Long-term results following mastoid obliteration in canal wall down tympanomastoidectomy

BACKGROUND: The primary goal in chronic otitis media is the creation of a dry, safe ear with hearing preservation and reconstruction. This study was designed to evaluate the authors' experience using autologous bone pate and conchal cartilage for mastoid obliteration in canal wall down tympanomastoidectomy. METHODS: A retrospective long-term review in 2003 of thirty-nine ears was performed, which underwent mastoid obliteration in canal wall down tympanomastoidectomy between 1993 and 2002 performed by the senior author. Data included questionnaire results, clinical observation as well as pre- and postoperative audiometry. RESULTS: Long-term follow-up shows, that 38 out of 39 ears maintained a small, dry, healthy mastoid cavity. Recurrent cholesteatoma occurred in a single patient. A self-cleaning mastoid bowl was achieved in 90 %, resulting in reduced follow-up visits. Postoperative vertigo in canal wall down revision surgery is clearly diminished due to the mastoid obliteration. Overall, 92 % of patients are satisfied with the surgical result. CONCLUSION: Obliteration of a canal wall down mastoid cavity by autologous bone pate and conchal cartilage is a reliable and effective technique that results in a dry, trouble free mastoid cavity in 90 % of the patients with chronic otitis media.     

保留乳突的改良完壁式鼓室成形术的临床疗效观察

目的 探讨局限于上鼓室区病变的慢性化脓性中耳炎、中耳胆脂瘤行上鼓室径路保留乳突的改良完壁式鼓室成形术的长期临床疗效.方法 诊断慢性化脓性中耳炎、中耳胆脂瘤47例(47耳)患者,结合患者专科检查,依据手术方式不同分A、B两组,A组行上鼓室径路保留乳突的改良完壁式鼓室成形术,B组行完壁式乳突切开+鼓室成形术.术后随访5～7...     

Canal wall reconstruction tympanomastoidectomy with mastoid obliteration

OBJECTIVES: This study was designed to evaluate the authors' experience with canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma. STUDY DESIGN: Institutional review board approved retrospective case review. METHODS: Retrospective review was performed of all patients undergoing CWR tympanomastoidectomy with mastoid obliteration from 1997 to 2004. Data included pre- and postoperative audiometry, findings at second look surgery with ossiculoplasty, and postoperative complications including wound infection and canal wall displacement. RESULTS: One hundred thirty ears in 127 adults and children underwent the procedure. Mean time postoperative was 48 (range 2-94) months. A second look ossiculoplasty was performed in 102 (78%). Percentage of ears that remain safe without evidence of recurrence was 98.5. The postoperative infection rate decreased from an initial rate of 14.3% to 4.5% for the last 88 ears after protocol modification. Recurrence occurred in two (1.5%) patients, requiring conversion to a canal wall down mastoidectomy. CONCLUSIONS: A CWR technique can provide improved intraoperative exposure of the middle ear and mastoid without creating a mastoid bowl and reduces the incidence of recurrent disease. A single procedure is used for all patients with acquired cholesteatoma, including children.     

Causes of failure of mastoidectomy for chronic otitis media

The operative findings of 66 patients who underwent revision mastoid surgery for recurrent chronic otitis media were analyzed for the causes of failure of the primary procedures. Recurrent cholesteatoma was found in 41% of the canal wall down and 70% of the canal wall up procedures requiring revision. Additional causes of failure included granulation tissue in unexenterated cells, particularly in the tegmental cells (41% of all cases and 64% of cases without cholesteatoma) and cells of the sinodural angle (38% of all cases and 58% of cases without cholesteatoma). The need for thorough exenteration of cells, particularly the tegmental cells and cells of the sinodural angle, mastoid tip, and facial recess, and the importance of lowering the facial ridge in canal wall down procedures were stressed. Following these principles, the success rate in creating a dry ear in 48 patients who had undergone from one to three previous mastoid procedures was 85% (mean follow-up three years).     

Postauricular periosteal-pericranial flap for mastoid obliteration and canal wall down tympanomastoidectomy.

