syndrome, even when cholesteatoma extends into the mastoid.     

Mastoid obliteration with silicone blocks after canal wall down mastoidectomy

Objectives

To evaluate the usefulness of silicone blocks as graft material for mastoid cavity obliteration in the prevention of problematic mastoid cavities after canal wall down mastoidectomies.

Methods

Retrospective evaluation of 20 patients who underwent mastoid obliteration with silicone blocks between 2002 and 2009 at the Chonnam National University Hospital. The cases consisted of 17 patients with chronic otitis media with cholesteatoma and 3 patients with adhesive otitis media. The postoperative follow-up period was an average 49 months (range, 6 to 90 months). The surgical technique used at our institution composed four major steps: First, the canal wall down mastoidectomy was performed and the middle ear procedure was completed. The silicone blocks were used to fill up the mastoidectomized cavity. Then, a cortical bone pate was used to cover the surface of the silicone blocks. Finally, temporalis fascia and a split musculoperiosteal flap were used to surround the bone pate for reinforcement of the reconstructed canal wall. We examined postoperative success rate and hearing outcomes.

Results

In 19 cases (95%), the reconstructed canal wall maintained a cylindrical shape and the ear drum healed without perforation. In only 1 case (5%), the reconstructed canal wall was destroyed with ear drum perforation. The mean improvement in air-bone gap was about 12 dB (P<0.05), and the mean improvement in air-conduction was about 16 dB (P<0.05).

Conclusion

We suggest that silicone blocks could be valuable resources as graft materials for mastoid obliteration after canal wall down mastoidectomies.     

Posterior canal wall reposition for management of cholesteatoma: Technique and results

Objective

The main goal of surgery in acquired middle ear cholesteatomas is the complete eradication of the disease with an ear free of discharge. This can be performed either by open or closed techniques with their benefits and drawbacks. We present the technique of reposition of the posterior canal wall for the management of cholesteatoma cases and its results and outcome.

Functional and Anatomical Outcome of Inside Out Technique For Cholesteatoma Surgery

Background

To study the efficacy of inside-out technique in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing & and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations.

Persistent oro-nasal fistula after primary cleft palate repair: Minimizing the rate via a standardized protocol

Objectives

Multiple methods are described for cleft palate repair. Similarly, a wide range of postoperative oro-nasal fistula rates are described, depending on technique and series examined. We describe long-term outcomes and fistula rates for primary cleft palate repair for a single surgeon using a standardized protocol. Furlow palatoplasty was used for clefts limited to the soft palate, and two-flap palatoplasty was used for clefts involving both the hard and soft palate.

Methods

Retrospective review of prospectively gathered data.

Results

Eighty-two patients underwent cleft palate repair within the study period. Average age at time of repair was 1.69 years (range 0.47–12.1 years), 19 patients had cleft palate as a part of a known genetic syndrome, and male:female ratio was 1.05:1. Overall fistula rate requiring repair was 5.5%, and fistula development was not significantly associated with type of cleft repair or use of AlloDerm in the repair.

Conclusions

A very low rate of oro-nasal fistula and good postoperative outcomes were achieved utilizing this protocol for cleft palate repair. It is effective both in isolated cleft palate, as well as in more complicated syndromic patients. It is possible that significant associations between repair technique and fistula rate exist that were not elucidated in this study as a result of the small number of oro-nasal fistulas.     

Significance of intraoperative findings in revision tympanomastoidectomy

Purpose

The study was designed to assess correlations between intraoperative findings in revision tympanomastoidectomy as predictors of cholesteatoma recurrence.