A middle ear implant with a titanium canal wall prosthesis for a case of an open mastoid cavity

Objective

Open mastoid cavity rehabilitation should focus on both anatomical and functional aspects. We hereby report the technique and results of a combined strategy to reconstruct the external ear canal using a titanium wall implant and the middle ear using a fully implantable active middle ear device.

Methods

A fully implantable active middle ear implant was used to rehabilitate the mixed hearing loss of a 63-year-old woman, and a titanium posterior canal wall prosthesis was used to reconstruct the external ear canal during the same procedure. The middle ear implant was placed directly on the footplate. The auditory results were compared to the preoperative unaided thresholds and to the amplification of a conventional hearing aid.

Results

Following the procedure, there was an anatomically normal external ear canal with a healed tympanic membrane separating the external from the middle ear spaces. The postoperative auditory gains were on average 31.8 dB on pure-tone audiometry, and 20 dB on speech reception threshold. No complications occurred.

Conclusion

The rehabilitation of the external ear canal in an open mastoid cavity allows for clinical follow-up of the patient, and the implantation of an active middle ear implant provides appropriate auditory gains both in pure tones and in speech reception thresholds.     

Cochlear implantation in patients with chronic otitis media

Objective

Patients with complications of otitis media present a significant challenge to safe cochlear implantation. We describe our experience of cochlear implantation in patients with chronic ear disease, and propose management principles according to the presenting status of the ear.

Methods

Cochlear implantations were performed as treatment for complications of otitis media in seven patients. They consisted of four patients with adhesive otitis media, two patients with an open cavity after surgery for otitis media and one patient with eosinophilic otitis media.The electrodes were inserted by an approach via the external auditory canal in patients with poor growth of the mastoid antrum or adhesion of the tympanum. For the patients with an open cavity, we created a posterior wall for the external auditory canal and perform the mastoid obliteration. Modified Rambo's technique with blind sac closure of the external auditory canal was performed for the case of eosinophilic otitis media as a single-stage procedure.

Results

The post-operative courses were good. However, a post-operative infection developed in one patient who had previously undergone radiation therapy following surgical excision of a cerebellar tumor.

Conclusion

Transcanal approach is effective in a poorly pneumatized mastoid or severe adhesive otitis media.A decision whether implantation as a single-stage or multiple stages depends on the condition of each cases. But there is a possibility of infection even if we selected a stage operation.     

Keratinic amyloidosis of the external auditory canal

Objective

We present a rare case of keratinic amyloidosis of the external auditory canal. This is only the seventh case reported of localized cutaneous amyloidosis of the external auditory canal with no systemic symptoms.

Patient

A 62-year-old man, who had complained of an itchy external auditory canal and left-side hearing loss, was referred to our hospital because of a bilateral external auditory canal mass.

Intervention

Biopsy of the external auditory canal mass suggested a diagnosis of amyloidosis. However, total systemic examination failed to identify any disease due to systemic amyloidosis. This led us to diagnose him with localized cutaneous amyloidosis of the external auditory canal.

Main outcome measure

We follow up periodically with systemic examination and local observation.

Results

Thirty months after the initial diagnosis, he remains in follow-up and has not shown any significant aggravation of the disease.

Conclusion

In previous cases, the chief complaints were itching sensations and pain in the external auditory canal as well as a sense of discomfort when wearing a hearing aid. This suggests that chronic stimulation and inflammation of the skin lining the external auditory canal induced amyloidosis.     

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.     

Anatomic Variants on Computed Tomography in Congenital Aural Atresia and Stenosis

Objectives

To quantitatively analyzing the anatomic variants on temporal computed tomography (CT) in congenital external auditory canal stenosis (EACS), congenital aural atresia (CAA), and normal ear structure.

Methods

Through a retrospective study, we analyzed 142 temporal high-resolution CT studies performed in 71 microtia patients. The following 6 parameters were compared among the three groups: Marx classification, medial canal diameter, vertical facial nerve (VFN) anterior displacement, tegmen mastoideum position, tympanic cavity volume, and malleus-incus joint or malleus-incus complex (MIC) area.