OBJECTIVE: To describe an effective technique for mastoid cavity obliteration in canal wall down tympanomastoidectomy for chronic otitis media and review its efficacy in producing a dry, low-maintenance, small mastoid cavity. DESIGN:: Retrospective clinical study of a consecutive series of procedures from 1995 to 2000. SETTING: Tertiary referral center and institutional academic practice in otology and neurotology. PATIENTS: Sixty consecutive procedures for active chronic otitis media with a minimum follow-up of 12 months (mean, 31 mo; range, 12-80 mo). INTERVENTION: All patients had canal wall down mastoidectomy with simultaneous tympanoplasty including split-thickness skin grafting. An inferiorly pedicled, periosteal-pericranial flap was used in conjunction with autologous bone pate to obliterate the mastoid cavity. The additional length provided by the pericranial extension of the flap permitted it to reach superior to the lateral canal and into the sinodural angle, with improved coverage of bone pate and better reduction of cavity size. OUTCOME MEASURES: The primary outcome measure was control of suppuration and creation of a dry, low-maintenance mastoid cavity, which was assessed using a previously developed semiquantitative scale. This scale includes a temporal dimension to assess control of infection. Secondary outcome measures included postoperative complications (i.e., hematoma, infection, flap necrosis, and meatal stenosis) and incidence of recurrent or residual cholesteatoma. RESULTS: Forty-nine ears (82%) maintained a small, dry, healthy mastoid cavity. Five ears (8%) had intermittent otorrhea easily controlled by topical treatment. Six ears (10%) had suboptimal control of otorrhea, of which four had meatal stenosis. There were no residual or recurrent cholesteatomas. Outcomes remained stable over progressively longer follow-up, up to 80 months. CONCLUSION: Obliteration of a canal wall down mastoid cavity by a postauricular periosteal-pericranial flap with autologous bone pate is a reliable and effective technique that results in a dry, trouble-free mastoid cavity in 90% of patients with active chronic otitis media.     

中耳胆脂瘤和慢性化脓性中耳炎手术临床分析

目的　探讨中耳胆脂瘤和慢性化脓性中耳炎术式选择及临床效果。方法　对110例中耳乳突病变,包括中耳胆脂瘤和慢性化脓性中耳炎,根据范围显微镜下实施完壁式或开放式乳突根治,部分同时鼓室成形术,随访术后干耳状况、并发症、复发情况以及术后听力改善程度等。结果　110例患者中66例中耳胆脂瘤、44例慢性化脓性中耳炎,出现颅内外并发症者7例。手术方式：51例（46.36%）行完壁式乳突根治术,46例（41.81%）同时行鼓室成形术,59例（53.64%）行开放式乳突根治术。完壁式乳突根治术后听 力提高＞25 dB 37例（33.64%）,＞15 dB 14例（12.72%）;开放式乳突根治术后听力提高＞15 dB 5例（4.55%）,听力减退4例（3.64%）,比较手术前后言语频率区平均听阈,差异有统计学意义（P＜0.05）。术后随访1年发现开放式和完壁式两组胆脂瘤复发共4例。结论　中耳胆脂瘤与慢性化脓性中耳炎通过选择恰当手术方式可获得较好的临床疗效。     

胆脂瘤中耳炎与咽鼓管上隐窝

目的探讨咽鼓管上隐窝及其与上鼓室空气通道的状态在胆脂瘤中耳炎发病过程中的意义。方法观察胆脂瘤中耳炎52例（52耳，观察组）及乳突气化良好无慢性中耳炎病史的外伤性面神经麻痹患者16例（16耳，对照组）术中咽鼓管上隐窝及其与上鼓室通道开放状态。结果对照组16耳均呈清晰的咽鼓管上隐窝结构，呈膜性闭锁4耳（25．0％）。观察组52耳（100％）咽鼓管上隐窝与上鼓室前方呈完全闭锁，无相通病例。与对照组差异有统计学意义（Х^2=46．421，P=0．000）。其中骨性闭锁34耳（65．4％），膜性闭锁18耳（34．6％）；上鼓室空间狭小。全组均为硬化或气化不良型乳突。结论咽鼓管上隐窝与上鼓室的气流通道闭塞更容易造成上鼓室和乳突负压状态，可能是形成胆脂瘤的原因之一；咽鼓管上隐窝与上鼓室通道的解剖学变异可能是胆脂瘤中耳炎的易患因素。提示胆脂瘤中耳炎行完壁式鼓室成形术时开放该通道可能有助于防止术后复发。     

Canal wall down mastoidectomy for cholesteatoma: experience at the University of Crete

