Computed Tomography in Chronic Suppurative Otitis Media: Value in Surgical Planning

The present study was conducted prospectively to evaluate how accurately high resolution computed tomography scanning could define the extent and severity of the underlying disease in patients with chronic suppurative ear disease, thus, helping convert a surgical exploration into a planned procedure. Sixty adult consecutive cases of chronic suppurative otitis media underwent a detailed high resolution computed tomography by a single radiologist. The recorded radiological findings in various heads were then compared to the surgical findings during mastoid exploration of these patients by a single otologist and the two statistically compared. The presence and distribution of soft tissue in the middle ear cleft and mastoid could confidently be predicted using this modality. The malleus, body and short process of incus were well visualized, but not the long process of incus and the stapes suprastructure. Lateral semicircular canal fistulae could be demonstrated with an acceptable degree of accuracy. It was possible to detect facial nerve dehiscence and defects in tegmen tympani in significant number of cases although, statistical values were low for these structures. High resolution scanning is a modality which can accurately image the pathological anatomy in unsafe chronic suppurative otitis media. Otologists should use it more often, especially in complicated cases as an adjunct to better preoperative assessment, and thus, the surgical outcome. Its accuracy is likely to improve with larger studies and better experience, wherein its routine use may become justifiable.     

An Evaluation of Preoperative Computed Tomography on Patients with Chronic Otitis Media

This study aimed to compare the veracity of computed tomography findings on patients undergoing surgery for chronic otitis media (COM) with the surgical findings, and to determine to what extent the preoperative computerized tomography (CT) findings are useful to the surgeon. A series of 56 patients with COM undergoing preoperative CT scanning followed by surgical exploration of the middle ear and mastoid. Operative notes were recorded and data collected on the nature of soft tissue masses, the status of the ossicles, presence or absence of facial canal dehiscence and semicircular canal (SCC) dehiscence and the presence or absence of dural plate erosion, and sigmoid sinus thrombosis. Fifty-six patients were recruited in the study, 30 males and 26 females. The age range was from 16 to 67 years with a mean of 26.51 ± 1.4 years. The preoperative CT scan imaging in cases of cholesteatoma, ossicular chain erosion and SCC dehiscence have good correlation with the intraoperative findings. The specificity of preoperative CT scan in detecting facial canal dehiscence, dural plate erosion and sigmoid sinus thrombosis in patient of COM were weak. Preoperative computed tomography evaluation is fairly useful especially in cases of cholesteatoma. According to the results of this study, CT is of value particularly in the definition of cholesteatoma, and in determining ossicular chain erosion and semicircular canal fistula.     

A clinicoradiological study of cholesteatoma

A clinical and radiological evaluation in diagnosing the cases of cholesteatoma of the middle ear cleft was made on 54 patients of chronic suppurative otitis media. Radiological examination revealed scaleratic mastoid in 50 cases and celluar type of mastoid in 4 cases. Forty (74.08%) out of 54 cases showed radioligical evidence of cholesteatoma; in remaing 14 cases, there was no evidence of cholesteatoma. On surgical exploration in 18 cases, there was cholesteatoma with granulation tissue in the middle ear. In 8 cases, there was destruction of sinus plate and in 6 cases, the dural plate was eroded by cholesteatoma. The sinodural angle was destroyed in 2 cases and ossicular destruction was present in 11 cases. Perisinus absess and the sequestrum was found in one case.     

Middle Ear Cleft in Chronic Otitis Media: A Clinicohistopathological Study

Chronic mucosal diseases of middle ear cleft or chronic suppurative otitis media has been traditionally defined as a chronic inflammation of the middle ear and mastoid usually associated with perforation of the tympanic membrane and otorrhoea. Understanding the pathology and pathogenesis of chronic suppurative otitis media is important in predicting the management, prognosis and sequelae of the disease. The present prospective study was conducted to evaluate the clinical, intraoperative and histopathological changes in middle ear cleft. 100 patients diagnosed with CSOM who underwent surgery were taken. The mucosa and granulation tissue was removed along with ossicles wherever indicated and sent for histopathological examination. On clinical examination, 72 cases were found to be of tubotympanic type and 28 cases of atticoantral variety. However, intraoperatively, of the tubotympanic cases 8 were found to be of unsafe type which was also proven histologically. Stratified squamous epithelium was revealed in most of the cases accompanied by changes in the submucosa. Ossicular chain was involved in 40 cases with incus being the commonest bone to be eroded.     

Surgical anatomy of tympano-mastoid segment of facial nerve

Objective

Facial nerve is known to have a considerable variations more so in the temporal bone. An otologist with inadequate familiarity with facial nerve usually have a tendency to do incomplete surgery in chronic suppurative otitis media. The present study was conducted to explore the microanatomy of tympanic and mastoid segments of facial nerve.

Setting

Temporal bone lab.

Materials and Methods

This study was conducted at PGIMS Rohtak in 25 wet temporal bones which were dissected under the microscope. Various parameters studied included the length of tympanic and mastoid segments of facial nerve, various anomalies, depth from the cortex and relation to various important structures.

Results

The mean length of tympanic segment was 11.1 mm±0.88 and mastoid segment was 15.4 mm±2.4. The angle at second genu was 95–125° and the facial canal was dehiscent in 12% cases.

Conclusions

The tympanomastoid segment of facial nerve has variations in length and in its relation with various middle ear structures. Further the nerve, in Indians is also at variance as compared to Japanese and Americans probably because of different racial configuration of the skull.     

Mastoid Osteoplasty—A study of twenty cases

A study of mastoid cavity obliteration by autogenous bone pate (Mastoid Osteoplasty) was carried out on 20 cases of chronic suppurative otitis media of atticoantral type. After thorough eradication of cholesteatoma autogenous bone pate (uninfected) was used alongwith tragal cartilage for obliteration of mastoid cavity and reconstruction of the posteorosuperior meatal wall. 10 (50%) cases resulted in dry stable ear at the end of six months. Relevant literature on the subject has been reviewed and long term follow up is recommended.     

Use of acetylcysteine in middle ear suppuration

Use of a mucolytic agent in cases of middle ear suppuration to liquefy the discharge for better suction clearance and enhanced middle ear medication is evaluated. Acetylcysteine and antibiotics were used to treat 100 cases of chronic suppurative otitis media. The results were compared with a control group of 20 cases and were found encouraging.     

Comparison of bacteriology in bilaterally discharging ears in chronic suppurative otitis media

Chronic suppurative otitis media is a disease with worldwide prevalence having potentially serious long term effects. It is a disease well known for its recurrence and persistence despite treatment. A study on culture and sensitivity of aural discharge collected from 40 cases of bilateral chronic suppurative otitis media was done to compare the bacteriological profile of either ear. Pseudomonas aeruginosa was the major organism isolated in both ears and was sensitive to Amikacin and newer drugs like Gatifloxacin. It was concluded that the infecting organisms in case of bilateral chronic suppurative otitis media are remarkably similar. If adequate treatment is instituted early, it can go a long way in reducing the prevalence of this socially embarrassing disease.     

Is Routine Use of High Resolution Computerized Tomography of Temporal Bone in Patients of Atticoantral Chronic Suppurative Otitis Media without Intracranial Complications Justified?

Role of high resolution computerized tomography (HRCT) of temporal bone is established in cases of atticoantral chronic suppurative otitis media (CSOM) with intracranial complications. Routine use of HRCT in management of patients of atticoantral CSOM without intracranial complications has been an issue of debate. The aim of this study was to evaluate the routine use of HRCT of temporal bone in such cases. This study was a prospective study done at LG hospital, AMC MET Medical College, Ahmedabad to evaluate and compare the temporal bone findings in HRCT and intraoperative findings in 100 patients with atticoantral CSOM. All patients underwent HRCT screening followed by surgical exploration of middle ear cleft. In extent of disease HRCT showed very high sensitivity and specificity for epitympanum (100, 94%) and mesotympanum (98, 98%) areas. It gave valuable information of disease extent in hidden areas like sinus tympani and facial recess of mesotympanum. HRCT satisfactorily delineated malleus and incus erosion but had 75% sensitivity for detecting erosion of stapes suprastructure, though specificity was of 97%. For bony anatomical landmarks HRCT showed very high sensitivity and specificity for detecting erosion of lateral semicircular canal, tegmen tympani and sinus plate. Detection of facial canal erosion on HRCT had moderate sensitivity of 75%. We concluded that routine use of HRCT is justified as a reliable preoperative tool in patients with atticoantral CSOM without intracranial complications and it helps to plan type of surgical intervention. HRCT has limited role to distinguish between granulations and cholesteatoma and also to delineate stapes supra structure and facial nerve canal.     

Acute otitis media in neonatal life: a review

Acute otitis media is frequently encountered by general practitioners and pediatricians. In the neonatal period acute otitis media may present as an isolated local infection or as part of septicemia. Diagnosis of the condition by otoscopy is difficult. Considering the wide spectrum of middle ear disorders (acute otitis media, otitis media with effusion, chronic suppurative otitis media) one can appreciate why opinions on the management of the condition are diverse. This is a review of the literature on clinical presentation, etiology, risk factors, treatment and prevention of acute otitis media in neonatal life.     

Acute Otitis Media in Neonatal Life: A Review

Abstract

Acute otitis media is frequently encountered by general practitioners and pediatricians. In the neonatal period acute otitis media may present as an isolated local infection or as part of septicemia. Diagnosis of the condition by otoscopy is difficult. Considering the wide spectrum of middle ear disorders (acute otitis media, otitis media with effusion, chronic suppurative otitis media) one can appreciate why opinions on the management of the condition are diverse. This is a review of the literature on clinical presentation, etiology, risk factors, treatment and prevention of acute otitis media in neonatal life.     

中耳癌的研究进展

中耳癌是发生在中耳和乳突区的少见恶性肿瘤,病理上以鳞癌最常见,恶性程度高.早期临床症状多不典型,常与慢性中耳炎的表现相似,不易早期发现,诊断主要依靠影像学检查及病理检查.近年来国际上对中耳癌的治疗策略不一,以外科手术为主的综合治疗是本病主要的治疗措施,且预后较差.     

中耳癌的研究进展

中耳癌是发生在中耳和乳突区的少见恶性肿瘤,病理上以鳞癌最常见,恶性程度高.早期临床症状多不典型,常与慢性中耳炎的表现相似,不易早期发现,诊断主要依靠影像学检查及病理检查.近年来国际上对中耳癌的治疗策略不一,以外科手术为主的综合治疗是本病主要的治疗措施,且预后较差.     

Congenital Cholesteatoma of Temporal Bone with Bezold’s Abscess: Case Report

Congenital cholesteatoma is a rare entity. It may originate at various sites in the temporal bone, for example, in the petrous apex, the cerebellopontine angle, the middle ear cavity, the mastoid process or in the external auditory canal. The least common site being the mastoid process. Most common presentation is a retrotympanic pearly white mass with no previous history of ear discharge, perforation or any ear surgery. It can lead to various complications, both intracranial and extracranial, some of which may be life threatening. Bezold’s abscess is an extracranial complication which is usually seen in children following acute otitis media with mastoiditis. Here we present a rare case of a 60 year old patient with congenital cholesteatoma complicating to Bezold’s abscess. After necessary investigations patient underwent surgery for complete removal of cholesteatoma and the abscess drainage.     

The middle ear mucosa in chronic suppurative otitis media

50 cases of chronic suppurative otitis media who under went aural polypectomy and/or tympanomastoidectomy were studied. The bacteriological study of the nasopharynx and the ear was done and com pared. No appreciable relationship between the organisms isolated from the nasopharynx and the ear under examination could be demonstrated, except in three cases. The histopa thology of the middle ear mucosa revealed stratified squamous epithelium in 26 cases. The tubercular granu loma, the lipoidal granuloma and the foreign body granuloma were found in one case each.     

Tympanosclerosis revisited

Tympanosclerosis is a common clinico-pathological entity encountered by the otosurgeon. Its pathogenesis and optimum management have eluded the otologists since time immemorial. The present study was undertaken to study the incidence of tympanosclerosis amongst patients with chronic suppurative otitis media and to study the correlation between the degree of hearing loss and the site of tympanosclerosis. Audiometric and operative findings of 200 patients of chronic suppurative otitis media were analysed. The incidence of tympanosclerosis was found to be 19% (3d cases out of 200 patients). Most cases of tympanosclerosis had a dry ear on presentation (78.9%). When tympanosclerosis was confined only to the tympanic membrane. 83.3% of the cases had an air-bone-gap less than 40 dB. On the other hand, when tympanosclerosis affected both the tympanic membrane and the middle ear. 75% of the cases had an air-bone-gap more than 40 dB. The hearing loss associated with tympanosclerosis was of the conductive type in the majority of cases. Ossicular mobility was found to be normal in 71.1% of the cases.     

