External auditory canal stenting utilizing a useful rolled, tapered silastic sheet (RTSS) post middle ear surgery

Objective

To overcome the demerits of conventional postoperative aural packing, we developed a useful protocol for postoperative stenting of the external auditory canal after middle ear surgery which enables transcanal drainage and simultaneously allows for visual inspection and treatment of the canal, as necessary.

Methods

Twenty-four surgeries, 21 patients underwent tympanoplasty with a postaural incision. At the end of all surgical procedures, the external auditory canal was packed with a 0.3 mm thickness rolled, tapered silastic sheet (RTSS) with antibiotic ointment applied to one surface. The inserted RTSSs were removed at 5–10 days postoperatively. We assessed the efficacy and the reliability of the RTSS.

Results

In 23 ear surgeries on 20 patients, we achieved successful postoperative ear packing utilizing our RTSS. With these patients, the tympanic membrane and the external auditory meatus were able to be observed immediately after the completion of the stenting during the surgery and the removal of the gauze over the operated ear at Day 1 to Day 3 postoperatively. During 4 surgeries with ventilation tube insertion to the tympanic membrane, there was secretion through the inserted ventilation tube which was easy to suction. In one surgery, on one patient, additional packing materials were utilized once only during a sandwich graft myringoplasty. No patients showed any harmful effects during the postoperative period.

Conclusions

The useful and reliable RTSS, with antibiotic ointment applied to one surface, has several positive advantages that the conventional packing methods do not.     

Middle ear metastasis of thymoma

Objective

We report an extremely rare case of thymoma which developed middle ear metastasis along with acute sensorineural hearing loss in the contra ear.

Method

We present a case report and a review of the world literature concerning thymoma metastases to the middle ear.

Results

A 54-year-old female patient with thymoma who developed middle ear metastasis along with acute sensorineural hearing loss in the contra ear.

Conclusion

We have not found out thymoma metastases to the middle ear in the past.     

Hearing restoration in NF2 patients and patients with vestibular schwannoma in the only hearing ear: report of two cases

Objective

To explore audiologic outcome of auditory brain stem implantation (ABI) and cochlear implantation (CI) in NF2 patients and patients with vestibular schwannoma (VS) in the only hearing ear.

Patients and methods

Study includes retrospective analysis of 2 cases. One is totally deaf patient due to NF2, and the other one is totally deaf due to VS development in only hearing ear. Tumor was removed by retrosigmoid approach in NF2 patient and ABI was performed simultaneously. For the VS in only hearing ear case, tumor was removed by translabyrinthine approach and CI was performed simultaneously.

Results

ABI patient showed quite well outcome during the 15 months of follow-up. She has 25 dB hearing threshold at speaking frequencies. She developed open set speech discrimination with 87.5% word discrimination score, and 70% sentence discrimination score. She uses device daily manner, she can use telephone. For CI patient, outcome is not perfect but satisfactory. She couldn’t develop open set speech discrimination during the 18 months of follow-up. She has 67% the disyllabic words recognition score (close set). She is daily user of device. CI improves quite well lip reading.

Conclusion

ABI and CI are the two options to restore hearing in VS caused deafness. We advocate giving every effort to preserve cochlear nerve during the VS resection and place CI simultaneously. However if it is not possible to preserve cochlear nerve during surgery, ABI is also a good alternative for hearing restoration.     

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.     

Thyroid carcinoma surgery in children and adolescents – 15 years experience surgery of pediatric thyroid carcinoma

Objectives

The purpose of this study is to evaluate the characteristics of thyroid gland surgery focusing on malignancies at the pediatric age with the main concern on treatment results and complications in extensive primary treatment.

Methods

The records of all patients 18 years and younger with surgically treated thyroid diseases in the Prague Hospital, Motol, between 1991 and 2006 were retrospectively reviewed.

Results

Thyroid surgery was performed on 148 pediatric patients (including 56 carcinomas). The youngest patient involved in the study was seven years old, the oldest patient 18 years old (mean 13.7 years). Most frequent histological cancer type was PTC (42 cases, 75%). Follicular cancer was diagnosed in five cases (8.9%) and medullar cancer in nine cases (16.1%). A prophylactic thyroidectomy was performed in three cases (5.4%) without clinical signs of thyroid tumor with diagnosed RET gene mutation.

Conclusions

We consider total thyroidectomy with subsequent radioiodine ablation and TSH suppression as the basic approach in the treatment protocol of pediatric WDTC. The observed 100% recurrence-free and overall survival together with a low incidence of postoperative complications strongly supports the idea of a total thyroidectomy with selective neck dissection in the treatment of metastases of WDTC and MTC.     

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.     

Earigate™ for softening ear wax: Is it safe when the eardrum is perforated?