OBJECTIVE: To evaluate clinical and audiologic data as well as operative findings and postoperative follow-up in the management of chronic cholesteatomatous otitis media with canal wall down mastoidectomy (CWDM). STUDY DESIGN: A retrospective review of cases followed up between 1990 and 2002. SETTING: Tertiary referral centre. METHOD: Two hundred one patients with chronic otitis media with cholesteatoma underwent CWDM. MAIN OUTCOME MEASURES: Clinical presentation, surgical findings, and audiologic evaluation were assessed. RESULTS: Preoperatively, eight patients suffered from vertigo and four presented with facial nerve paralysis. In 40 patients (20%), erosion of the lateral semicircular canal was found, and in 31 patients (15%), there was dehiscence of the facial nerve canal. Dural plate erosion and sinus plate dehiscence were found in 13 and 17 patients, respectively. Nine patients experienced serious endocranial complications at their admission. The malleus was noted to be intact in the majority of patients in all age groups. The incus was eroded or absent in most of the cases in all age groups. On postoperative evaluation 3 months after surgery, 195 audiograms were performed, with a mean pure-tone average of 55 dB HL and a mean air-bone gap of 30 dB HL. CONCLUSION: Although CWDM has the disadvantages of the necessity to avoid water insertion in the external auditory canal and lifelong mastoid care, it is an effective treatment in a single-step procedure for patients with advanced disease and for those who refuse to submit to postoperative follow-up.     

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.     

Five years experience using the intact canal wall tympanoplasty with mastoidectomy for cholesteatoma: Preliminary report.

Many advances have occurred in the treatment of acute suppurative inflammation of the middle ear; however, the problem of chronic otitis media with cholesteatoma still persists today. This paper deals with the author's experience over 5 years using the intact canal wall tympanoplasty with mastoidectomy treatment in chronic otitis media with particular emphasis on the treatment of cholesteatoma both in adults and children. From May 1, 1976 to May 1, 1981, 204 ears were operated on for chronic otitis media with the tympanoplasty with mastoidectomy technique. Of this group, 104 ears were operated on using the intact canal wall technique when there was cholesteatoma present. The major emphasis of this paper will be to evaluate those ears with cholesteatoma. The technique of the procedure used and modifications that have been made are outlined with particular reference as to why modifications were made as problems arose while observing this group of patients. The results of this study suggest that there is a greater incidence of recurrence of cholesteatoma using the intact canal wall technique in children than in adults. It is believed that this higher rate is due to ongoing eustachian tube difficulties present in children. It is also felt that the intact canal wall technique does provide a better chance of auditory functional rehabilitation than an open cavity ear procedure. The problem of residual cholesteatoma still exists using the intact canal wall procedure; however, the problem seems to be well taken care of using a planned two-stage procedure. This is particularly necessary because two-thirds of all residual cholesteatoma was found to be in the middle ear. The conclusions of the study suggest that a planned two-stage intact canal wall tympanoplasty with mastoidectomy can accomplish the goals of cholesteatoma surgery, i.e., control of the disease and improved functional results. It is felt that, if cholesteatoma recurs in a child, the revision operation should be converted to a properly performed open cavity procedure. It was felt that the anatomic removal of the posterior bony canal wall in an open cavity procedure does not render an ear safe from further problems.     

乳突根治加鼓室成形术临床疗效观察

目的 :在传统乳突根治术的基础上 ,探讨保留部分外耳道后壁鼓室成形术的方法 ,以期提高化脓性中耳乳突炎病人的干耳率 ,提高听力的可能性。方法 :对 2 6例 (2 9耳 )化脓性中耳乳突炎患者进行乳突根治术 ,保留部分外耳道后上壁 ,一期重建中耳传音结构。结果 :2 6例 (2 9耳 )术后 8个月～ 2 4个月随访 ,术后干耳并听力提高达实用听力水平 (2 5d B以上 ) 2 6耳 ,治愈率达 89.7% ,复发 3耳 ,复发率为10 .3%。结论 :对于耳咽管功能良好的化脓性中耳乳突炎病人在彻底清除乳突中耳病变的同时 ,行保留部分外耳道后壁及鼓环的鼓室成形术 ,更接近中耳生理结构 ,即清除炎性病变 ,又提高听力 ,值得推广。     

Tympanoplasty: review of 400 staged cases

Staging of tympanoplasty is important in the management of patients with chronic otitis media. It allows establishment of an air-containing middle ear space and adequate postoperative hearing levels in a large proportion of patients with severely diseased ears. The results of 400 staged procedures performed over a 3-year period at the House Ear Clinic, Los Angeles are reported. Staging was performed in 75% of tympanoplasty with mastoidectomy cases and in 15% of ears not requiring mastoid surgery. Closure of the air-bone gap to 20 dB or less occurred in 68% of patients with intact stapes. Mucous membrane problems were the most common reason for staging. Almost one third of cases with middle ear cholesteatoma at the first stage had residual disease on reexploration. Staging of tympanoplasty continues to be an important technique in management of severely diseased ears.     

Effects of Burow's solution as an ear drop on Intractable chronic suppurative diseases of the external ear canal and middle ear

OBJECTIVE: Burow's solution was developed by Karl August von Burow in the 19th century as an ear drop. Thorp et al. reported its excellent effect on chronic suppurative otitis media in 1998. We applied Burow's solution to intractable chronic purulent diseases of the external and middle ear in the 12 months from February 2001. SUBJECTS: Subjects were 25 ears of 21 patients--35-79 years old, 10 men's ears and 15 women's ears--whose disease has continued for an average of 3.78 years. Diseases and patients are as follows: 1) 11 ears with postoperative mastoid cavity problems, 2) 7 ears with chronic external otitis and chronic eczema of the external ear canal, 3) 7 ears with fungal otitis externa, 4) 6 ears with chronic otitis media with perforation, and 5) 2 ears of chronic granulated myringitis. METHOD: The solution was dropped into the ear canal once a day for 10 min or cotton balls soaked with the solution were applied to the canal wall. Criteria of efficacy were divided into cured, effective and unchanged. RESULTS: 8/11 ears with a cavity problem were cured (72.7%) and 3 ears showed treatment to be effective. All 7 ears with chronic external otitis and chronic eczema were cured. All 7 ears with fungal otitis externa were cured. 4/6 ears (66.6%) with chronic perforated otitis media were cured and 1 ear each showed treatment to be effective and 1 unchanged. Two chronic granurated myringitis were cured. Twenty of 25 ears (80%) were cured. Pre- and posttreatment audiometries showed almost the same. The cure appeared within 3 days to 3 weeks. The solution was not effective against mucoid secretion, cholesteatoma, or residual mastoid cells. The day after treatment, serous secretion appears temporarily. CONCLUSION: Burows's solution is seemed to be very effective and nonototoxic as an otic drop for treating suppurative ear diseases.     

Reconstruction of the radical mastoid.

Open cavity techniques (radical mastoidectomy, canal wall down tympanomastoidectomy, modified radical mastoidectomy) are well established surgical procedures for the treatment of chronic otitis media. Despite their effectiveness in exteriorizing cholesteatoma, they are associated with a 20 to 60 percent incidence of persistent intermittent drainage. In an effort to eliminate this problem, we have employed a Palva flap and medial graft technique to reconstruct the mastoid cavity and middle ear space in those patients with chronically draining ears. Between 1987 and 1990, 28 patients underwent this procedure. Twenty-six of these (93%) had complete obliteration of the mastoid cavity and successful tympanic membrane reconstruction. Two of 28 (7%) had a persistent tympanic membrane perforation and intermittent drainage following their surgery. Based on these results, this procedure is effective in eliminating intermittent drainage associated with the open cavity techniques. The indications for this procedure, the specifics of the surgical technique, and the postoperative results are discussed.     

完壁式乳突根治鼓室成形术治疗胆脂瘤中耳炎

目的:探讨完壁式乳突根治鼓室成形术治疗胆脂瘤中耳炎的临床效果和相关的经验教训.方法:对57例胆脂瘤中耳炎患者实施完壁式乳突根治鼓室成形术.结果:随访1～8年,平均3.7年.术后5例感染流脓,其中3例经及时处理得到控制并愈合,2例二次手术处理后愈合;3例术后因胆脂瘤复发行开放式乳突手术获干耳;鼓膜完整但有内陷者29例,其中2级内陷者13例;术后8个月及1年人工听骨脱出各1例.术后言语频率气导听阈降低>10 dB HL为72.2%(39/54),气骨导差<20 dB HL为53.7%(29/54),气骨导差缩小25 dB HL以上占42.6%(23/54).结论:施行完壁式乳突根治鼓室成形术,如果适应证掌握得当,技术条件许可,患者能按时随访.可以有效保留原中耳乳突解剖结构和改善听力,提高患者生活质量,应予优先选择该术式.     