Secondary fungal infections in chronic suppurative otitis media

A clinical, bacteriological and mycological study of 103 cases of ‘safe’ chronic suppurative otitis media with intractable otorrhoea was conducted to observe the role of fungi in the pathogenesis and perpetuation of the disease process. Mycotic otitis media was found in 42 cases (40.77%). 45 patients with draining ears which grew pure bacterial growth were treated with ear drops. Fifteen of these patients were treated with topical antibiotics (polymyxin, Neomycin & Gramicidin). Other 15 patients were put on antibiotic steroid (Polymxin, Neomycin and Hydrocortisone) ear drops. The remaining 15 patients acted as controls with dry mopping treatment only. It was noted that prolonged exposure to antibiotic ear drops and antibiotic-steroid ear drops led to the growth of pathogenic fungi in 5 patients (33.33%) each from two study subgroups while the third control subgroup of 15 patients grew fungi of low virulence in 3 cases (20%). It was concluded that the routine and prolonged use of topical antibiotics or antibiotics-steroids in cases of wet ‘safe’ chronic suppurative otitis media, from the onset is not justified.     

Myringosclerosis: An Indication of A Blocked Aditus

Tympanoplasty has been the mainstay of treatment in chronic otitis media. In a non cholesteatomatous chronic otitis media, there has been much debate whether a cortical mastoidectomy is required or not. Creating an aerating mastoidectomy in cases of blocked aditus ad antrum helps in reducing the recurrence. However, the status of aditus is not always known unless a mastoidectomy is performed. In this study we try to find out if there is any clinical clue regarding a blocked aditus ad antrum by looking at the tympanic membrane. Fourty-three cases of cortical mastoidectomies were retrospectively studied in this series. Patency of aditus ad antrum was analyzed with respect to presence of myringosclerosis and the status of middle ear mucosa. In this study myringosclerosis was found to be significantly associated with a blocked aditus while no such association was found with the status of middle ear mucosa. The presence of myringosclerosis may indicate a blocked aditus ad antrum and performing a cortical mastoidectomy in such cases may help in creating an aerated mastoid, thereby possibly reducing the recurrence rate.     

Aural Polyp is not Always Due to Chronic Otitis Media (COM): Preoperative Computed Tomographic Scan is Good Pointer for Sinister Lesions

Twenty five patients of aural polyp who underwent canal wall down mastoidectomy were analysed retrospectively. Histopathological examination revealed cholesteatoma in 22 (88%) patients. However, histopathological diagnosis in 3 of these patients was unusual and rare benign tumors of the middle ear cleft-meningioma, neurilemmoma and capillary hemangioma. Review of the preoperative High Resolution Computed Tomography (HRCT) temporal bone revealed an unusual picture in all of the three cases. Features noted were: widening of the jugular foramen (meningioma), destruction of the anterior wall of mesotympanum (neurilemmoma), enhancing soft tissue density lesion (capillary hemangioma). Further, there was only partial loss of pneumatisation of the mastoid air cells in all of the 3 cases. It was observed that though HRCT temporal bone is a commonly advised investigation in patients of chronic otitis media (COM) with aural polyp, meticulous interpretation may reveal unusual features pointing towards sinister diagnosis. Conclusion: Aural polyp with preservation of pneumatisation of mastoid air cells points towards diagnosis other than COM.     

Doing Mastoidectomy Along with Tympanic Membrane Repair Reduces the Need for Revision Procedures: A Prospective Study

To determine the role of cortical mastoidectomy on the results of tympanoplsty in tubotympanic type of chronic suppurative otitis media. A prospective, observational, interventional study was conducted from a period of October 2006–October 2008. This included 40 patients of either sex in the age group of 15–45 years having tubotympanic type of CSOM. Tympanoplasty with mastoidectomy was done in all the patients and they were followed up for graft acceptance and hearing impairment for 5 years to see the long term results. Per-operatively, the antrum was involved in 17, aditus in 11 and middle ear in 8 patients. Incus was necrosed in 10 cases and malleus and incus were absent in a single case. Mucoid discharge was found in the middle ear in 12 out of 40 patients. Mucoid discharge ears had antral mucosal hypertrophy in 100%, blocked aditus in 75% and middle ear mucosal hypertrophy in 58% cases; ossicular necrosis in 75% cases. 90% of the cases had graft accepted. In dry ears, graft take up rate was 89% and in ears with mucoid discharge it was 92%. Average air–bone–gap reduced to 13.90 dB as compared to average air–bone–gap (Av. AB Gap1) preoperatively of 38.62 dB. After 5 years, 83.5% patients had >10 dB improvement in hearing. We recommend opening of the mastoid if on inspection of middle ear one finds mucoid type of discharge.