Objective

To determine the safety of Earigate™ as an ear wax softening product.

Study Design

Prospective, controlled animal study.

Methods

Bilateral wide myringotomies were performed in eleven chinchillas. In each animal, Earigate™ was delivered to a randomly selected experimental ear canal as 2 puffs twice a day. Auditory brainstem response (ABR) was used to assess the hearing of the animals before, 3 days and 10 days following the local application of Earigate™. The ABR threshold shifts were compared for both experimental and control ears.

Results

The mean hearing threshold shifts in the experimental animals were comparable at all frequencies and at days 3 and 10. No statistically significant differences were observed in the mean threshold shifts for all of the frequencies evaluated, between the control and experimental ears.

Conclusions

The administration of Earigate™ to the middle ear of chinchillas did not cause any ototoxicity as assessed by ABR.     

Cochlin in autoimmune inner ear disease: Is the search for an inner ear autoantigen over?

Definition

Autoimmune inner ear disease (AIED) is characterised by a rapidly progressive, often fluctuating, bilateral sensorineural hearing loss over a period of weeks to months. It is an uncommon disease accounting for less than 1% of all cases of hearing impairment or dizziness. The diagnosis is often missed and this impacts on the prognosis as the condition responds well to steroids and immunosuppressants if recognised early.

Lacuna in knowledge

No useful specific test for autoimmunity affecting the inner ear exists.

Objective of study

To gather evidence regarding cochlin in AIED.

Methodology

Systematic review of human studies and animal experimental studies on inner ear antigens was undertaken.

Search strategy

We searched MEDLINE (1965–2012), and Pubmed for relevant studies. A combination of key words for inner ear, autoimmunity (autoimmune, immune mediated) and cochlin were used.

Results

A number of antigens have been implicated in autoimmune inner ear disease. Cochlin is a major component of the extracellular matrix in the inner ear and a promising candidate. We present evidence in literature on the role of this protein in the pathogenesis of autoimmune inner ear disease.     

Infants under the age of six months with acute mastoiditis. A descriptive study of 15 years in Sweden

Objective

To investigate the occurrence, clinical signs and outcome of acute mastoiditis in infants under the age of 6 months in Sweden between the years 1993–2007.

Methods

All ENT departments in Sweden reported children 0–5 months treated for acute mastoiditis 1993–2007 and all records were reviewed. The clinical course and various characteristics were recorded.

Results

Seventeen young infants with acute mastoiditis were identified. Three patients had suffered acute otitis media earlier, otherwise the children were previously healthy. Preceding the episode of acute mastoiditis, the children had an upper respiratory tract infection or fever for seven days in mean (median three days) and the mean number of days with ear-symptoms was three days (median two days). Three patients were treated with antibiotics prior to admittance. Almost all children presented with clear retroauricular signs with protruding ear and redness behind the ear. The children were hospitalised for six days (mean and median). Eight patients (47%) suffered from a subperiosteal abscess. All but one patient underwent surgery: myringotomy (13); incision or punction of the mastoid (5); mastoidectomy (3). Streptococcus pneumoniae was the most frequent bacterium identified in cultures. No intracranial complications or other severe complications were found.

Conclusion

Acute mastoiditis is extremely rare in infants under the age of 6 months. The patients in this study did not have any predisposing diseases. An upper respiratory tract infection had preceded the episode of acute mastoiditis for some time in the majority of cases, but the time from first ear symptoms to hospitalization was very short. Acute mastoiditis is a potentially life-threatening disease, but the timely administration of intravenous antibiotics and surgical intervention prevented the occurrence of severe complications in these young infants.     

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.     

Middle ear and mastoid glomus tumors (glomus tympanicum): An algorithm for the surgical management

Objective

Glomus tumors are slow-growing benign lesions and represent the most common primary neoplasms of the middle ear. The objective of the present study is to report our surgical strategy in the management of glomus tympanicum tumors.

Methods

Between December 1988 and July 2008, 68 patients with histologically confirmed glomus tympanicum tumor underwent surgical treatment. The follow-up of the series ranged from 6 to 194 months (mean, 33.4 months).

Results

Distribution of tumors according to Fisch and Mattox classification was as follows: type A, 44 cases (64.7%); type B, 24 cases (35.3%). All of the 44 Class A tumors were safely removed via either a stapedectomy-type transcanal approach or a retroauricolar-transcanal approach. Five patients with Class B tumors were operated on through a transmastoid approach. Nineteen patients with larger Class B tumors underwent a subtotal petrosectomy with blind sac closure of the external auditory canal and middle ear obliteration. Gross total tumor removal was achieved in all 68 cases. In one case (1.4%) there was recurrence after 9 years, for which the patient was re-operated. No residual/recurrence has been detected on computed tomography in the rest of the patients.

