The modified radical mastoidectomy.
The historical evoluation of mastoid surgery is described. The indications, technique, and postoperative management of modified radical mastoidectomy are discussed and clinical illustrations are presented.
Adult↗
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Acute gram-negative bacillary infections of middle ear and mastoid.
Thirty-three patients with acute purulent otitis media and mastoiditis caused by Gram-negative bacilli are presented. The main features of the disease include: predilection for young male infants, a high rate of complications that include sepsis, mastoiditis and osteomyelitis of the base of the skull. Patients that are diagnosed early respond well to drainage and ventilation of the infected middle ear combined with in vitro effective antibacterial therapy. Patients that receive prior inappropriate antibacterial therapy tend to have prolonged courses and require mastoid surgery. It is suggested that early myringotomy and bacterial cultures be performed in all patients with acute middle ear infections.
Acute Disease↗
Metastatic atrial myxoma to the temporal bone: case report.
A 25-year-old male underwent right mastoid surgery for removal of a soft tissue mass. At age 29 a left cardiac atrial myxoma was excised. At age 34 an expanding right supra-auricular mass with extension into the middle and posterior fossa necessitated total temporal bone resection. Pathology proved to be myxoma. Retrospective review of tissue obtained from the initial mastoid procedure was also myxoma. The temporal bone lesion was considered to be persistent and metastatic atrial myxoma. A review of atrial myxomas and this most unusual metastatic presentation is discussed.
Adult↗
Bilateral temporal bone encephaloceles after cranial irradiation. Case report.
Irradiation of the central nervous system may cause significant morbidity, including endocrine dysfunction and intellectual impairment. The authors report a case of bilateral temporal bone encephaloceles in a 21-year-old man who had received prophylactic central nervous system irradiation for acute lymphocytic leukemia in early childhood. Endaural encephaloceles are uncommon, and most occur as a complication of mastoid surgery. The etiology, clinical features, radiological diagnosis, and surgical treatment of temporal bone encephaloceles are discussed.
Adult↗
Acute mastoiditis in pediatric age.
The object of the present paper is to review 39 cases of acute mastoiditis treated surgically at the 2nd and 4th ENT Clinics of the University of Rome 'La Sapienza'. The aetiological factors were investigated observing an association of the acute mastoid abscess with cholesteatoma. Moreover 5 patients developed mastoiditis after previous mastoid surgery. The rationale of surgical management is discussed.
Abscess↗
Typing of Pseudomonas aeruginosa ear infections related to outcome of treatment.
Of 142 patients with Pseudomonas aeruginosa (PSA) ear infections, 88 (62 per cent) had chronic otitis media and 54 (38 per cent) external otitis. Following serotyping and pyocin typing of their bacteria, and relating the type to outcome, patients could be divided into three groups: (1) 120 patients who had no recurrence with isolation of only one PSA strain, (2) 13 patients who had recurrent infections and in whom the same PSA strain was isolated in repeated cultures, and (3) nine patients who had recurrent disease, but who had a change in their PSA strains. Most of the PSA strains isolated from patients in groups (1) and (2) were stable to pyocin, and resistent to gentamicin. Patients in the first group were all cured initially by medical management. Of the nine patients in group (3) who had a different serotype on repeated cultures, medical treatment was successful in eight (89 per cent), but of the 13 patients in group (2) who had the same Pseudomonas aeruginosa serotype cultured, medical therapy failed in six (46 per cent) and mastoid surgery was required. Serotyping of Pseudomonas aeruginosa otitis may be helpful in predicting the type of management in patients who have recurrent infections.
Adolescent↗
Chronic suppurative otitis media: complicated versus uncomplicated disease.
To determine prognostic factors in patients with chronic otitis media who develop suppurative complications, we performed a retrospective study of all patients with chronic suppurative otitis media who underwent mastoid surgery between the years 1981 and 1989. Patients who developed complications were compared with those who did not with respect to six prognostic variables. The results indicated that patients with complications were younger (p less than 0.001), had shorter duration of ear discharge (p less than 0.001), were more likely to have pars tensa perforations (p less than 0.05), and had a higher degree of mastoid sclerosis in the operated and contralateral ears (p less than 0.001). The presence of cholesteatoma and the sex of the patient were of no prognostic value. Bacteriology of CSF and pus specimens from patients who developed intracranial complications mostly revealed mixed flora (62.9%). Proteus species was the most frequent isolate (34%) and anaerobes were present in 21.3% of specimens. Mastoid abscess occurred in more than half the patients in the complicated group. Brain abscess (57.4%) was the most frequent intracranial complication. On the basis of our findings we recommend that risk factors in patients with chronic suppurative otitis media be identified early to enable effective measures to be taken to eradicate the disease.
Adolescent↗
Fate of patients with bilateral cholesteatoma.