Results

The results showed that the microtia distributions in the Marx classification in these three groups were significantly different, as 86% (31 of 35) of ears with major microtia (third-degree dysplasia) had an atresia, and in 54.8% (23 of 42) of the minor microtic (first-degree or second-degree) ears, the bony or cartilaginous part of the external auditory canal was stenotic. Measurement data also showed that the potential medial canal diameter of the atresia group was obviously shorter than that of the stenosis group. The VFN anterior displacement and temporomandibular joint backward-shift together lead to medial canal diameters in ears with atresic canals that is smaller than those with stenotic canals. The tegmen mastoideum position was not significantly different between the three groups.

Conclusion

The mal-development of the external auditory canal is significantly associated with auricle and middle ear developmental anomalies. Compared with CAA ears, EACS have better development of the auricle, canal, tympanic cavity and MIC and relatively safer surgical operation except for the position of the tegmen mastoideum and the VFN.     

The pathology of silent otitis media: A predecessor to tympanogenic meningitis in infants

Objective

To determine the association of bacteria embedded within a fibrous matrix in the middle and inner ear in infants with tympanogenic meningitis.

Methods

Thirty-one cases with meningitis from the human temporal bone collection at the University of Minnesota were screened to select those with tympanogenic meningitis. Inclusion criteria for tympanogenic meningitis were acute meningitis with histopathological evidence of chronic otitis media, and no other source of infection. The presence of labyrinthitis and pathologic changes such as granulation tissue, fibrosis, cholesterol granuloma, cholesteatoma, tympanic membrane perforation, tympanosclerosis, and the type of effusion were noted. The extent and location of bacteria embedded in a fibrous matrix were also explored.

Results

Seventeen temporal bones, from nine cases that included two females and seven males, ranging in age from five to twenty-three months, met our criteria of tympanogenic meningitis. Eighty two percent of these temporal bones had bacteria within the fibrous matrices (BFM). BFM were located in one anatomical region in one temporal bone and multiple anatomic regions in sixteen temporal bones. The most common locations were the areas near the oval and round windows. They were also commonly seen in the epitympanum, facial recess, and supratubal recess. BFM within the inner ear were observed in the scala tympani and modiolus in the middle and basal turns of the cochleae of nine temporal bones. In one of these temporal bones, BFM were seen in the internal auditory canal. Labyrinthitis was seen in all ears. The tympanic membrane was intact in all cases. BFM were not seen in three temporal bones from two patients. In one case only one side was available for study.

Conclusions

Our findings show an association between the presence of BFM in the ear with chronic pathologic changes and tympanogenic meningitis. Potential pathways of bacteria from the middle ear include hematogeous spread and/or direct spread to dura through the tympanic tegmen, and/or to the inner ear through the oval and round windows, and from there to the modiolus and the meninges. Chronic pathologic changes in the middle ear behind an intact tympanic membrane and the lack of ear symptoms may result in potentially serious sequelae and complications in infant age groups. There should be a heightened awareness of this condition.     

Early complications following cochlear implantation in children and their management

Objectives

To report the early postoperative complications of cochlear implantation (CI) in the pediatric population and discuss the intervention measures.

Methods

We retrospectively analyzed 260 consecutive pediatric cochlear implantations performed at the First Affiliated Hospital of Zhengzhou University between March 2010 and July 2013. All patients were younger than 12 years old at the time of implantation, with a mean age of 4.3 years, and 47 cases had inner ear malformations. Complications correlated to age at CI and inner ear malformations were analyzed using the χ² test.

Results

Of the 260 patients, early postoperative complications were observed in 17 (6.54%) cases, of which 16 (6.15%) were minor and one (0.38%) was major, none required surgical device removal or reimplantation. Among the 16 minor complications, transient vertigo was the most common (nine cases, 3.46%), three (1.15%) of them with severe CSF gusher during the surgery; followed by transient facial nerve palsy (two cases, 0.77%, both were reversible); external auditory canal injury, subcutaneous hematoma each in two cases (0.77%), and minor dural injury in one case (0.38%). One major complication included an epidural hematoma in a 7-year-old boy who recovered completely without any neurologic deficits following immediate evacuation. Inner ear malformations were significantly associated with the surgical complications, especially vertigo and gusher (P < 0.05).

