Mature teratoma of the nasal vestibule: a case report

Teratomas are rare congenital neoplasms that arise from pluripotent cells. They consist of tissue from all three embryonic germ layers. According to most studies, teratomas of the head and neck account for only 2 to 9% of all cases. In this article, we report the first case of a teratoma of the nasal vestibule in a newborn. We also discuss methods of diagnosis and treatment of upper airway teratomas, and we include a brief review of the literature.     

The old-fashioned Politzer maneuver: a video clip demonstration

Politzer maneuver causes retrograde inflation of the middle ear by forcing air through the eustachian tube, and it has been proposed by many authors as the main nonsurgical treatment of middle ear effusion. To our knowledge, this is the first case in the literature in which air entering into a middle ear with effusion through a Politzer maneuver has been captured on video (www.laryngoscope.com).     

Anatomy of the chinchilla bulla and eustachian tube: I. Gross and microscopic study

The middle ear mucosa and eustachian tube of the normal chinchilla were studied quantitatively and under light microscopy to determine the distribution of each cell type of the lining epithelium and subepithelial gland. The middle ear mucosa consisted of columnar epithelium, cuboidal epithelium, and squamous epithelium. The lining epithelium of the eustachian tube was ciliated pseudostratified columnar epithelium. These epithelia were composed of ciliated, secretory, nonciliated (nonsecretory), and basal cells. The density of the ciliated cells was highest in the columnar epithelium area of the transitional zone of the middle ear mucosa. However, the density of the secretory cells was highest in the pharyngeal orifice of the eustachian tube. The nonciliated cell density was highest in the squamous epithelium area of the middle ear mucosa and decreased progressively toward the tympanic orifice of the eustachian tube. In the eustachian tube, the nonciliated cell density was highest in the pharyngeal portion of the eustachian tube, especially in the upper portion of the lateral wall. The subepithelial glands were tubuloacinar mixed glands composed of serous demilunes and mucous acini. The glands were localized primarily in the pharyngeal orifice and pharyngeal portion of the eustachian tube, and their ductal openings were present primarily in the inferior portion of the eustachian tube.     

Eustachian tube function in tympanoplasty

This paper describes central and peripheral eustachian tube function in relation to tympanoplasty. Central obstruction of the eustachian tube at the pharyngeal orifice is frequently correctable and is not a contraindication to tympanoplasty, whereas chronic cicatricial peripheral obstruction of the eustachian tube at the isthmus is a contraindication to tympanoplasty. These findings are based on tubal patency pressure studies measured with a mercurial manometer with the patient performing the Valsalva maneuver, with catheterization of the eustachian tube, and with politzerization. If the patient can autoinflate the middle ear and if the eustachian tube will open with politzerization, then the likelihood exists that there is no peripheral obstruction of the eustachian tube and you have a good candidate for tympanoplasty. When there is a perforation of the ear drum, the best test for eustachian tube function is microscopic examination of the middle ear mucosa. If the middle ear mucosa is perfectly normal, then you know that you have good eustachian tube function and can proceed with the tympanoplasty.     

Theoretic analysis of middle ear gas composition under conditions of nonphysiologic ventilation.

As gas flows in and out of the nasopharynx, the pressure in that region fluctuates. It drops below or rises above atmospheric pressure, which is itself not constant but is subject to changes in altitude and weather. Such pressure changes in the nasopharynx produce a pumping of gas into and out of the middle ear. The net amount of middle ear gas transferred from or to the nasopharynx will, component for component, in steady state exactly equal the amount of middle ear gas transferred to or from the microcirculation by means of diffusional absorption by (or release from) the mucosa. In the case of a permanently patulous eustachian tube, a single parameter, characteristic of the rate of ventilation through the open eustachian tube, is found to determine the gas composition in the middle ear, whereas in the case of a middle ear ventilated by tympanostomy, two rate-of-ventilation parameters, one for gas flow through the ventilation tube and one for flow through a periodically open eustachian tube, determine the steady state gas composition. A high rate of ventilation favors absorption of oxygen and venting of carbon dioxide from the middle ear in both cases.     

Hypertrophy of the tensor tympani muscle presenting as a middle ear mass

A wide variety of benign and malignant middle ear masses have been reported in the literature. We present here an example of a previously unreported type of lesion, a case of hypertrophy of striated muscle, probably the tensor tympani muscle, presenting as a middle ear mass in a 17-year-old male. Clinical evaluation revealed a marked conductive hearing loss and eustachian tube obstruction.     

Gas composition and pressure in the middle ear: a model for the physiological steady state

The gas contents of the physiological middle ear periodically cycle through two phases in steady state. During phase I, the eustachian tube is shut and the middle ear gas space is effectively closed. Gas is absorbed or produced at the mucosal surface, and the total pressure changes correspondingly. During phase II, which is of very short duration, the eustachian tube opens, a bolus of gas passes between the middle ear and the nasopharynx, and the total pressure in the middle ear rapidly adjusts to that in the nasopharynx. Since nasopharyngeal pressure fluctuates in time, so does the pressure in the middle ear. The effect of these pressure changes is to produce a level of ventilation in the middle ear, which depends on a combination of three parameters: the volume of the middle ear, multiplied by the mean amplitude of pressure variations in the nasopharynx, divided by the mean elapsed time between successive eustachian tube openings. Assuming steady-state conditions, the composition of middle ear gas can be computed and is predicted to range from PN2 = 621, PO2 = 46, PCO2 = 46, PH2O = 47 mm Hg in the case when nasopharynx fluctuations are small, to a match with nasopharyngeal gas composition, when the fluctuations are large.     