INTRODUCTION: This study was designed to assess the clinical and surgical findings and long-term results of therapy in patients treated for bilateral chronic cholesteatomatous otitis media. PATIENTS AND METHODS: A series of 54 patients who underwent mastoid surgery for bilateral acquired cholesteatoma were followed regularly for a mean of 7.9 years (range 2 to 21 years). Results of treatment were compared with the results obtained in 349 patients treated for unilateral acquired cholesteatoma with a mean follow-up of 6.7 years. Hearing level was defined as the mean air conduction threshold at frequencies of 0.5, 1, and 2 kHz. Audiograms obtained the day before operation and at last follow-up examination were used for comparison. Results were analyzed using the t test and chi 2 test. RESULTS: Patients with bilateral cholesteatoma were more likely to be men (60% v 61%) and young (28 years v 38 years). A majority of patients underwent canal wall down mastoidectomy. Seventy-three percent of patients had ossicular erosion. During follow-up, residual recurrent cholesteatoma was found in 8 ears (7.4%). This compared with a recurrence rate of 8.3% in patients with unilateral cholesteatoma. The mean postoperative air conduction threshold (46.1 dB) was similar to patients with unilateral cholesteatoma (46.6 dB). At last follow-up, 43% of patients with bilateral cholesteatoma had a hearing level of 30 dB or better in their best ear. No patient had bilateral anacusis. DISCUSSION: Cholesteatoma is a burdensome disease. Our 54 patients with bilateral cholesteatoma underwent a total of 125 surgical procedures. Acquired cholesteatoma has a great tendency to recur. Fortunately, this study shows that recurrence is not higher in a group of patients with bilateral cholesteatoma when compared with the unilateral group. Unfortunately, the fate of hearing in patients with bilateral cholesteatoma is not so favorable. Only 19% had hearing levels of 30 dB or better in both ears. Hearing levels of less than 40 dB in one ear was present in 34% of patients. Fortunately, there was no case with severe sensorineural hearing loss as a complication of surgery in the present series. This reflects great efforts directed at reduction of infection preoperatively, avoidance of ossicular manipulation, and preservation of cholesteatoma matrix over fistula when encountered.
Adolescent↗
Reduced mastoidectomy complications with an open meatoplasty stent.
Open-tube stents were compared with standard petroleum gauze packs in meatoplasties after canal-wall-down mastoid surgery to determine whether any difference existed in postoperative complications. Tube stents were associated with much lower incidences of postoperative meatoplasty stenosis and postauricular wound complications in this series.
Adolescent↗
[More than 10 years of revision-cleaning and revision-reconstructive ear surgery in chronic otitis media; good long-term results].
OBJECTIVE: To describe the long-term results of revision surgery in patients with chronic otitis media. SETTING: University Hospital, Utrecht, the Netherlands. METHODS: A personal series of 323 revision mastoidectomies and (or) revision tympanoplasties was evaluated. Surgery was performed between 1981-1995 with a follow-up of one (minimal) to 14 years (maximal). Anatomical and functional results of various subgroups were compared. RESULTS: A preoperative incidence of cholesteatoma of 34% (n = 99) dropped after revision surgery to 11% residual/recurrent cholesteatomas (n = 9). A dry, safe and disease-free ear with a closed tympanic membrane was obtained in nearly 90% of the cases. However, in 5% (n = 10) without pre-existent cholesteatoma (n = 199), a cholesteatoma developed de novo after revision surgery. A residual air-bone hearing gap < or = 30 dB resulted in 79% of the patients after revision tympanoplasty only (n = 27). Revision mastoidectomy with revision tympanoplasty in open (n = 91) and closed (n = 92) procedures lead to a residual air-bone gap < or = 30 dB in 56% of the open cases (n = 91) and in 73% of the closed cases (before the operation the figures were 37% and 55% respectively). CONCLUSION: Revision mastoid surgery and (or) revision tympanoplasty can be quite rewarding and successful.
Adolescent↗
Chronic tympanomastoiditis with formation of calculi.
Numerous calculi of varying sizes and shapes were discovered in the mastoid, antrum, and attic during mastoid surgery for persistent chronic suppurative inflammation of the middle ear cleft with retroauricular and external meatal fistulas in an 8-year-old boy. Light microscopic and scanning electron microscopic examinations and x-ray microanalysis revealed the calculi to consist of masses of crystals containing calcium-oxalate and calcium- and magnesium-phosphate. No signs of tuberculosis were found. Since the patient had multiple dysplasias, including ipsilateral macrotia, in addition to chronic otitis media and mastoiditis, it is suggested that the formation of the calculi may have been due to congenital predisposition.
Calcinosis↗
Routine identification of the facial nerve using electrical stimulation during otological and neurotological surgery.
We routinely identify the facial nerve to avoid facial nerve injury during most otologic surgery. Since 1985, we have used a facial nerve stimulator/monitor as an added safety feature in 383 consecutive otologic and neurotologic cases. In our last 30 middle-ear, 8 retrolabyrinthine vestibular neurectomy, and 14 acoustic neuroma cases we used the monopolar stimulator probe-tip to determine threshold currents needed to produce facial twitch. Stimulation thresholds varied according to the amount of soft tissue or bone overlying the facial nerve. The stimulator was useful for predicting dehiscences in the bony facial canal during middle-ear and mastoid surgery. The exposed facial nerve usually stimulated at a level less than 0.1 mA (mean 0.05 mA), and the horizontal facial nerve covered by bone stimulated at 0.25 mA or greater (mean 0.6 mA). The stimulator was also used to predict the amount of bone overlying the vertical facial nerve at the annulus. An approximate relationship of 1.0 mA of threshold current to 1.0 mm of bony covering was found. After acoustic neuroma surgery, the stimulation threshold of the facial nerve at the brain stem helped predict postoperative facial function. Cases with current thresholds of 0.3 mA or less resulted in normal facial function. During ear surgery, routine identification of the facial nerve with the aid of a facial nerve stimulator will help avoid facial nerve injury.