Conclusions

Cochlear implantation in children is fairly a safe procedure with a relatively low complication rate. The most common early postoperative complications are minor, but serious and life threatening complications rarely may occur. Awareness of complications helps clinicians to adopt the specific preventive measures and immediate interventions so that the outcome will be successful.     

Application of high resolution computer tomography in external ear canal cholesteatoma diagnosis

Objective

To evaluate High Resolution Computer Tomography (HRCT) in the diagnosis of external ear canal cholesteatoma.

Myringoplasty using rotation flap of canal skin for total tympanic membrane perforation

Objective

To evaluate the efficacy of a novel technique of using rotation flap of canal skin in patients with total or subtotal tympanic membrane (TM) perforation with no anterior residual tympanic membrane.

Methods

A retrospective study of 50 patients with total or subtotal perforation repaired with rotation flap of canal skin. Clinical and audiometric data were recorded.

Results

The overall perforation closure rate was 96%. A statistically significant shortened healing time was observed.

Conclusion

The rotation flap of canal skin could be an effective and safe technique for perforations with no anterior residual TM.     

A long-term analysis of auricular position in pediatric patients who underwent post-auricular approaches

Objective

Post-auricular approach is commonly used in otologic surgery. The objective of this study was to ascertain whether post-auricular approach alters the position of the auricle.

Methods

All patients who underwent post-auricular approach for mastoidectomy or tympanoplasty from October 2010 to June 2012 were enrolled. Measurements of ear prominence at three distinct sites were taken preoperatively, and postoperatively at day one and at three and 12 months. Data were analyzed with repeated measures ANOVA analysis.

Results

Nineteen patients were included in the study. Mean age at surgery was 9.05 years; 11 were male and 8 were female. Overall, there was no statistically significant long-term postoperative change in any of the three measurements, indicating stability of the auricular position. No difference was also noted on the basis of patient variables.

Conclusion

Post-auricular approach did not alter the position of the external ear in our patient population.     

Hearing loss in the shaken baby syndrome

Objectives

To evaluate hearing in children diagnosed with shaken baby syndrome.

Methods

A retrospective study conducted in a pediatric tertiary care center between 2006 and 2012. Children diagnosed with shaken baby syndrome were included for hearing evaluation by conventional audiometry, distortion product otoacoustic emissions and auditory brainstem responses.

Results

Twenty-eight children were included (22 boys and 6 girls). The mean age of children at presentation was 8 months (range 1–26 months) and the mean delay before audiometric evaluation was 30 months (range 1–87 months). One child was diagnosed as having a moderate sensorineural hearing loss. The tympanic membrane mobility was normal (type A) for both ears in 22 children, one child had a reduced tympanic mobility in one ear, two children had a negative pressure, one child had a functional trans-tympanic tube and test was not performed in 2 patients.

Conclusion

This is the first study reporting hearing loss as a possible result of shaken baby syndrome. However, further studies with larger number of children would be preferable. We recommend hearing evaluation for these children to rule out hearing loss.     

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.     

Chronic tympanic membrane perforation in an animal model

Objective

The aim of this study was to revalidate and reproduce a chronic tympanic membrane perforation animal model.

Study design

Prospective, animal study.

Methods

Eight female chinchillas underwent bilateral thermal myringotomy. The edges of the perforation were folded inward using microflaps. The perforations were followed over time to monitor the course of closure.

Results

Two animals were excluded from the study because of ear infection. None of the other tympanic membrane perforations remained open. The closing time varied from 4 to 6 weeks.

Conclusions

Our findings demonstrate that the thermal myringotomy combined with infolding technique is not a reliable and consistent method to create a chronic tympanic membrane perforation. The closing time is shorter than expected and varies among the study subjects.There is a clear need for developing a reliable chronic tympanic membrane perforation model.     

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.     

Ossicular reconstruction: Incus versus universal titanium prosthesis

Objectives

The main purpose of this study is to compare audiological outcomes of incus reconstruction, Xomed Medtronic universal titanium partial ossicular replacement prosthesis (PORP) and total ossicular replacement prosthesis (TORP). We also compared results based on surgical technique, history of previous surgery, form of the prosthesis head, pathology and frequency.

Methods

A chart review was performed and included reconstructions performed between June 2003 and December 2006. Results were based on air–bone gap and pure tone average.

Results

Postoperative mean air–bone gap and mean pure tone average are significantly lower using incus reconstruction compared with the titanium prosthesis groups. PORP and TORP groups yielded similar outcomes. Closure of ABG is similar in all three groups. Postoperative results were better using an intact canal wall mastoidectomy compared with a canal wall down technique, but ABG closure was similar in both groups. Primary surgeries gave better results than revisions of reconstructions performed by the senior author or elsewhere.

Conclusion

Though Xomed Medtronic titanium prostheses are effective in ossicular reconstruction, incus reconstruction is at least as effective when feasible. Canal wall down mastoidectomy should be reserved for cases where preservation of the canal wall is contraindicated. Previous same ear surgery is a poor prognostic factor for successful outcome. Preliminary results indicate that round head PORPs may be superior to their oval head counterparts.     

Landmarks for the preservation of the middle temporal artery during mastoid surgery: Cadaveric dissection study

Importance

The middle temporal artery flap is a vascularized periosteal flap that is highly useful for otologic reconstruction including the middle cranial fossa, mastoidectomy defect, and external auditory canal. The course of the artery is close to the external auditory canal and is easily injured during preliminary exposure and elevation of flaps.

External auditory canal microbiology and hearing aid use

Objective

The aim of this study was to determine the presence and nature of bacterial flora on hearing aids and the ears of this population. We wonder if the microbiology of the ears with hearing aid wearing differs from the other ear.

Setting

Tertiary referral center.

Design

A prospective, clinical study.

Subjects and methods

Three samples were taken, one from the surface of the hearing aid's ear mold; one from the hearing aid-wearing ear canal and the last one from the ear without hearing aid. Samples were cultured to determine qualitatively and quantitatively the pathogenic microorganisms present.

Results

A total of 123 samples, obtained from 41 hearing aid users, were analyzed. Methicillin-resistant coagulase-negative staphylococci, methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, Pseudomonas aeruginosa, Escherichia coli, Acinetobacter species, Staphylococcus auricularis, and Stenotrophomonas maltophilia were identified organisms.

Conclusions

We identified unexpected microorganisms both on hearing aids and hearing aid using ears. This study demonstrates that using hearing aid alters the ear canal flora. To avoid otitis externa, it is important to use an appropriate hygiene routine to clean and disinfect hearing aids and ear molds.     

Classification of External Auditory Canal Cholesteatoma by Computed Tomography

Objectives

We propose here a classification system for external auditory canal cholesteatoma (EACC). We classified the EACC by the computed tomography findings and clinical findings of the patients, and we evaluated the EACC characteristics by the proposed staging system.

Methods

Stage classification was done according to the results of temporal bone computed tomography and the clinical findings of the patients. Stage I indicates that the EACC lesion is limited to the external auditory canal. Stage II indicates that the EACC lesion invades the tympanic membrane and middle ear. Stage III indicates that the EACC lesion creates a defect of the external auditory canal and it involves the air cells in the mastoid bone. Stage IV indicates that the EACC lesion is beyond the temporal bone. Between 1996 and 2006, 29 patients with EACC and who underwent surgery were prospectively collected. This study was comprised of 16 males and 13 females with a mean age of 22.8±15.0 yr. We reviewed the characteristics and results of surgery by our proposed staging system.

Results

A total of 29 patients who underwent operation due to EACC were classified by this system, and the number of stage I, II, III, and IV cases was 14, 3, 10, and 2, respectively. Symptoms such as otorrhea, hearing impairment and otalgia occurred in 12, 17, and 17 cases, respectively. The most common wall invaded by EACC was the inferior wall. The number of cases that had a spontaneous, congenital, post-traumatic, post-inflammatory or tumorous origin was 14, 9, 2, 2, and 1, respectively. Cholesteatoma recurred in 2 patients after surgery. Both cases were stage 1 and both were caused by congenital disease. There were 3 cases with meatal stenosis after surgery, and their primary disease was congenital.

Conclusion

This proposed staging is simple and easily applicable for use when deciding the treatment plan for patients with EACC.     

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.