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

Objective

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

Methods

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

Results

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

Conclusion

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

Second branchial cyst in the parapharyngealspace: a case report

Objective

We report the clinical findings and management of a large retro- and parapharyngeal branchial cyst in a 54-year-old man whose only complaint was a 12-month history of snoring.

Method

Case report and a review of the world literature concerning parapharyngeal cysts are presented.

Results

On computed tomography (CT) images, a well-marginated cystic mass was observed in the left retro- and parapharyngeal spaces, with displacement of the left internal and common carotid arteries. The cyst contained thick, sterile, yellowish pus, without malignant cells. We performed a transoral resection without any surgical complications. No recurrence was observed 2 years later.

Conclusion

Parapharyngeal branchial cysts are rare and often paucisymptomatic. The transoral approach can provide good exposure allowing complete resection without significant post-operative complications or cervical scarring.     

Chronic tympanic membrane perforation in an animal model

Objective

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

Study design

Prospective, animal study.

Methods

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

Results

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

Conclusions

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

Wyniki strukturalne myringoplastyki metodą podkładania

Introduction

The method of tympanic membrane repairing is called myringoplasty.

Aim of the study

We analysed the reasons of failure of this procedure.

Material and methods

The structural results were observed among 36 patients under restricted criteria with diagnosed chronic otitis media. The unsuccessful procedure was one with reperforation. We studied Eustachian tube function and also localisation and size of the perforation.

Results

The failure rate was 25%, which was mainly observed among individuals with incorrect Eustachian tube function – 70% and margin perforations – 50%. The localisation and the size of the perforation did not matter.

Conclusions

The main reasons of myringoplasty failure were incorrect Eustachian tube function and margin perforations of tympanic membrane.     

Transoral laser microsurgery in previously irradiated patients with laryngeal cancer

Purpose

Early laryngeal cancer is successfully managed with transoral laser microsurgery. Previously radiated patients may experience more post-operative complications. We investigate disease-free survival and secondarily prolonged pain and chondronecrosis.

Materials and methods

Retrospective review of 52 patients undergoing transoral laser microsurgery after previous radiation.

Results

Mean disease-free survival was 36.7 months. Overall disease-free survival was 57.6% at 3-year and 48.4% at 5-year follow-up, with no significant difference between surgery within as opposed to after 60 months of radiation or within as opposed to after 12 months of radiation. Thirteen patients, all with surgery within 60 months of radiation, experienced prolonged pain. Twelve experienced chondronecrosis, all within 12 months of surgery.

Conclusion

Transoral laser microsurgery for early laryngeal cancer is an adequate therapeutic option in patients with history of radiation with comparable disease-free survival to other reports. Patients undergoing transoral laser microsurgery within 60 months of radiation treatment are more likely to experience prolonged pain.     

Transoral negative-pressure catheter drainage of a retropharyngeal and mediastinal abscess

Purpose

A retropharyngeal abscess (RPA) is an extremely rare entity in adults that has a tendency to spread vertically and cause a mediastinal abscess. Traditionally, immediate aggressive drainage is recommended via a transcervical or transthoracic approach for the treatment of a retropharyngeal abscess with mediastinal extension. Here, we present a case of a retropharyngeal and mediastinal abscess using a transoral negative-pressure catheter drainage approach.

Patients and methods

A 24-year-old woman was admitted with a 4-day history of severe sore throat and painful swallowing. Computed tomography identified a retropharyngeal abscess extending to the upper posterior mediastinum. We performed transoral negative-pressure catheter drainage.

Results

The postoperative course was uneventful. The patient reported a rapid improvement in symptoms and had a good tolerance of the catheters in the nasal cavity. At 2 years postoperatively, physical examinations revealed no recurrence or surgical complications.

Conclusions

Transoral negative-pressure catheter drainage is a minimally invasive operation for the treatment of RPA in adults with or without a mediastinal abscess. This method could be recommended as an alternative approach in such cases.     

Inlay “butterfly” cartilage tympanoplasty

Objectives

The aim of this study was to analyze the outcome of inlay “butterfly” cartilage tympanoplasty.

Methods

The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry.

Results

The mean patient age was 27 years (range, 14–75 years), and the mean duration of follow-up was 24 months (range, 3–36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear.

Conclusion

Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear.     

Is sensorineural hearing loss with chronic otitis media due to infection or aging in older patients?

Objective

To clarify true incidence of sensorineural hearing loss in ears with chronic otitis media (COM).

Methods

Bone conduction (BC) hearing thresholds of 180 preoperative patients (207 ears) with COM and 226 normal individuals (289 ears) were measured by audiometry, and the percentage of ears with BC thresholds being higher than normal range was evaluated in the COM group. In the COM group, the size of the perforation on the eardrum (n = 196) and the cross-sectional area of the mastoid air cells based on the axial CT image (n = 103) were also measured and correlated with the results of BC threshold.

Results

The percentage of ears with BC thresholds being higher than normal range calculated from comparison to the control group tended to increase with age, ranging from 4.5% in the 20s to 34.1% in the 60s with an average of 26.6%. The increase in the BC thresholds did not correlate with the size of eardrum perforation, but correlated well with the size of the mastoid air cells.

Conclusion

These results may suggest that all measures for early cure, including surgery, should be considered as early as possible for patients with COM.     

Late crust formation as a predictor of healing of traumatic,dry, and minor-sized tympanic membrane perforations

Objective

The goal of this study was to evaluate the effects of crust formation on the healing of traumatic, dry, and minor-sized tympanic membrane perforations (TMPs) in humans.

Study design

Case series with a chart review.

Setting

Tertiary university hospital.

Materials and methods

The clinical records of patients with traumatic TMPs who met the case selection criteria were retrieved and categorized according to the presence of a crust and the timing of crust formation into three groups: no crust, early crust formation, and late crust formation. Healing outcomes (i.e., healing rate and time) in the three groups were analyzed.

Results

In total, 83 patients were analyzed. The perforation closure rates were 92%, 100%, and 78% in the groups with no-crust, early crust formation, and late crust formation, respectively. No significant difference was seen between the groups with no-crust and with late crust formation (p > 0.05). By contrast, closure rates differed significantly between the early and late crust formation groups (p < 0.05). Overall, the no-crust and early crust formation groups showed shorter healing times compared with the late crust formation group (p < 0.05). However, closure times did not differ significantly between groups with early crust formation and no crust (p > 0.05).

Conclusions

Crust formation at the margin of a traumatic TMP may serve as a predictor of healing outcome. Compared with perforations with early crust formation or no crust, late crust formation can result in delayed healing and failure to close completely.     

Risk factors for decreased distance between internal carotid artery and pharyngeal wall

Objectives

The risk of disastrous bleeding during pharyngeal surgery is increased in cases of an internal carotid artery (ICA) that is medially displaced due to its anomalous course. We attempted to assess the distance between the ICA and the pharyngeal wall (DIP) and to evaluate the predisposing factors associated with ICA variation.

Methods

The course of ICA was studied in 509 CT scans, and a retrospective chart review was performed. The course of ICA and DIP were evaluated at each level of the pharynx: nasopharynx (NP), oropharynx (OP), and hypopharynx (HP).

Results

The mean DIP value was greatest (15.8 ± 4.6 mm) at NP, decreased at OP (15.8 ± 4.6 mm), and was shortest at HP (13.5 ± 6.0 mm). DIP was significantly shorter in females compared with males at all three pharyngeal levels. Age was inversely correlated with DIP at NP and OP. Tortuous ICA was most common (51.4%), followed by straight (41.2%), kinking (6.9%), and coiling (0.5%) types. DIP was longest in the straight type and decreased as the curvature of ICA increased. The most common ICA type differed between younger (<60 years; 56.2% having the straight type) and older groups (≥60 years; 66.2% having the tortuous type). Females older than 60 years displayed a higher incidence of kinking ICA compared with males.