Conclusion

Surgical excision of glomus tympanicum tumors is a safe procedure, allowing total tumor removal with minimal morbidity, a low recurrence rate, and a low complication rate.     

Improving outcomes by combining septoplasty with primary external dacryocystorhinostomy

Purpose

External dacryocystorhinostomy (EXT-DCR) is the gold standard in the treatment of acquired nasolacrimal duct obstruction. Intranasal pathology can compromise the success of primary and revision external dacryocystorhinostomy EXT-DCR procedures. Nasal septal deviations resulting in unfavorable anatomy are an identified cause of DCR failures. In this study, we examine the causes of failure in our patient population and propose that concomitant treatment of septal deviations at the time of primary EXT-DCR can decrease the rate of revision surgery.

Materials and methods

Retrospective review of patients who had undergone an EXT-DCR.

Results

Over a five year period, 12 EXT-DCR failures were identified and 8 were directly attributable to nasal septal deviations. Revision surgery was successful in all 8 cases after correction of the nasal septal deviation. A second cohort of patients was identified who had undergone primary EXT-DCR and septoplasty concomitantly. Eight consecutive patients underwent the combined procedure for a total of 10 EXT-DCR and 8 septoplasties. The only failure was due to a common canalicular obstruction (90% success rate for the combined approach).

Conclusions

As a result of our findings, we believe that treating nasal septal deviation at the time of the initial surgery can help minimize the need for revision surgery.     

Middle ear impedance measurements in large vestibular aqueduct syndrome

Objective

To assess the effect of inner ear pressure on middle ear impedance in patients with large vestibular aqueduct syndrome (LVAS).

Methods

Data from admittance tympanometry and multifrequency tympanometry on 8 LVAS patients and control subjects were studied.

Results

Static acoustic compliance (SAC) values for the ears with stable sensorineural hearing loss (SNHL) were within the limits of the mean values of control groups except for two ears. The resonance frequency (RF) values of the ears with stable SNHL were lower than the mean values of control groups except for three ears. SAC values for the two ears with fluctuating SNHL were lower and the RF values were higher than the mean values of control groups.

Conclusion

Decreased SAC values and increased RF values found in the ears with fluctuating SNHL might be an indirect indicator of increased inner ear pressure, while low RF values in the ears with stable SNHL might reflect the decreased inner ear impedance.     

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.     

Fully endoscopic resection of juvenile nasopharyngeal angiofibroma – Own experience and clinical outcomes

Objectives

The treatment of choice in juvenile nasopharyngeal angiofibroma (JNA) is surgery – nowadays endoscopic techniques. The aim of the study was to present the results of endoscopic treatment in patients diagnosed with juvenile angiofibroma.

Materials and methods

In this retrospective case series, 10 patients with a diagnosis of JNA treated at the Department of Otolaryngology of the Medical University in Poznań from 2006 to June 2013 were included. The age of patients were between 11 and 19 years old (14.6 on average). In 9 out of 10 patients the treatment was preceded by embolization. The surgery used the endoscopic approach through one nostril and the four-handed technique.

Results

Total resection was possible in all cases. Blood loss ranged from 100 to 250 ml. Post-operative hospitalization lasted from 3 to 5 days (3.3 days on average). Recurrence was reported in one patient. The observation lasted from six months to seven years (3.55 on average).

Conclusions

Endoscopic resection of juvenile angiofibroma is safe for the patient. Moreover, if the evaluation of the tumour size and staging is correct, the ability of total removal of the tumour is very high. It is also connected with small blood loss, short hospital stay and good cosmetic effects.     

Chronic oroantral fistula: Combined endoscopic and intraoral approach under local anesthesia

Objective

To evaluate the outcome of combined surgical treatment of oroantral communications associated with chronic maxillary sinusitis.

Patients and methods

8 consecutive patients affected by complicated oroantral fistula were included in the study. The protocol consisted of: clinical, endoscopic and radiological preoperative evaluation (panoramic tomogram and computed tomography); systemic antibiotic and steroid therapy 2 weeks before surgery; one-stage surgical procedure under local anaesthesia consisting in uncinectomy with enlargement of the osteomeatal complex through endoscopic nasal approach associated with the closure of the oroantral communication by means of a mucoperiosteal flap; postoperative antibiotic and cortisone-based therapy. Follow-up consisted of weekly clinical evaluation during the first month, and nasal endoscopy at 3, 8 and 24 weeks after surgery.

Results

After surgical treatment, all patients were symptom-free and had no endoscopic and radiological evidences of maxillary sinusitis at the 6-month follow-up. No recurrent oroantral fistulas were found.

Conclusions

The current prospective study showed that a one-stage, combined endoscopic and intraoral approach under local anaesthesia represents a feasible and minimally invasive procedure for the long-term effective treatment of chronic complicated oroantral communications. Moreover, it represents an easily applicable approach also in outpatient clinics with minor patient discomfort.     

YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery

Objectives

Assess the overall quality of information on adenotonsillectomy and ear tube surgery presented on YouTube (www.youtube.com) from the perspective of a parent or patient searching for information on surgery.

Methods

The YouTube website was systematically searched on select dates with a formal search strategy to identify videos pertaining to pediatric adenotonsillectomy and ear tube surgery. Only videos with at least 5 (ear tube surgery) or 10 (adenotonsillectomy) views per day were included. Each video was viewed and scored by two independent scorers. Videos were categorized by goal and scored for video/audio quality, accuracy, comprehensiveness, and procedure-specific content. Study design: Cross-sectional study. Setting: Public domain website.

Results

Fifty-five videos were scored for adenotonsillectomy and forty-seven for ear tube surgery. The most common category was educational (65.3%) followed by testimonial (28.4%), and news program (9.8%). Testimonials were more common for adenotonsillectomy than ear tube surgery (41.8% vs. 12.8%, p = 0.001). Testimonials had a significantly lower mean accuracy (2.23 vs. 2.62, p = 0.02), comprehensiveness (1.71 vs. 2.22, p = 0.007), and TA specific content (0.64 vs. 1.69, p = 0.001) score than educational type videos. Only six videos (5.9%) received high scores in both video/audio quality and accuracy/comprehensiveness of content. There was no significant association between the accuracy and comprehensive score and views, posted “likes”, posted “dislikes”, and likes/dislikes ratio. There was an association between “likes” and mean video quality (Spearman's rho = 0.262, p = 0.008).

Conclusion

Parents/patients searching YouTube for information on pediatric adenotonsillectomy and ear tube surgery will generally encounter low quality information with testimonials being common but of significantly lower quality. Viewer perceived quality (“likes”) did not correlate to formally scored content quality.     

Effect of the stapedotomy technique on early post-operative hearing results--Preliminary results

Objective

To compare three stapedotomy modalities used to fenestrate the stapes footplate in patients with primary otosclerosis.

Materials

The non-randomized and unblinded one-center study included 48 patients with primary otosclerosis who underwent stapes surgery between May 2008 and April 2009. The patients were divided into three groups (single shot and two-shot CO₂ laser stapedotomy, perforator) depending on the modality used for stapedotomy. Bone conduction (BC) and air conduction (AC) thresholds, air–bone gap (ABG), and the difference between mean pre-operative and 2- to 3-week post-operative BC thresholds were analyzed.

Results

The temporary BC deterioration was most pronounced at 6 and 8 kHz after 2-shot laser stapedotomy. A significant drop in AC or BC was not found in any of our 48 patients. Age, high-dose cortisone therapy, and ‘preoperative hearing’ did not influence the post-operative hearing results.

Conclusion

Even though the number of patients presented here was small and statistical analysis was limited, the study showed a trend toward worse BC thresholds at 6 and 8 kHz after a second shot CO₂ application. Whenever possible, treatment should avoid a second laser shot on the already opened inner ear with the laser parameters used for the initial shot.     

Effect of lentiviruses carrying enhanced green fluorescent protein injected into the scala media through a cochleostomy in rats

Purpose

The purposes of the current study were to assess the feasibility of post-auricular microinjection of lentiviruses carrying enhanced green fluorescent protein (EGFP) into the scala media through cochleostomies in rats, determine the expression of viral gene in the cochlea, and record the post-operative changes in the number and auditory function of cochlear hair cells (HCs).

Methods

Healthy rats were randomly divided into two groups. The left ears of the animals in group I were injected with lentivirus carrying EGFP (n = 10) via scala media lateral wall cochleostomies, and the left ears of the animals in group II were similarly injected with artificial endolymph (n = 10). Prior to and 30 days post-injection, auditory function was assessed with click-auditory brainstem response (ABR) testing, EGFP expression was determined with cochlear frozen sections under fluorescence microscopy, and survival of HCs was estimated based on whole mount preparations.

Results

Thirty days after surgery, click-ABR testing revealed that there were significant differences in the auditory function, EGFP expression, and survival of HCs in the left ears before and after surgery in the same rats from each group. In group I, EGFP was noted in the strial marginal cells of the scala media, the organ of Corti, spiral nerves, and spiral ganglion cells.

Conclusion

Lentiviruses were successfully introduced into the scala media through cochleostomies in rats, and the EGFP reporter gene was efficiently expressed in the organ of Corti, spiral nerves, and spiral ganglion cells.     

Endoscopic endonasal surgery in the management of selected malignant naso-ethmoidal tumors

Objective

The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection.

Methods

Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach.

Results

In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach.

Conclusions

In selected T1–T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures.