Management options for cochlear implantation in patients with chronic otitis media

ObjectivePatients with chronic otitis media with/without cholesteatoma present a significant challenge to safe cochlear implantation (CI). The aim of our study is to describe our experience and propose management options for CI in patients with chronic otitis media.Study designRetrospective case study.SettingTertiary academic center.Subject and methodsWe enrolled the 9 ears of 8 subjects who received CI in the ear with chronic otitis media from 2006 to 2013 by a single surgeon. CI was performed as a single-stage or staged operation with mastoid surgery according to the activity of ear infection.ResultsSix patients had bilateral chronic otitis media and 2 patients had long history of sensorineural hearing loss at contralateral ear. CI was performed with simultaneous radical mastoidectomy with closure of the EAC as a single-stage in 3 ears with a history of previous open cavity mastoidectomy and no active discharge. Staged CI was performed in 6 ears, after radical mastoidectomy with closure of the EAC in 3 ears and after intact canal wall mastoidectomy in 3 ears, due to active inflammation or complications related to otitis media. In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence.ConclusionDecision whether implantation as a single-stage or staged operation depends on the presence of active inflammation. Single-stage CI with proper mastoid surgery can be performed in patients without active inflammation. Staged procedure need to be done in ears with active inflammation. Proper application of mastoid surgery leads to safe CI for patients with chronic otitis media.     

Facial nerve paralysis secondary to chronic otitis media without cholesteatoma.

Numerous papers have been written on facial nerve paralysis caused by chronic suppurative otitis media. However the authors found none documenting the results of therapy in a series of patients in whom facial nerve dysfunction was caused by chronic otitis media without cholesteatoma. Thus, there is little factual information available to help select a specific therapeutic plan for such cases. Over the past decade, the senior author has managed five cases (6 ears) of chronic suppurative otitis media without cholesteatoma in which facial paresis (4 ears) or paralysis (2 ears) developed 10 days or less before surgery. The chronic otitis media involved the mastoid and middle ear in five cases; and the mastoid, middle ear, and petrous apex in one case. Modified radical mastoidectomy was performed in four ears, tympanomastoidectomy with facial recess exposure in one ear, and complete mastoidectomy with middle cranial fossa petrous apicectomy in one ear. Five patients had complete recovery of facial nerve function (House grade I), and one patient had 90 percent recovery (House grade II). The results provide support for semi-emergent surgery in the management of chronic suppurative otitis media when facial nerve paralysis supervenes.     

Tuberculous otitis media as a secondary infection to chronic otitis media with cholesteatoma

A series of six cases of tuberculous otitis media is reviewed. All patients had a history of chronic otorrhea and were operated on with a presumptive diagnosis of chronic otitis media with cholesteatoma. Postoperatively the diagnosis of tuberculosis was established by histologic examination of the granulation tissue from the middle ear and mastoid. We believe that any patient with a long history of discharging ears needs histologic examination, as tuberculous otitis might be the cause of infection. We report our findings in these patients and discuss the possibility of penetration of tuberculous mycobacteria into the ear and mastoid. In our opinion, the tuberculosis is secondary to established ear infection.     

易漏诊的隐匿性中耳炎

目的探讨隐匿性中耳炎的临床特点,避免误诊。方法回顾分析13例隐匿性中耳炎患者的临床资料,从病史、鼓膜检查、听功能检测、颞骨CT及手术所见等方面总结分析其特征。结果所有病例无明显耳漏病史,鼓膜和外耳道局部无明显阳性体征,均以听力下降、耳闷、耳鸣、耳痛等症状就诊,病程8天～2个月;纯音听阈显示4耳为传导性听力损失,9耳为混合性听力损失,0.5～4kHz气导平均听阈为44.15±4.50dB HL;鼓室导抗图B型12耳,C型1耳;颞骨CT显示鼓窦、乳突区密度增高;术中见2耳上鼓室有包裹性积液及肉芽,9耳上鼓室、鼓窦、乳突腔有肉芽组织,部分听骨链中断,2耳乳突腔见胆脂瘤。手术清除病变,解除引流通道的阻塞,13例均治愈,随访6个月至3年,无复发。结论易漏诊的隐匿性中耳炎无明显临床症状,对于有反复原因不明的耳痛、耳闷感、耳鸣、听力下降等症状者,无论鼓膜完整与否,均应早期行听力及高分辨率颞骨CT扫描等检查以确诊;手术是该病有效的治疗方法。     

total obliteration of the mastoid,middle ear,and external auditory canal. A review of 27 cases.

In the past 22 years, 27 patients have undergone total obliteration of the mastoid, middle ear, and external auditory canal. Most of the patients had severely diseased ears, many with multiple previous operations. When performed for chronic otorrhea, the operation resulted in a dry ear in all but two cases, though healing was prolonged in some. Secondary revisions for hearing were unsuccessful. We review the indications for this procedure and the experience of others who have used similar techniques. Though seldom indicated, the mastoid obliteration operation results in a dry ear in almost all patients.     

Magnetic resonance imaging of the mastoid cavity and middle ear: prevalence and clinical significance of incidental abnormal findings in a nonotolaryngologic adult and pediatric population

OBJECTIVE: The purposes of this study were to determine the prevalence of abnormalities in the mastoid cavity and middle ear in a nonotolaryngologic population and to correlate the results with clinical data. DESIGN: Prospective, cross-sectional study. SETTING: An academic tertiary care centre. METHODS: We evaluated 100 adults and 30 children from May to July 2003. Patients who had a history of mastoid or middle ear surgery or were presently suffering from otitis media were excluded. Magnetic resonance imaging (MRI) was conducted for the suspected intracranial pathology. MAIN OUTCOME MEASURES: The T2-weighted image was reviewed. The abnormality detected by MRI was divided into (1) mastoid cavity abnormality and (2) middle ear abnormality. All patients were asked to complete a questionnaire pertaining to the symptoms of the mastoid or middle ear pathology and the history of the otitis media. Also, their ears were examined carefully by an otoscope or otomicroscope. RESULTS: In both groups, most of the abnormalities were found in the mastoid cavity. Analysis of the clinical data revealed that abnormal MRI findings of the mastoid cavity were significantly correlated to clinically significant mastoid or middle ear disease in adults. CONCLUSIONS: Incidental MRI abnormalities in the mastoid cavity and middle ear detected in a nonotolaryngologic population were relatively uncommon compared with incidental paranasal sinus abnormalities. However, clinicians should remember the possibility of the pathologies that demand active treatment among these abnormalities, especially when a high signal abnormality is found in the mastoid cavity of an adult.     

Temporal bone study of residual mastoid inflammation in ears with normally appearing tympanic membrane

We examined 395 temporal bones with an intact tympanic membrane to explore the relationship between residual inflammation in the middle ear cavity and development of mastoid pneumatization. Histopathological changes were studied in the middle ear cavity. Mastoid pneumatization was classified as good or poor based on the extent of mastoid tip development to the lateral semicircular canal. Specimens were 344 temporal bones with well-pneumatized mastoid and 51 with poorly-pneumatized mastoid. Otitis media was noted in 119 (34.6%) bones in the good group and 9 (17.6%) in the poor group. In well-pneumatized mastoid, chronic inflammatory changes were frequently observed at the lower portion of mastoid cells, the round window niche, and the tympanic sinus. In contrast, no such incidence of inflammatory change was noted in poorly-pneumatized mastoid. Our findings indicate that an intact tympanic membrane does not always mean freedom from mastoid inflammation, especially when the mastoid is well-pneumatized. This makes it important to check for possible remaining otitis media in patients with a well-pneumatized mastoid, even if the tympanic membrane appears normal.     

The relationship between the degree of chronic middle ear inflammation and tympanic bulla pneumatization in the pig as animal model

The relationship between the degree of chronic middle ear inflammation and pneumatization was investigated in the pig as an animal model, since its tympanic bulla closely resembles the human mastoid air cell system. Ten piglets (sire: Landrace-Hampshire crossbreed; dam: Duroc) were used for this experiment. Four ears of two animals served as the normal control group and 16 ears of eight animals were the experimental group. In this latter group, otitis media was induced by injecting glycerin into the middle ear clefts 1 month after birth, and the degree of inflammation was varied by administering or withholding antibiotics (cefamandole and dibekacin) and adjusting the dosage regimen. The animals were sacrificed 6 months after birth and examined for the relationship between the degree of chronic middle ear inflammation present and tympanic bulla pneumatization. Various degrees of inflammation were successfully induced by injecting the antibiotics: the more severe the inflammation found, the greater was the inhibition of pneumatization. Findings demonstrated that the degree of inhibition of pneumatization produced was directly proportional to the severity of chronic middle ear inflammation.     

中耳胆固醇肉芽肿的诊断及治疗

目的:探讨中耳胆固醇肉芽肿的发病原因、诊断和接受中耳乳突手术治疗后的效果。方法:回顾性分析我院1999年8月～2004年4月接受中耳乳突手术治疗和经病理证实的18例(19耳)中耳胆固醇肉芽肿患者的临床资料,其中,接受完壁式乳突根治加鼓室探查加中耳置管术7耳,完壁式乳突根治加鼓室探查加听骨链成形加中耳置管术2耳,完壁式乳突根治加鼓室探查术3耳,完壁式乳突根治加鼓膜成形术2耳,开放式乳突根治加鼓室成形术4耳,单纯乳突切除术1耳。结果:置管者术后1～3个月拔除中耳通气管,鼓膜愈合良好;未置中耳通气管者,1～2个月鼓膜颜色正常。术后听力均有不同程度提高,纯音测听达到应用水平(语频气导平均听阈30dB以内)15耳(79%)。所有患者随访0.5～2年,除1耳因咽鼓管不通,长期留置中耳通气管外,其余患者无复发。结论:中耳胆固醇肉芽肿的病因为中耳炎症引起含气腔通气受阻,引流障碍及含气腔出血。确诊有赖于病理诊断。中耳乳突手术彻底去除病变,建立乳突鼓室咽鼓管良好的通气系统,是手术成功的关键。     

330例乳突再手术相关因素分析

目的对慢性化脓性中耳炎和中耳胆脂瘤乳突再手术的相关因素进行分析。方法回顾性分析330例(338耳)乳突再手术的临床资料。记录再手术前患者的影像学检查、是否合并慢性鼻-鼻窦炎、术中所见、病菌培养结果、术后病理结果及听力变化情况等。结果乳突轮廓化不全256耳;外耳道口狭窄247耳;面神经嵴高169耳;乙状窦前移105耳;中颅窝脑板低垂97耳;面神经走行异常8耳;咽鼓管鼓室口病变118耳;慢性鼻-鼻窦炎91耳;术后未定期换药18耳;二期听力重建8耳;术后面瘫3耳。病菌培养结果:真菌感染82耳,细菌感染74耳,真菌合并细菌感染12耳;术后病理:慢性炎症183耳,胆脂瘤140耳,肿瘤6耳。再手术行听力重建的125例患者术后平均气导听阈及平均气骨导差均较术前显著下降(P<0.001)。结论乳突再手术常见原因有术后不干耳、二期听力重建、术后面瘫,预防术后不干耳可以有效降低再次手术发生率。     

Aural Barotrauma in Submarine Escape: Is Mastoid Pneumatization of Significance?

OBJECTIVE: Submarine escape training is carried out by preselected, healthy young men under strictly controlled conditions regarding exposure to pressure and the rate of pressure change. This provides a unique opportunity to investigate the relations between middle ear characteristics and susceptibility to barotrauma while avoiding possible confounding parameters. We examined a possible association between mastoid pneumatization and middle ear barotrauma (MEB) in submarine escape trainees. STUDY DESIGN: Cross-sectional, parallel-group design. METHODS: Sixty-six subjects aged 19 to 28 participated in the study. The escape simulation included pressurization to 30 or 60 feet followed by a buoyant ascent to the surface. Subjects were evaluated for MEB after each ascent. A Schuller's mastoid radiograph was taken for the evaluation of mastoid pneumatization. RESULTS: Fifteen (23%) of the subjects suffered from MEB, and 6 (40%) of them had bilateral involvement. Repeated impedance audiometry after the completion of a successful ascent revealed a significant increase in middle ear compliance. Schuller's radiographs were obtained from 49 (74%) of the subjects. Of these radiographs, 16 (16%) were of ears that had suffered MEB. Mastoid pneumatization for all ears approached a normal Gaussian distribution, with a mean area of 9.58 cm. The mastoid areas and the proportion of ears with mastoid pneumatization at the extremes of the study population did not differ between barotrauma and no-barotrauma ears. CONCLUSION: In a population with no history of recurrent or chronic otitis media and normal tympanic membrane morphology and compliance, the amount of mastoid pneumatization probably represents merely the normal distribution of variation in organ size and is not related to the ability to equalize pressure in the middle ear.     

开放式鼓室成形术治疗胆脂瘤型中耳炎疗效观察

目的探讨开放式鼓室成形术治疗胆脂瘤型中耳炎的临床效果和影响预后的因素.方法对胆脂瘤型中耳炎116例行开放式鼓室成形术,并对手术方法进行分析.结果经1-5年随访,颞肌筋膜完全成活109例,6例再穿孔,1例复发流脓,患者均有短且大的外耳道,术腔上皮化、干耳.术后9个月听力提高10dB56例、15-20dB34例,25-30dB6例,20例无变化.结论施行开放式鼓室成形术,只要彻底清除乳突、中耳病变,恢复中耳通气功能,可以消除炎症,防止胆脂瘤复发和提高听力.     

Relation between the onset of chronic middle ear inflammation and the development of the middle ear air cell system

The relation between the onset of chronic middle ear inflammation and the degree of pneumatization was investigated in porcine tympanic bullae, which closely resemble the human mastoid air cell system. Pneumatization was inhibited in all inflamed ears, and the later the induction of otitis media, the lesser the degree of inhibition of pneumatization. It was concluded that chronic middle ear inflammation inhibits the development of the middle ear air cell system, and the time of onset plays an important role in the degree of pneumatization.     

隐匿性中耳炎的诊断与治疗

目的 探讨隐匿性中耳炎的诊断及治疗方法,提高隐匿性中耳炎的诊治效果.方法 回顾性分析我院1994年1月～2005年12月经手术治疗和病理证实的15例隐匿性中耳炎患者的临床资料,总结其病因及临床特点.结果 所有病例无明显耳漏病史,鼓膜和外耳道局部无明显阳性体征发现,3例急性发作时有鼓膜充血,1例伴鼓膜穿孔及脓液搏动.听力损失多为传导性聋.颞骨CT扫描示病变主要集中在上鼓室和鼓窦,4例病变充满乳突气房及鼓室、鼓窦.主要症状为听力渐进性下降、头闷痛、耳闷堵塞感及耳鸣等.术中探查中耳气房内有肉芽组织10例,其中4例伴有积液及胆固醇肉芽肿;另2例为胆脂瘤病变.手术主要是清除病变,解除引流通道的阻塞并一期行鼓室成形术.术后随访6个月～5年,病变无复发,听力平均提高16.3 dB.结论 应提高对隐匿性中耳炎的认识,对不明原因的听力下降及局部胀痛不适者应行纯音听力测试、声导抗检查及高分辨率颞骨CT扫描.高分辨率颞骨CT扫描可作为诊断隐匿性中耳炎的主要手段,手术是有效的治疗方法.     

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...     

双软组织血管瓣填塞乳突术腔的临床研究

目的 探讨耳后双软组织血管瓣乳突术腔填塞应用于开放式乳突根治术的临床疗效和意义。方法 胆脂瘤中耳乳突炎患者98例(98耳),在施行开放式乳突根治术基础上,治疗组52例(52耳)应用耳后双软组织血管瓣填塞乳突腔;对照组46例(46耳)应用带血管蒂的颞肌筋膜瓣填塞乳突术腔。结果 治疗组与对照组的干耳时间分别为(17.07±1.28)d和(22.96±6.21)d,治疗组干耳时间明显短于对照组,差异有统计学意义(P<0.05)。结论 耳后区双软组织血管瓣乳突术腔填塞术应用于开放式乳突根治术,有以下优点:①面积更宽广,可最大限度地覆盖术腔骨面;②可加快术腔上皮化,缩短术后干耳时间;③术后基本无需乳突术腔清理。     

乳突根治术后同种异体肋软骨中耳重建71例报告

目的：探讨乳突根治术后,让术耳向外耳道开放的乳突腔重新中耳化和Ｉ期听力重建的方法。方法：以同种异体肋软骨为外耳后壁重建、乳突充填和听骨链重建的材料,对７１例（耳）于乳突根治术后行中耳重建术。结果：７１耳术后经０．５￣５年随访,除２耳外,全部病例重建外耳道接近正常生理结构;听力提高１５ｄＢ以上或达应用水平５５耳（７７．５％）,听力提高未达１５ｄＢ１１耳（１５．５％）,因不同原因失败５耳（７．０％）。     

Clinical significance of incidental magnetic resonance image abnormalities in mastoid cavity and middle ear in children

OBJECTIVE: Magnetic resonance imaging of the head may reveal incidental findings in paranasal sinuses. The purpose of this study was to discover whether similar changes could be identified in the mastoid cavity and middle ear as well. METHODS: A group of 50 children undergoing magnetic resonance imaging of the head for suspected intracranial pathology were prospectively gathered. Their parents completed a questionnaire concerning each child's medical history connected with acute otitis media. Otoradiologists evaluated the pictures for mastoid cavity and middle ear and paranasal sinus abnormalities. RESULTS: In six (12%) children, magnetic resonance imaging detected abnormalities resembling acute inflammatory changes, although none had had acute otitis media during the preceding last 3 months. Abnormalities detected in the paranasal sinuses were not correlated with abnormalities in the mastoid cavity and middle ear. CONCLUSIONS: High signal intensity in magnetic resonance images from the mastoid cavity and middle ear may be incidental and without any clinical significance. These findings must be interpreted together with knowledge of the child's medical condition and clinical examination of the ears.     

The use of homograft stapes

Homograft stapes were used for ossicular reconstruction in 43 ears over a three-year period. The average hearing improvement was 7.9 db. These cases were divided into two groups: those with an intact posterior canal wall and those with an open mastoid cavity. The latter group fared better, with an average improvement of 15 db. Fourteen of the 43 ears were subsequently re-explored. Satisfactory bony union between the homograft stapes and recipient footplate was found in eight cases, four cases showed poor bony union, and bony resorption of the homograft had occurred in two patients with eustachian tube dysfunction. This technique offers promise for reconstruction of the ear with a loss of the stapes arch, especially in the presence of an open mastoid cavity and thus a shallow middle ear.     

Cholesteatoma in the petrous apex

Six patients with extensive cholesteatoma in the petrous pyramid are reported. All patients had a facial palsy of long duration. In five patients with a history of otitis media, radiographic examinations and surgical explorations revealed chronic inflammatory changes in the middle ear, which suggested that the cholesteatoma in the petrous pyramid was associated with a preceding otitis media. Only in one patient, without a past history of otitis media, was the cholesteatoma assumed to be of congenital origin. The cholesteatoma was totally removed in five patients using a translabyrinthine approach and in one by a middle cranial fossa approach. Control of middle ear infection, obliteration of the mastoid petrosal cavity, and facial nerve repair were supplementary but significant surgical problems.