Technique and clinical importance of eustachian tube radiography

The intact eustachian tube is essential for a successful tympanoplasty. Since clinical function tests do not provide satisfactory results in every case, radiologic examination of the tube becomes very significant. The technique, which we have employed since 1966 in sixty-seven cases of transtympanic radiography of the eustachian tube, is described. The most important indications for this examination are discussed (cases of chronic middle ear suppuration, post-traumatic tube stenosis, and early diagnosis and clarification of tumors of the nasopharynx and middle ear). The transtympanic method is physiologic, simple to perform, and essential for hearing improvement.     

The trigeminal sensory innervation to the middle ear, eustachian tube, and pharynx: a study by the horseradish peroxidase tracer method.

The trigeminal sensory innervations to the middle ear, the eustachian tube, and the pharynx were examined using the horseradish peroxidase (HRP) method in cats. After HRP application to the middle ear and the eustachian tube, HRP-labeled cells were found mainly in the posterolateral portion and the anteromedial portion of the trigeminal ganglion, respectively. In the case of injection into the epipharynx and the mesopharynx, HRP-labeled cells were found in the anteromedial portion and the posterolateral portion, respectively. HRP-labeled cells were hardly observed when HRP was applied to the hypopharynx. These results indicate that trigeminal nerve sensory fibers branch to the middle ear, including the eustachian tube, epipharynx, and mesopharynx.     

Combined transoral and nasendoscopic resection of an eustachian tube hairy polyp causing neonatal respiratory distress

Hairy polyps are rare congenital malformations that can arise in the nasopharynx. It is rarer for them to originate from the eustachian tube. They present with intermittent airway obstruction and respiratory distress. A thorough ear, nose, and throat examination can be required to identify these lesions. We present a case of eustachian tube hairy polyp causing neonatal respiratory distress in a 1-month baby successfully removed by a combined transoral and nasendoscopic resection.     

Dehiscence of intrapetrous segment of the internal carotid artery in a dermoid cyst of the eustachian tube

Dermoid cysts are rare congenital tumors. Localization in the Eustachian tube is even less frequent. We report the case of a two-year-old girl diagnosed with a left ear dermoid cyst of the Eustachian tube. The carotid canal was dehiscent in the middle ear space. Careful interpretation of the preoperative imaging studies was important in order to prevent serious operative complications. A review of the literature concerning dermoid cysts of the Eustachian tube is also discussed.     

Unilateral progressive proptosis in neonate

Orbital teratomas are congenital germ cell tumors that present at birth or within the first few months of life with unilateral proptosis. Primary orbital teratomas produce diffuse enlargement of the orbit. Orbital teratoma contains a wide diversity of tissues ranging from undifferentiated mass of tissue to a fully differentiated fetus in fetus. The tumor components are derived from two or more germinal layers. Most teratomas are cytnlogically benign, having both cystic and solid areas and on occasions may undergo a malignant change. Most patients in the past have been treated by orbital exenteration. We report a case of orbital teratoma that rapidly progressed over a course of days.     

Effects of irradiation on the ciliary activity of the eustachian tube and the middle ear mucosa

Radiation-induced changes in the ciliary activity of the eustachian tube and middle ear mucosa were investigated in a laboratory model. Twenty-four guinea pigs were sacrificed, and a mucosa at the bony portion of each eustachian tube and from the middle ear proximal and distal to the tube were sampled. The mucosal samples were irradiated with 200 kV hard X-rays discretely at a dosage level of 0.5-30.0 Gy, and the induced changes in ciliary activity were expressed as a percent deviation from baseline levels before irradiation. The present study demonstrates that the cilia of the eustachian tube and middle ear mucosa show different reactions to irradiation according to their tympanic locations.     

Eustachian tube function in patients with eosinophilic otitis media associated with bronchial asthma evaluated by sonotubometry

OBJECTIVE: To determine eustachian tube function in patients with asthma and with or without eosinophilic otitis media (EOM), a new middle ear disease entity with a highly viscous middle ear effusion containing many eosinophils and usually associated with bronchial asthma. One of the most important causes of otitis media (OM) is eustachian tube dysfunction. DESIGN: Retrospective case review. SETTING: A referral center. PATIENTS: Twenty patients with EOM and patients with asthma but without OM. MAIN OUTCOME MEASURES: We studied eustachian tube function using sonotubometry and a questionnaire. Sonotubometry was also performed on 13 control patients with chronic otitis media (COM) and 7 normal controls. RESULTS: The tubal opening duration was significantly longer in patients with EOM than in patients with asthma but without OM, controls with COM, and normal controls, indicating the presence of patulous eustachian tubes in patients with EOM. Responses to the questionnaire also supported the presence of patulous eustachian tubes in the patients with EOM. CONCLUSIONS: The presence of a patulous eustachian tube may be a major cause of EOM in patients with bronchial asthma. In patients with asthma who have a helper T-cell 2-dominant predisposition, a patulous eustachian tube easily allows the entry of antigenic materials into the middle ear, causing eosinophil-dominant inflammation.     

