Mastoid condition and clinical course of cholesteatoma

This study was carried out to establish which type of cholesteatoma is controllable by conservative treatment from the viewpoint of mastoid ventilation. We examined the area of the air cell system and airspace (aeration) in the mastoid cavity by computed tomography and eustachian tube (ET) function by inflation-deflation test in 20 ears (20 patients) with severe attic retraction for over 12 months (retraction pocket group), 16 ears (16 patients) with cholesteatoma which could be controlled only by conservative treatment for over 12 months (nonsurgical group) and 43 ears (43 patients) which required surgery within a year in spite of similar conservative treatment (surgical group). The size of the mastoid air cell system in the retraction pocket group, nonsurgical group and surgical group was 2.9 +/- 1.3, 1.9 +/- 0.7 and 1.5 +/- 0.9 cm(2) on average, respectively, with no significant difference between both cholesteatoma groups (nonsurgical and surgical group). While aeration was observed in the mastoid in 17 of 20 ears (85.%) in the retraction pocket group and in 12 of 16 ears (75.0%) in the nonsurgical group, aeration was present only in 9 of 43 ears (26.5%) in the surgical group, being significantly less in the surgical group than in the nonsurgical group and the retraction pocket group. In all ears in the retraction pocket and nonsurgical groups, and 19 of 30 ears in the surgical group, ET function was poor, there being no significant difference among the three groups. The present clinical observations suggest that progressiveness of cholesteatoma could be related to the ventilatory conditions in the mastoid rather than ET function, and that conservative treatment may be effective when ears with cholesteatoma have aeration in the mastoid.     

Eustachian tube function in ears with cholesteatoma

Eustachian tube (ET) function was measured before and after surgery in patients with acquired cholesteatoma. The cholesteatoma group and a group of patients without cholesteatoma but with dry tympanic membrane perforations (TM-Perf) were compared in this respect. ET function was measured by the air pressure equalization technique; if necessary, a transmyringeal tube was inserted to establish direct communication between the external ear canal and the middle ear cleft. No difference in ET function was found before and after surgery in the cholesteatoma group. The ET testing results in the cholesteatoma group were inferior to those in the group with TM-Perf. These findings are discussed in relation to proper surgical procedure in ears with cholesteatoma.     

Comparative study on adhesive otitis media and pars tensa cholesteatoma in children

Objective: Recurrent otitis media and persistent otitis media with effusion in early childhood may cause an atelectatic eardrum and adhesive otitis media, which sometimes progress to pars tensa cholesteatoma. When and how children with adhesive otitis media should be operated on remain controversial. Therefore, this study aimed to analyze the clinical characteristics of children with adhesive otitis media and pars tensa cholesteatoma, and to determine the risk factors of progression to cholesteatoma.Methods: Seventeen ears of 15 children with adhesive otitis media (adhesive group) and 14 ears of 13 children with pars tensa cholesteatoma (tensa cholesteatoma group) who underwent tympanoplasty were included in this study. We analyzed the following clinical characteristics of children in both groups: medical and life history, associated diseases, sites of the adhesion, and development and aeration of mastoid air cells as shown by temporal bone computed tomography.Results: Most of the children in both groups had a history of recurrent otitis media and/or persistent otitis media with effusion. They showed a male predominance and a frequent association of allergic rhinitis. The number of ears showing undeveloped mastoid air cells in the tensa cholesteatoma group was significantly larger than that in the adhesive otitis media group (P=0.0068). A lack of aeration of the middle ear, including the eustachian tube, was more frequently found in ears with pars tensa cholesteatoma than in ears with adhesive otitis media (P=0.0012). Using multivariate logistic regression, the presence of otorrhea (odds ratio [OR], 14.847; 95% confidence interval [CI], 0.834–264.184), total adhesion (OR, 28.550; 95% CI, 0.962–847.508), and undeveloped mastoid air cells (OR, 19.357; 95% CI, 1.022–366.589) were related to pars tensa cholesteatoma.Conclusion: Children with adhesive otitis media should be carefully followed up in the outpatient setting. Ears with poor mastoid development may develop pars tensa cholesteatoma. Additionally, ears with middle ear effusion, total adhesion, and the presence of otorrhea tend to be at risk of pars tensa cholesteatoma. Tympanoplasty or tympanostomy tube insertion should be considered for children with adhesive otitis media who have these risk factors to prevent progression to pars tensa cholesteatoma.     

The size of the mastoid air cell system among black and white children with middle ear effusion

The incidence of middle ear disease among black American children is lower than among white children. Many factors may contribute to this difference. The possibility of an anatomical variation regarding the cellularity of the mastoid process was investigated. The size of the mastoid air cell system was measured in black and white children with and without middle ear effusion. A significantly smaller mastoid air cell system was found in the groups with middle ear disease compared to those without disease. No difference between white and black children in diseased as well as non-diseased ears could be demonstrated.     

Evaluation of mastoid air cell system by three-dimensional reconstruction using sagittal tomography of the temporal bone

The mastoid air cell system has been recognized as an important contributor to the pathophysiology of middle ear inflammatory diseases. Various methods of temporal bone imaging have been designed to investigate the correlation between middle ear disease and mastoid pneumatization. In this study, the mastoid air cell system was reconstructed three-dimensionally from sagittal tomographic images of the temporal bone on X-ray films, using a personal computer to evaluate the mastoid pneumatization in a total of 29 patients with chronic otitis media, adhesive otitis media, adhesive-type cholesteatoma, attic cholesteatoma and cholesterol granuloma, and in five normal subjects as controls. Reconstructed three-dimensional images of the mastoid air cell system and its volume were analyzed. The reconstructed images were helpful in recognizing the three-dimensional solid appearance of the mastoid air cell system. The volume of the reconstructed mastoid air cell system was significantly reduced compared with that in the controls in each of the patient groups. Mastoid pneumatization in the patients with adhesive-type cholesteatoma was significantly suppressed compared with that in the adhesive otitis media patients. Interestingly, the adhesive otitis media group showed cell development at the tip of mastoid process, whereas the group of adhesive-type cholesteatoma did not, suggesting a difference in the pathophysiology in the two diseases. We found that three-dimensional reconstruction of the temporal bone using sagittal tomographic images was useful in evaluating the state of mastoid air cell system development in individual cases and in investigating the pathophysiology in middle ear disease.     

A quantitative study of the suppression of the development of the mastoid air cells by the presence of congenital cholesteatoma

Background: The mastoid air cells are considered to develop better in children with congenital cholesteatoma but only a few quantitative studies have examined.

Aims/objectives: The present study was undertaken in order to clarify the relationships between the development of the mastoid air cells in children with congenital cholesteatoma and clinical factors.

Materials and methods: Mastoid air cell development was evaluated in 53 children with congenital cholesteatoma. The sizes of the mastoid air cells were measured on computed tomography scans of the temporal bone, and clinical factors, including age, the extent of invasion, and whether it was located close to the eustachian tube were evaluated.

Results: The cross-sectional area of the mastoid air cells was significantly smaller on the affected side than on the unaffected side, especially in the older patients. The cases involving invasion into the mastoid portion also had smaller mastoid cells. Whether the cholesteatoma was located close to the eustachian tube had no effect.

Conclusions and significance: The mastoid air cells on the affected side were less well developed. Our findings indicate that a high age and the presence of cholesteatoma in the mastoid region might be associated with suppressed mastoid pneumatization.     

Gas Exchange Function Through the Mastoid Mucosa in Ears After Surgery

Gas exchange function through the mastoid mucosa was investigated in ears after surgery using nitrous oxide. Increase in the mastoid pressure was assessed by a micropressure sensor placed in the mastoid cavity during the second-stage revision operation performed under general anesthesia using 67% nitrous oxide, 33% oxygen, and sevoflurane on 14 ears with chronic adhesive otitis media or cholesteatoma as well as on seven ears without inflammation as controls. All seven control ears showed pressure increase in the mastoid in various degrees. In the 14 postoperative ears, nine of the 10 ears on which the mastoid mucosa had previously been able to be preserved in various degrees showed pressure increase in the mastoid, but none of the remaining four ears, which had previously had mastoidectomy, showed any pressure increase. The presence or absence of the mastoid pressure increase of those ears was also found to be correlated well with the presence or absence of mastoid aeration on computed tomography examined just before the second-stage operation. These results appear to indicate that, in ears after surgery, recovery of both the gas exchange function and aeration in the mastoid is expected only when the mastoid mucosa can be preserved even partially.     