Conclusions

Hypopharynx, old age, female gender, and tortuous or kinking ICA types were risk factors for a decreased distance between the ICA and the pharyngeal wall. Meticulous examination of the pharyngeal wall should therefore be performed prior to pharyngeal surgery in patients with these associated risk factors.     

Closure of minor tracheoesophageal fistulae with calcium hydroxlapatite

Objective

To demonstrate a novel technique for the closure of a pinhole tracheoesophageal fistula using Radiesse (calcium hydroxylapatite).

Methods

Two patients underwent closure of a persistent tracheoesophageal fistula with four quadrant injections of Radiesse around the fistulous tract.

Results

Both patients had their fistulas successful closed. The first patient died after 3 months due to lung metastasis. The second patient required a further attempt at closure with Radiesse injection and has been without a leak for 18 months at his last follow up appointment.

Conclusion

We feel this is an acceptable minimally invasive method to close a persistent pinhole tracheoesophageal fistula after failed management with chemical cautery.     

Efficacy of controlling rhinosinusitis on the prevention of complications in pituitary surgery with transsphenoidal approach

Objective

The microscopic transcolumellar transseptal transsphenoidal approach (TSA) is the one of the most widely used methods for the surgical treatment of sellar and parasellar lesions. But nasal and paranasal sinus inflammation is the relative contraindications of TSA. This study was performed to investigate the results of pre TSA treatment options according to the degree of nasal and paranasal sinus inflammation on the paranasal sinus computed tomography scan (PNS CT).

Methods

From January 2005 to September 2010, 145 consecutive patients underwent operation of pituitary lesions through the TSA. The preoperative CT images for these patients were reviewed, and 26 patients were identified with sinus opacification on PNS CT. We then analyzed presenting symptoms, physical and endoscopic examination, Lund–Mackay score on PNS CT and preoperative management of the sinus problem retrospectively.

Results

Twenty-six patients had sinus opacification on PNS CT. Eight patients had the symptoms of sinusitis corresponding to PNS CT finding, so they had therapeutic antibiotics, and had TSA after symptomatic improvement. Three patients had the symptoms of sinusitis and sinus opacification with mean Lund–Mackay score of 5.33, so they underwent endoscopic sinus surgery first, and they got TSA a few months after. One patient underwent endoscopic sinus surgery and TSA simultaneously. No patient had a serious complication including intracranial infection.

Conclusion

TSA is a relatively safe technique, but intracranial complication after surgery may be fatal. Therefore rigorous evaluation and management is mandatory. It is especially important to treat rhinosinusitis issues preoperatively. Our preliminary data may be helpful to evaluate and manage the paranasal sinus inflammation before TSA.     

Influence of size and site of perforation on fat graft myringoplasty

Objectives

In this retrospective study, we investigated the outcomes of fat graft myringoplasty (FGM) in different perforation sizes and locations. The outcomes were evaluated in terms of closure rates and audiological test results.

Methods

The study population included 172 patients who were operated between 2007 and 2012. 161 had unilateral and 11 had bilateral chronic otitis media; and 183 ears were operated by FGM. The patients were divided into two groups based on size as small and larger (size of ≤30 of TM was defined as small perforations, and size of >30% TM was defined as a medium–large perforations); and two groups based on location of perforation [anterior and other (non-anteriorly located)]. Patients’ follow-ups were performed between 1 and 5 years; and follow-up examinations were performed with otoendoscopy. Air conduction (AC) thresholds and air-bone gap (ABG) were evaluated both preoperative year and postoperative 1st year.

Results

The total perforation closure rate was 84.7%. In this study, we found out that FGM is effective closing medium–large perforations just as small perforations with the success rate of 79.1% and 86.4% respectively (p > 0.05). When audiological outcomes were evaluated in both groups, AC values got lower and ABG values improved postoperatively, whereas regarding AC thresholds and ABG improvement among the size groups, patients with small perforations had significantly better postoperative results (p < 0.05). In terms of perforation location, closure rates were 85.2% in anteriorly perforations and 84.5% in the other located perforations. Audiological outcomes demonstrated that in both groups, AC values got lower and ABG values improved postoperatively; and hearing results were not different in anteriorly located perforations and other locations.