乳突切除术治疗分泌性中耳炎

目的：探讨乳突切除术治疗分泌性中耳炎的疗效。方法：回顾性分析22例（24耳）行乳突切除手术的分泌性中耳炎患者,其中行完壁式并面隐窝开放手术20耳,开放式手术4耳,同期行鼓膜切开置管术3耳。术后6个月拔管,测试术前、术后的听力。结果：所有患者术后均未出现听力下降,19耳有不同程度的听力提高,鼓室导抗图为A型曲线者17耳,C型曲线者7耳。术后随访6-36个月,未见中耳炎复发。结论：对反复发作、长期迁延经治疗无效的分泌性中耳炎,乳突切除术可改善乳突、鼓窦、鼓室和咽鼓管的通气引流,减少分泌性中耳炎的复发。     

Surgical treatment of chronic middle ear disease. III. Revisions after tympanomastoid surgery

Revision surgery was performed in 185 ears which had earlier undergone a total of 276 tympanomastoid operations. An open cavity had been made in 98, obliteration in 44 and canal wall up surgery in 43 ears. All ears were now operated upon by the open method combined with ear canal reconstruction and mastoid obliteration. Mastoid cholesteatoma was found in 50% of the open cavities and in 63% of intact canal wall ears, while 80% of the obliterated ears showed mastoid retraction pockets with cholesteatoma. Semicircular canal fistulae occurred in all groups, most frequently in open cavities (11%). During the follow-up period after revision (average 5 years) 3% were reoperated upon because of a new cholesteatoma. In the whole series, average hearing levels were slightly better postoperatively and in 34% of the ears the A-B gap was 20 dB at most. The main reason for failure after primary surgery was inadequate mastoid and epitympanic bone work and failure to obliterate the medial parts of the cavity thoroughly.     

开放式乳突切开+鼓室成形术中乳突填塞材料的应用进展

开放式乳突切开+鼓室成形术是一种治疗中耳胆脂瘤和慢性化脓性中耳炎等疾病的有效外科手术技术,旨在彻底清除病灶,从而达到干耳、促进病灶引流、避免颅内外并发症发生的目的。但手术遗留的大乳突空腔可能导致术耳反复流脓、术后需定期清理痂皮、与温度变化有关的前庭功能紊乱、继发术腔感染和隐形助听器佩戴不方便等问题,严重影响患者的生活质量。因此,乳突缩窄术对提高开放式乳突切开+鼓室成形术后疗效是非常重要的。随着医学技术的进步和材料科学的不断发展,越来越多的材料被临床医生应用到乳突缩窄术的临床实践当中,但各种材料的取材方式、组织量、是否容易存活和吸收等特点各不相同,各有优缺点。因此,论文就乳突缩窄术在开放式乳突切开+鼓室成形术中的应用及乳突填塞材料的选择进行综述。     

Long-term results of surgery for childhood cholesteatoma.

The study includes 54 cholesteatomatous ears in 50 children aged 16 years or less. The mean follow-up period after surgery was 7.1 years. In 26% of the ears the cholesteatoma was 'huge' involving the middle ear and the attic and filling the entire mastoid air cell system. A patient had lateral sinus thrombophlebitis. Patients with large cholesteatomas underwent canal wall down mastoidectomy with simultaneous tympanoplasty and, in most cases, cavity obliteration. Limited cholesteatomas were removed using either intact canal wall mastoidectomy or tympanotomy approach. Recurrence rate (including both residual and recurrent cholesteatomas) for the total series was 15% and 12% for the 50 cases undergoing one-stage surgery. Serviceable hearing (< or = 30 dB) was achieved in 57% of the ears. A reoperation was necessary in 26% and a third operation in 2%. At last follow-up examination, 94% of the ears had intact tympanic membranes but 4 patients (8%) suffered from cavity-related problems. Possible reasons for the disappointing results of surgical treatment for childhood cholesteatoma are discussed.     

筋膜外植法鼓室成形术的手术体会

目的 探讨筋膜外植法在鼓室成形术中的应用及价值.方法 回顾分析筋膜外植法鼓室成形术63耳,随访观察患者的外耳道宽敞度、鼓膜形态及听力恢复情况.结果 本组病例包括中耳胆脂瘤25耳,慢性化脓性中耳炎38耳.手术方式分别为筋膜外植法鼓室成形术、筋膜外植法鼓窜成形术+完肇式乳突根治术和筋膜外植法鼓室成形术+开放式乳突根治术三种类型,中耳胆脂瘤和慢性化脓性中耳炎患者实施三种手术的数最分别为4、17、4耳和19、18、1耳.术后切口全部Ⅰ期愈合.随访0.5～3.5年,外耳道宽敞,鼓膜形态良好,听力提高或维持术前水平,未有听力下降者.按时随访者未发现有明显并发症.结论 筋膜外植法鼓室成形术具有操作流程规范、术野暴露充分、病变清除彻底等优点,在慢性中耳炎的外科治疗中具有积极意义.