Mastoid pneumatization in children with congenital cholesteatoma: An aspect of the formation of open-type and closed-type cholesteatoma

Objectives: To clarify mastoid pneumatization in children with congenital cholesteatoma and compare their clinical characteristics. Study Design: The mastoid pneumatization of 34 children with congenital middle ear cholesteatoma, of 34 age-matched children with unilateral acquired cholesteatoma, and of 17 age-matched control children without middle ear diseases was studied. Methods: The sizes of the mastoid cells were measured from 1.5-mm sliced semiaxial sections of a temporal bone computed tomography scan. The sum of the two areas from the two images, one showing the lateral semicircular canal and the other, 3 mm below this, was defined as the area of the pneumatized mastoid cells. Results: The mastoid cells in ears of children with congenital cholesteatoma were poorly pneumatized compared with those of control children without middle ear diseases, but were better pneumatized compared with those of children with acquired cholesteatoma. In children with congenital cholesteatoma, the degree of pneumatization in the cholesteatoma side was significantly poorer than that in the opposite side. A well-pneumatized mastoid was seen in ears with no episode of otitis media, in ears with the open-type cholesteatoma, and in ears with ossicular anomalies. Conclusions: The presence of cholesteatoma matrix accelerates the inflammatory response when middle ear infections occur, and this probably leads to the suppression of mastoid pneumatization. The authors also propose the hypothesis that cholesteatoma in most congenital cases is the open type, and that middle ear inflammation may contribute to the formation of cystic and closed-type cholesteatoma.     

Prognostic evaluation of secretory otitis media as a function of mastoidal pneumatisation

Fifty-two secretory otitis media (S.O.M.) ears with protracted course were compared roentgenologically (Schuller projection) with 52 S.O.M. ears which recovered after insertion of a single ventilating tube. Measurements were done first by comparing the pneumatised area millimetrically and later semiquantitatively according to the size of the mastoid cells--grading the mastoid cells from 1 (eburnize) to 10 (very big mastoid cells). S.O.M. ears with protracted chronic course showed an average mastoid area of 312 mm2, their cell size showing on the average a diploic or small-diploic cells--corresponding to grade 3.5. On the other hand, S.O.M. ears which recovered promptly had an average mastoid area of 440 mm2, and their mastoid cells began to show as actual cells (small up to medium cells), corresponding to grade 5.7. The difference, both millimetrically and grade-wise, between the two groups was found to be very significant (P greater than or equal to 0.01). We may conclude that the prognosis of S.O.M. is related to the size of their mastoid cells or alternatively to the amount of air in the middle ear cleft as a whole.     

A clinico-radiological study of the contralateral ear in acquired unilateral cholesteatoma

OBJECTIVE: Clinico-audiological and CT scan assessments of the contralateral ear in patients with unilateral cholesteatoma can be a good predictive method for the fate of these ears. MATERIAL AND METHODS: Fifty patients with unilateral cholesteatoma and 25 control subjects with bilateral normal ears were subjected to otomicroscopical and audiological assessment. Axial and coronal computed tomography (CT) for the mastoid bone at 1 mm slice thickness was done for all ears. A simplified method was used to find out the surface area (SA) of the air cells at each individual section and semi-automatically calculate the total volume of the matstoid air cells. RESULTS: Otomicroscopically, 72% of the contralateral ears showed signs of retraction pockets, granulation tissues and other signs of chronicity. Audiologically 20% of the control ears showed moderate to severe conductive hearing loss while 10% showed mixed hearing loss. As regards mastoid pneumatization, the mean air cell volumes were 6.1, 12.68 and 29.92 CC in cholesteatomatous, contralateral and control ears respectively. This indicates a highly significant difference in the mean air cell volume between the control ears and the other two groups. CONCLUSION: It can be concluded that continuous follow up of the contralateral ear in cholesteatomatous ears is mandatory to detect subtle pathological changes and manage them early. Volumetry of contralateral ear using the applied simple method can lead to a reduction in major surgery and can affect the choice of the surgical approach.     

Influence of the Gas Exchange Function Through the Middle Ear Mucosa on the Development of Sniff-Induced Middle Ear Diseases

To investigate the influence of gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases, the authors examined the mastoid pneumatization among patients with sniffing habit using computed tomography, and also examined the change of negative middle ear pressure induced by sniffing using tympanogram. In 20 ears with cholesteatoma or adhesive otitis media, the areas of mastoid cavity measured at the level of the lateral semicircular canal were significantly smaller than those in 26 ears with otitis media with effusion (OME) or attic retraction and in eight normal ears with sniffing habit (P < .01 and P < .0001, respectively). In 26 ears with OME or attic retraction, the areas of mastoid cavity were significantly smaller than those in eight normal ears with sniffing habit (P < .0001). By contrast, in the four ears with sniff-induced middle ear disease, the recovery of negative middle ear pressure in 5 minutes without swallowing was less than 10 mm H₂O, whereas in all seven ears with normal eardrum, negative middle ear pressure recovered by more than 20 mm H₂O in 5 minutes. These findings suggested that impairment of gas exchange function through the middle ear mucosa, as well as eustachian tube dysfunction, might be closely related to the development of sniff-induced middle ear diseases.     

Cholesteatoma in children

Of 325 previously untreated cholesteatomas, 109 were found to be in children 13 years old and younger--however, these 109 ears were not found to consist of one clinical entity. Sixty-three of the 109 ears presented a marginal perforation or a retraction pocket, at the level of Shrapnell's membrane or beyond the postero-superior quadrant. In this group the cholesteatoma was distributed mainly in the attic and mastoid and was associated with a non-cellular mastoid. A second group comprising 31 ears presented with cholesteatoma behind an intact drum and were considered to be primary cholesteatomas. These were distributed mostly in the tympanic cavity as cystic epidermoid formations--their mastoid was usually pneumatized. Eight cholesteatomas were related to a central perforation. These ears presented features very similar to the primary cholesteatomas i.e., a pneumatized mastoid and tympanic cavity distribution. The similar features of this group make us think that they may have also originated as primary cholesteatomas which eventually perforated and bring the percentage of primary cholesteatomas in children to 38.3%. Seven of the 109 ears with cholesteatoma were of an indeterminate character.     

An analysis of mastoid cholesteatomas

Fifty-five extensive mastoid cholesteatomas filling all the air cell system were found in our material of 2,192 operated-on chronic ears. They concentrated in younger age groups than ordinary cholesteatomas, although they could also be seen in older people. In the group, 95% of them had attic or posterosuperior perforation. In one-fourth of the cases the tympanum was also epidermized. The main bacteria were Proteus strains, Staphylococcus aureus/epidermidis, E. coli and Pseudomonas aeruginosa. Preoperatively, cholesteatoma could always be diagnosed but its mastoid type could be predicted only in a minority (13%) of cases. Roentgenology proved an unreliable means for revealing cholesteatoma. The extent of the mastoid air cell system varied from extensive to small depending only on the patient's age, with a correlation of smaller size to higher age. Of the ears studied, 16% were complicated and all belonged to the adult group. The growth characteristics of these extensive cholesteatomas are basically the same as in other cholesteatomas, the only difference being that, due to especially favorable environmental conditions at present unknown, the epidermosis takes the form of a more aggressive and active spreading in soft connective tissue. The effect on bone is lytic and relatively slow, passive. The operation, which must aim at the complete eradication of the cho-lesteatomatous process, did not essentially improve the hearing. On the other hand, only two ears drained postoperatively and only one had to be reoperated on, revealing residual cholesteatoma tympanally. Thus, this material with most difficult and dangerous middle ear cleft pathology, gave conclusive proof that the obliterative operation technique was safe and appropriate regardless of the quality and extent of the process.     

Aeration in chronic otitis media*

The mastoid air cell system must be looked upon as an air reservoir. The tympanic membrane is an air pressure regulator. The smaller the air volume of the mastoid the more pronounced is the volume displacement of the tympanic membrane. The more inefficient the Eustachian tube function, the more pronounced is the tympanic membrane displacement. The significance of these factors must be considered not only when discussing the etiology of chronic otitis media including cholesteatoma, but also when it comes to selecting procedures in restoring middle ear anatomy and physiology in chronic middle ear surgical disease.     

Eustachian tube patency and function in tympanoplasty with cartilage palisades or fascia after cholesteatoma surgery.

OBJECTIVE: To compare the Eustachian tube patency and function after tympanoplasty with either cartilage palisades or fascia grafting after one-stage surgery in children with tensa cholesteatoma. STUDY DESIGN: In children operated for tensa cholesteatoma, cartilage palisade tympanoplasty was performed in 32 ears and fascia tympanoplasty in 29 ears. The patency of the Eustachian tube was evaluated by the Valsalva maneuver before the operation, 1 to 3 months after the operation, and at a follow-up examination 46(1/2) months later (median). Eustachian tube function was evaluated by the nine-step inflation/deflation tympanometric test and the Toynbee test at the follow-up examination. Otomicroscopy and hearing evaluation were performed before and after surgery as well as at the follow-up. MAIN OUTCOME MEASURES: Eustachian tube patency and function. Hearing, postoperative eardrum perforation/retraction, and cholesteatoma recurrence. RESULTS: The Valsalva maneuver was positive in 30% of the ears before the operation, in 65% primarily after the operation, and in 78% at the follow-up examination. A poor tubal function was found in 57% at follow-up. Overall, the late functional hearing results were better in ears with a positive Valsalva maneuver. There were no differences in tubal patency or function in relation to graft material, cholesteatoma, and tympanoplasty type. In ears with a poor tubal function, the hearing results were significantly better in the palisade group (63% success), compared with the fascia group (17% success). All of the four perforations, most of the retractions, and a single moist eardrum were found in the fascia group at the reevaluation. We found no correlation between the condition of the eardrum and the Eustachian tube function at the last evaluation. However, in ears with a poor tubal function, a nonretracted, nonperforated drum was found with higher frequency in the palisade group. Decision matrix analysis showed that the last postoperative Valsalva maneuver was the best predictor of the drum condition at the reevaluation. CONCLUSIONS: The Eustachian tube patency frequently improves after tympanoplasty after cholesteatoma surgery in children, regardless of graft material. The patency and function of the Eustachian tube seem to be without relation to graft material, cholesteatoma, or tympanoplasty type. Cartilage palisade tympanoplasty may be a better reconstruction technique after cholesteatoma surgery, especially in ears with a poor tubal function.     

Surgical treatment of cholesteatoma: a comparison of closed and open techniques in a follow-up of 164 ears

Reimer A., Andreasson L. & Harris S. (1987) Clin. Otolaryngol. 12 , 447–454 Surgical treatment of cholesteatoma: a comparison of closed and open techniques in a follow-up of 164 ears In the Malmö community (230 000 inhabitants) 188 ears with cholesteatoma were operated on during 1975–1981. This number corresponds to an incidence of 12 cholesteatomas per 100000 inhabitants a year. A detailed follow-up was possible in 164 ears. The primary operation was performed with an intact canal wall technique (CAT) in 148 ears and a radical operation in 40 ears. A planned second look was performed in 138 of the CAT ears and residual cholesteatoma was found in 41 or 30%, mainly in the epitympanic space. An initially good healing and hearing result was obtained in 71 % but in the course of time several ears developed new retractions and a new mastoid cholesteatoma. The number of ears with perfect hearing tended to decrease with time, but about one-third of CAT ears remained intact with good hearing. The CAT technique is preferable in ears with a large mastoid air cell system and when the cholesteatoma is easily accessible by the approach. A planned second look should be performed including ossiculoplasty and obliteration of the antrum. In the remaining cases a radical operation including middle ear reconstruction and obliteration of the mastoid cavity is preferred.     

Pneumatization correlated to myringoplasty and tubal function

The prognostic significance of the size of mastoid air cell system in the results of myringoplasty has been a matter of debate. Fifty ears with dry central perforation following C.S.O.M. were investigated. The size of mastoid air cell system was determined with planimetry of the X-ray picture and eustachian tube function was assessed using flourescein dye and nasal endoscopy. Myringoplasty was performed in all the 50 ears and postoperative results in terms of graft take up and hearing gain were assessed. The correlation between the size of mastoid air cell system, results of myringoplasty and tubal function has been discussed. The results show no correlation between the size of mastoid air cell system, postoperative results of myringoplasty and eustachian tube function.     