Conclusion

Fat graft myringoplasty (FGM) may be used in all small and medium–large, and anteriorly and other located perforations. Although hearing improvement was detected in each of the small; and medium–large perforations; patients with small perforations had more satisfied audiological outcome than medium–large perforations.     

The effect of rapid maxillary expansion on pharyngeal airway pressure during inspiration evaluated using computational fluid dynamics

Introduction

Recent evidence suggests that rapid maxillary expansion (RME) is an effective treatment of obstructive sleep apnea syndrome (OSAS) in children with maxillary constriction. Nonetheless, the effect of RME on pharyngeal airway pressure during inspiration is not clear. The purpose of this retrospective study was to evaluate changes induced by the RME in ventilation conditions using computational fluid dynamics.

Methods

Twenty-five subjects (14 boys, 11 girls; mean age 9.7 years) who required RME had cone-beam computed tomography (CBCT) images taken before and after the RME. The CBCT data were used to reconstruct 3-dimensional shapes of nasal and pharyngeal airways. Measurement of airflow pressure was simulated using computational fluid dynamics for calculating nasal resistance during exhalation. This value was used to assess maximal negative pressure in the pharyngeal airway during inspiration.

Results

Nasal resistance after RME, 0.137 Pa/(cm³/s), was significantly lower than that before RME, 0.496 Pa/(cm³/s), and the maximal negative pressure in the pharyngeal airway during inspiration was smaller after RME (−48.66 Pa) than before (−124.96 Pa).

Conclusion

Pharyngeal airway pressure during inspiration is decreased with the reduction of nasal resistance by the RME. This mechanism may contribute to the alleviation of OSAS in children.     

Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery

Purpose

We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS) between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated.

Methods

Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the “combined” study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois).

Results

Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p = 0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p < 0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported.

Conclusions

Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS.     

Difference of delayed post-tonsillectomy bleeding between children and adults

Objective

To analyze the characteristics of post-tonsillectomy bleeding and its management comparing with adults.

Methods

A retrospective chart review of 1489 patients who underwent tonsillectomy in our institution (June 2003–June 2006).

Results

Post-tonsillectomy bleeding rate was 3.1%, 2.5% and 10.8% in younger children (age ≤ 11 years), older children (12 ≤ age ≤ 15 years) and adults (age > 15 years), respectively. Although adults showed an unimodal peak time for onset of post-tonsillectomy bleeding, children showed a bimodal peak time. In the younger child group, all of the 28 bleeders had spontaneous hemostasis. However, in the older child group, there was no spontaneous hemostasis. Bleeding was controlled under local anesthesia in 3 patients and 2 patients required general anesthesia for bleeding control. In the adult group, spontaneous cessation of bleeding occurred in 25 patients (60.9%) and hemostasis under local or general anesthesia was performed in 16 (39.1%) patients.

Conclusions

Post-tonsillectomy bleeding occurred more frequently in adults than in children. Spontaneous hemostasis was more prevalent in children than in adults. Post-tonsillectomy bleeding in the younger child group was controlled with close observation alone.     

Erratum to “Is sensorineural hearing loss with chronic otitis media due to infection or aging in older patients?” [Auris Nasus Larynx 36 (2009) 269–273]

Objective

To clarify true incidence of sensorineural hearing loss in ears with chronic otitis media (COM).

Methods

Bone conduction (BC) hearing thresholds of 180 preoperative patients (207 ears) with COM and 226 normal individuals (289 ears) were measured by audiometry, and the percentage of ears with BC thresholds being higher than normal range was evaluated in the COM group. In the COM group, the size of the perforation on the eardrum (n = 196) and the cross-sectional area of the mastoid air cells based on the axial CT image (n = 103) were also measured and correlated with the results of BC threshold.