Effects of irradiation on the ciliary activity of the eustachian tube and the middle ear mucosa

Summary Radiation-induced changes in the ciliary activity of the eustachian tube and middle ear mucosa were investigated in a laboratory model. Twenty-four guinea pigs were sacrificed, and a mucosa at the bony portion of each eustachian tube and from the middle ear proximal and distal to the tube were sampled. The mucosal samples were irradiated with 200 kV hard X-rays discretely at a dosage level of 0.5–30.0 Gy, and the induced changes in ciliary activity were expressed as a percent deviation from baseline levels before irradiation. The present study demonstrates that the cilia of the eustachian tube and middle ear mucosa show different reactions to irradiation according to their tympanic locations.     

Mechanical obstruction of the eustachian tube by the benign tumor of the parapharyngeal space does not cause otitis media with effusion.

OBJECTIVE: We are reporting on eustachian tube and middle ear pathologic findings in patients with parapharyngeal tumors. PATIENTS: Eleven cases of eustachian tube involvement as indicated by obstruction due to compression of the tumor were assessed in this study. MAIN OUTCOME MEASURES: Each patient underwent otoscopy, nasopharyngoscopy, a pure-tone hearing test, impedance audiometry, and sonotubometry. RESULTS: All of the tumors were diagnosed benign according to the histologic examination. In 9 of the 11 patients, the pharyngeal opening of the eustachian tube narrowed or was blocked by the tumor. None of the patients showed any response on the tumor side in the sonotubometry. Therefore, gas exchange was prevented through the eustachian tube by the tumor; however, they also showed an intact tympanic membrane and normal hearing tests. CONCLUSION: According to our data, if there is drainage of middle ear fluid through the eustachian tube and the exchange of gas in the middle ear is preserved, otitis media with effusion will not occur even in cases such as these.     

Arteriovenöse Fistel der A. maxillaris, Tubenfunktionsstörung und Tinnitus nach Le-Fort-I-Osteotomie

A 36-year-old woman with a maxillary retrognathia underwent a Le Fort I osteotomy. Postoperatively, she complained of pulsatile noise and hearing loss in the left ear. Carotid arteriography revealed an arteriovenous fistula of the left maxillary artery; in addition, a persistent eustachian tube dysfunction with left middle ear effusion was noticed. After embolization of the fistula and ventilation tube treatment, improved hearing and a significant reduction of tinnitus were achieved. Arteriovenous fistulas after orthognathic surgery are very rare. Postoperative eustachian tube dysfunction has not yet been reported in the literature.     

Sensation of ear fullness caused by eustachian tube dysfunctions.

One hundred and ninety-four patients with a sensation of ear fullness were examined with the audiometry, tympanometry, and tubotympanoaero-dynamic graphy (TTAG) as a eustachian tube ventilatory test. In 74 cases of 194, the eustachian tube dysfunction was thought to cause an ear fullness sensation and patulous tube was found in 19 patients which is more frequent than expected. Functional unbalance of the both eustachian tubes which results from minimum ventilatory disturbance on the complaining side was also thought to be one of the causes of this symptom. The eustachian tube dysfunctions like stenotic or patulous tube could not be fully diagnosed by the audiometry and tympanometry because most patients with the eustachian tube dysfunctions showed normal middle ear pressure measured by the tympanometry. From our study, it could be concluded that eustachian ventilatory test like TTAG was very available in the patient with an ear fullness feeling which is one of the most common symptoms in the otolaryngological field.     

Teratoma of the middle ear: a real entity or a non-entity?

Space-occupying lesions of the middle ear range from wholly benign developmental anomalies to highly virulent and aggressive malignancies. Amongst the benign entities classed with the family of developmental anomalies, the middle ear choristoma is well known. But what of the middle ear teratoma? Recent reports suggest that, while rare, teratomas of the middle ear do exist. Middle ear teratomas are defined as tumors consisting of benign tissues derived from all three embryologic layers: endoderm, mesoderm and ectoderm. They are lesions of the neonatal period and early infancy. While complete surgical excision will be curative, a thorough histologic examination of the specimen is recommended to exclude the possibility of immature and/or frankly malignant elements being admixed with the benign teratomatous elements.     

Middle-ear lipoma presenting as airways obstruction: case report and review of literature

We report a case of a lipoma arising in the middle ear of a 64-year-old woman and extending down the eustachian tube to cause acute airways obstruction. The lipoma arose coincidentally after a stapedectomy operation and caused apparent late failure of the operation. A review of the literature revealed no similar cases.