Barotrauma vis-a-vis the "chronic otitis media syndrome": two conditions with middle ear gas deficiency Is secretory otitis media a contraindication to air travel?

We compared 17 patients (29 ears) with barotrauma with 171 patients suffering from "chronic ears" (secretory otitis media, atelectasis, or previously operated cholesteatoma). The patients with "chronic ears" were followed up prospectively, and none were found to suffer from barotrauma after flying on a commercial airplane. The mastoid pneumatization (seen on lateral mastoid radiographs) was significantly larger in ears with barotrauma, averaging 16.85 cm2, versus 12.9 cm2 in normal controls, whereas in "chronic ears" it was only 3.6 cm2. During flight on a commercial airplane, the middle ear has to equalize about 20% of its gas volume with the ambient pressure. This equalization must happen within 15 to 20 minutes of ascent and descent in order to avoid barotrauma. This 20% is a fivefold greater task for ears with a large mastoid pneumatization than for ears with an undeveloped pneumatization; "chronic ears" usually have an undeveloped mastoid pneumatization. The smaller the middle ear (mastoid) volume, the smaller the volume of gas needed to pass through the eustachian tube in order to equalize pressure changes during flying. This factor may explain why "chronic ears" rarely suffer from barotrauma. It also implies that eustachian tubes of secretory otitis, atelectatic, and cholesteatomatous ears have little problem in equalizing large pressure differences (over 2,000 mm H2O) within 15 to 20 minutes of landing, in contrast to what has been traditionally believed. Individuals with "chronic ears" can be advised that they can fly safely.     

咽鼓管上隐窝的形态学改变与中耳炎性病变的关系研究

目的:观察咽鼓管上隐窝的解剖特征及其在中耳炎性病变时的形态学改变,探讨咽鼓管上隐窝的形态学改变与中耳炎性病变的关系。方法:用颞骨薄层CT摄片方法,对正常耳和不同类型中耳炎患者患耳的咽鼓管上隐窝的形态、大小进行观察、测量。结果:正常耳咽鼓管上隐窝的前后径为(3.83±1.28)mm,垂直径为(3.67±1.14)mm,高度为(3.76±0.36)mm,齿突长度为(2.84±0.38)mm,左右侧比较差异无统计学意义(P>0.05);咽鼓管上隐窝的形态与乳突气化类型无关(P>0.05)。胆脂瘤型中耳炎患耳的咽鼓管上隐窝形态与正常耳比较差异有统计学意义(P<0.05),患耳咽鼓管上隐窝的形态(前后径、垂直径与高度以及齿突长度)均与乳突气化类型无关(均P>0.05);本组有8耳的咽鼓管上隐窝结构有确切的、不同程度的骨质破坏,占40%(8/20)。慢性化脓性中耳炎(单纯型)患耳咽鼓管上隐窝的形态与正常耳比较差异无统计学意义(P>0.05)。结论:胆脂瘤型中耳炎患耳的咽鼓管上隐窝的形态明显小于正常耳,咽鼓管功能不良时,则可能影响中耳通气引流系统,进而于鼓膜局部逐渐形成内陷囊袋,最终形成胆脂瘤型中耳炎。慢性化脓性中耳炎(单...     

Prognostic evaluation of secretory otitis media as a function of mastoidal pneumatisation

Summary Fifty-two secretory otitis media (S.O.M.) ears with a protracted course were compared roentgenologically (Schuller projection) with 52 S.O.M. ears which recovered after insertion of a single ventilating tube. Measurements were done first by comparing the pneumatised area millimetrically and later semi-quantitatively according to the size of the mastoid cells — grading the mastoid cells from 1 (eburnize) to 10 (very big mastoid cells).S.O.M. ears with protracted chronic course showed an average mastoid area of 312 mm², their cell size showing on the average a diploic or small-diploic cells —corresponding to grade 3.5. On the other hand, S.O.M. ears which recovered promptly had an average mastoid area of 440 mm², and their mastoid cells began to show as actual cells (small up to medium cells), corresponding to grade 5.7. The difference, both millimetrically and grade-wise, between the two groups was found to be very significant (P0.01). We may conclude that the prognosis of S.O.M. is related to the size of their mastoid cells or alternatively to the amount of air in the middle ear cleft as a whole.