Results

The percentage of ears with BC thresholds being higher than normal range calculated from comparison to the control group tended to increase with age, ranging from 4.5% in the 20s to 34.1% in the 60s with an average of 26.6%. The increase in the BC thresholds did not correlate with the size of eardrum perforation, but correlated well with the size of the mastoid air cells.

Conclusion

These results may suggest that all measures for early cure, including surgery, should be considered as early as possible for patients with COM.     

Tracheal invasion and perforation from advanced primary thyroid lymphoma: A case report and literature review

Objective

We report a case of an elderly female with primary diffuse large B-cell thyroid lymphoma causing an extensive tracheal defect that was managed expectantly with good results.

Method

Case report

Results

This is the only known reported case of a patient with tracheal invasion and perforation caused by primary thyroid lymphoma who has subsequently survived.

Conclusion

Due to the rarity of invasive primary thyroid lymphoma there is currently no standard surgical management of the airway. We propose that expectant management with temporary airway protection is an alternative to invasive procedures such as tracheotomy or tracheal stent placement, even in the scenario of serious airway defects.     

Analysis of obstruction site in obstructive sleep apnea syndrome patients by drug induced sleep endoscopy

Purpose

We analyzed site, pattern and degree of obstruction in Korean male obstructive sleep apnea syndrome (OSAS) patients by drug-induced sleep endoscopy (DISE). We also investigated possible links between BMI, AHI and DISE findings.

Materials and methods

Sixty-nine male patients underwent DISE. DISE findings were reported using our classification system in which modified ‘VOTE classification’ – obstruction type, site of obstruction, degree of obstruction and anatomical site contributing obstruction – was reported. Associations were analyzed among the results of the polysomnography, patients' characteristics and DISE finding.

Results

Multilevel airway obstruction was found in 84.06% of patients and 15.94% had a unilevel obstruction. Among those with unilevel obstruction, 90.90% had retropalatal level obstruction and 9.10% had retrolingual level obstruction. Palate with lateral pharyngeal wall obstruction (49.28%) is the most common obstruction type of the retropalatal level and tongue with lateral pharyngeal wall (37.68%) is the most common obstruction type of the retrolingual level. Examining the relation between obstruction site according to body mass index (BMI) and severity of OSAS (apnea hypopnea index, AHI), the lateral pharyngeal wall had an increasing tendency associated with higher BMI and higher AHI. But the lateral pharyngeal wall of both levels was statistically significant associated with higher AHI.

Conclusion

The majority of the Korean male OSAS patients have multilevel obstruction and according to BMI and AHI, the DISE findings indicate that the lateral pharyngeal wall is the most important anatomical site contributing to obstruction regardless of the level at which the obstruction lies.     

Lateral petrosectomy with obliteration cavity for spontaneous cerebrospinal otorrhea in children

Purpose

The most common causative factors of CSF otorrhea in children are injuries and congenital abnormalities of the temporal bone. Spontaneous CSF leak as a consequence of congenital temporal bone defects may result in recurrent meningitis. Diagnosis and management of such an entity are particularly difficult in early childhood.

Materials and methods

The aim of this study was to investigate clinical features and to discuss possible methods of treatment of spontaneous CSF otorrhea in children.

Results

Severe unilateral sensorineural hearing loss or total deafness was found in children with CSF otorrhea. CT and MRI of the temporal bones revealed dehiscences in the walls of the tympanic cavity and defects of the inner ear, which were confirmed intraoperatively. Lateral petrosectomy and closure of the fistula with muscle tissue and fat obliteration cavity were performed. The children remain free of otorrhea and recurrences of meningitis.

Conclusion

The diagnosis of spontaneous otorrhea in children is based on the severe unilateral sensorineural hearing loss and presence of CSF in the middl? ear cavity. It may be successfully treated by means of lateral petrosectomy with obliteration of the vestibule with muscle tissue and tympanic cavity with fat tissue.