Ear↗
Deafness and cholesteatoma complicating fracture of the mandibular condyle.
A case of posterior fracture-dislocation of the mandibular condyle which resulted in conductive deafness and cholesteatoma is presented. Initial management by condylectomy improved auditory canal patency but failed to prevent the development of cholesteatoma, necessitating mastoid surgery. Although major complications following fractures of the condyle are not common the need to consider the possibility of damage to the ear in such fractures is emphasised.
Adult↗
Squamous cell carcinoma of the middle ear. A 25-year retrospective study.
Squamous cell carcinomas of the middle ear cleft are highly unpleasant tumors which pose many problems for the otologist. We have retrospectively reviewed the hospital notes of 21 patients (22 ears) who presented with this disease in order to try to clarify those features which are of prognostic significance. We confirmed that a history of chronic suppuration with or without cholesteatoma predisposes the patient to tumor development and that, in the presence of continuing otorrhea, patients are not protected by mastoid surgery. These patients have been treated with conservative surgery and radiotherapy without en bloc resection of the temporal bone and, in these circumstances, the histological grade of the tumor at presentation appears to bear a direct relationship to survival.
Adult↗
Sigmoid sinus involvement in middle-ear infection.
It was thought that sigmoid sinus involvement from middle-ear infection would become a rare clinical entity with the introduction of antibiotics. However, this problem is still prevalent. Twelve hundred eighty cases of mastoid surgery were performed at Ghaem Medical Center and the author's private clinic between January 1978 and December 1985 in Mashad, Iran. In sixteen cases, surgically proven sigmoid sinus involvement was due to a bone eroding process of chronic ear infection. The pattern of the clinical picture is different than in the preantibiotic era.
Adolescent↗
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).
Cholesteatoma↗
Effect of otologic drill noise on ABR thresholds in a guinea pig model.
The noise generated by the otologic drill has been implicated as a cause of sensorineural hearing loss after ear surgery. However, clinical studies on this subject are contradictory and difficult to interpret. Therefore a guinea pig model was used to study whether the level of noise generated by the otologic drill can cause threshold shifts in the auditory brainstem response (ABR). The source noise was a recording obtained during a human cadaver mastoidectomy using a microphone and an accelerometer. Ten female Topeka-strain guinea pigs were exposed to the recorded drill noise for a period of 55 minutes. Exposure included both air-conducted energy from a speaker and bone-conducted energy from a bone vibrator applied directly to the skull. ABR threshold measurements were taken pre-exposure (baseline), immediately after exposure, and at weekly intervals thereafter for 3 weeks. Three control animals were subjected to the same procedure without the sound exposure. A significant threshold shift (p < 0.0001) was seen for each frequency tested (2, 4, 8, 16, 20, and 32 kHz) immediately after exposure to noise in all experimental animals. Thresholds returned to baseline within 3 weeks. We conclude that the level of noise generated by the otologic drill in mastoid surgery can cause a temporary threshold shift in this guinea pig model.
Analysis of Variance↗
Analysis of mastoid findings at surgery to treat middle ear cholesteatoma.
OBJECTIVES: To analyze mastoid findings, such as facial nerve dehiscence (FND), labyrinthine fistula, and dural exposure; to review its incidence at cholesteatoma surgery; to analyze its association with semicircular canal fistula; and to elucidate its relationship with dural exposure. DESIGN: One hundred fifty-two patients (65 males and 87 females; 155 ears) were enrolled in a retrospective study of tympanoplasty with or without mastoidectomy. SETTING: Medical university center hospital. RESULTS: The incidence of FND after exenteration of disease was 29.7% (46/155 ears) for total surgical procedures, 29.7% (43/145 ears) for initial procedures, and 30% (3/10 ears) for revision procedures. The prevalence of FND in the tympanic segment only was 87%, with 8.7% in the vertical segment only and 4.3% in both segments. Three patients (2.0%) developed facial palsy postoperatively, with 8 lateral semicircular canal fistulas (5.2% of total ears operated on), half of these with concomitant FND. The incidence of dural exposure of the mastoid tegmen in the entire surgical group was 16.8% (26 ears), 38.5% with concomitant FND. CONCLUSIONS: The overall incidence of FND in our sample was high at 29.7%, with rates of lateral semicircular canal fistula and dural exposure of 5.2% and 16.8%, respectively. The relationship between FND incidence and presence of lateral semicircular canal fistula was positive in our study. The surgeon should bear in mind that the location of FND with cholesteatoma coincides with the most common area of iatrogenic facial nerve injury during otologic surgery.
Adolescent↗