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PubMedDate not supplied

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.

Cholesteatoma↗
PubMed1995

[Study on middle ear ventilation using positional tympanometry--post mastoidectomy ear].

The middle ear is a cavity surrounded by solid bone, lined with mucosa with a lumen filled with gas. To examine this unique ventilation system under atmospheric pressure, the middle ear pressure of 50 normal ears was previously examined. Positional tympanometry, whereby the middle ear pressure is increased as the subject assumes the lateral position under atmospheric pressure was used. As a result, (1) The middle ear pressure was elevated by the change from the sitting position to the lateral position. Venous pressure was regarded as causative factor of this pressure elevation. (2) The elevation of the middle ear pressure in the lateral position suggested gas production from the mastoid cells of the middle ear. In this study, a proportion of the mastoid cells were removed to resect a tumor of the internal acoustic meatus in conjunction with resection of an acoustic tumor. After resection the area was filled with fascia and fatty tissue. The middle ear pressure of each subject was monitored to determine the effect of a decrease in the mastoid cell volume on middle ear pressure. The results were continuously recorded every 12 seconds for the lower ear when the subjects were in the lateral position. The following results were obtained. (1) The elevation of the middle ear pressure due to positional change among subjects which had had acoustic tumors resected was noticeably greater than the elevation in normal ears. This is thought to have been the result of an elevation in cerebrospinal fluid pressure attributable to positional change, along with an elevation in intravenous pressure. (2) We made comparisons of increases in middle ear pressure 10 minutes after assuming the lateral position in 14 ears after acoustic tumor resection and in 21 normal ears. No noticeable differences were found in the middle ear pressure increases between the two groups despite the fact that the volume of the mastoid cells in the group that had tumors resected had been greatly reduced.

Acoustic Impedance Tests↗
PubMed2001

[Primary restoration for congenital malformation of external and middle ear].

OBJECTIVE: To promote the hearing, improve the appearance, shorten the therapeutic course in congenital malformation of external and middle ear, the program of primary restoration has been designed. METHOD: Under general or local anaesthesia a Z-shaped incision is made in skin. After turn up the flap A (defective ear) and flap B(retroauricular skin), a periosteal flap C with pedicle in front is made and elevated from mastoid. Then made frameworklize on mastoid and perform tympanoplasty. Once the myringograft is put properly the flap C is turn into the mastoidal cavity to serve as the lining of anterior wall. Flap A is sutured with the edge of retroauricular incision to serve as the lower part of new auricle. Then use the flap B to wrap a siliceous frame to make the upper part of new auricle. Finally, the naked walls of mastoidal cavity are lined with free skin graft and the cavity is packed with vaseline gauze for two weeks. RESULT: Two cases of congenital malformation of external and middle ear were treated with the procedure mentioned above and were followed up for one and 3 years respectively. Both effects of shape and hearing were good. CONCLUSION: The primary restoration for congenital malformation of external and middle ear designed by the authors is an excellent method worthy to be recommended.

Adolescent↗
PubMed2006

Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia.

Important structures involved in the pathogenesis of occipital headache include the aponeurotic attachments of the trapezius and semispinalis capitis muscles to the occipital bone. The greater occipital nerve (GON) can become entrapped as it passes through these aponeuroses, causing symptoms of occipital neuralgia. The aim of this study was to identify topographic landmarks for accurate identification of GON, which might facilitate its anaesthetic blockade. The course and distribution of GON and its relation to the aponeuroses of the trapezius and semispinalis capitis were examined in 100 formalin-fixed adult cadavers. In addition, the relative position of the nerve on a horizontal line between the external occipital protuberance and the mastoid process, as well as between the mastoid processes was measured. The greater occipital nerve was found bilaterally in all specimens. It was located at a mean distance of 3.8 cm (range 1.5-7.5 cm) lateral to a vertical line through the external occipital protuberance and the spinous processes of the cervical vertebrae 2-7. It was also located approximately 41% of the distance along the intermastoid line (medial to a mastoid process) and 22% of the distance between the external occipital protuberance and the mastoid process. The location of GON for anaesthesia or any other neurosurgical procedure has been established as one thumb's breadth lateral to the external occipital protuberance (2 cm laterally) and approximately at the base of the thumb nail (2 cm inferior). This is the first study proposing the use of landmarks in relation to anthropometric measurements. On the basis of these observations we propose a target zone for local anaesthetic injection that is based on easily identifiable landmarks and suggest that injection at this target point could be of benefit in the relief of occipital neuralgia.

Aged↗
PubMed1989

[The "normal" pneumatization of the temporal bone].

Radiographs of the mastoids and the petrous pyramids of ear-healthy adults were investigated to ascertain the normal appearance of the temporal bone pneumatisation. The radiographs included those of patients with skull trauma, provided that these subjects had had no signs or symptoms of middle ear disease or hearing loss before the trauma. The extent of pneumatisation of the mastoid and petrous pyramid ranged from small cell groups around the mastoid antrum to extensive cell formations in the squamous temporal bone, in the apex of the petrous pyramid and in the retrosinus area. The planimetric measurements did not correspond to a normal distribution. It was also striking that ears could be found among these healthy individuals with irregular, asymmetric or indistinct pneumatisation, probably as a residual of sub-clinical middle ear disorders during the development of the cell system. After eliminating these irregular findings the ears with exclusively regular, symmetric and clear cell pictures also did not follow a normal distribution. Rather, they resulted in a typical curve with a steep ascent rising from a functionally-necessary minimum of about 4 cm2 to mean values of 8-12 cm2, and then a wide distribution reaching a value of 26 cm2. All these can be taken as genetically-determined "normal variants". The irregular cell-formations were seen mainly in the smaller pneumatised mastoids, so that it can be concluded that exogenous influences have at some time disturbed the pneumatisation process.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Treatment of cholesteatoma.

Clinicians view cholesteatoma as a middle ear condition in which stratified squamous epithelium produces non-self-cleansing amounts of keratin. This clinical definition includes retraction pockets as well as big, deep-seated epidermoids. The two may have different origins, and they often require different therapeutic approaches. Clearance and control of shallow retraction pockets may be achieved with suction cleaning. Larger or longstanding retraction pockets, if not too deep, may be excised, and the tympanic membrane grafted. Deep-seated cholesteatomas require more elaborate surgery, whether they involve advanced retraction pockets or big and deep-seated middle ear epidermoids. The intact wall technique, though elegant, has about a 50% failure rate, regardless of the surgeon's skill. The failures are due to either retraction pocket formation, with or without posterior wall atrophy or the reappearance of epidermoids (so-called residual disease). Reconstruction of the bony defect in the scutum does not prevent retraction pocket formation. It is obvious that an approach that envisages successful removal of the matrix as curing the disease is too simplified. The intact wall operation should be reserved for ears with extensive mastoid pneumatization and small cholesteatomas. Most ears with cholesteatoma (85%) are, however, poorly pneumatized and they fare best with a small radical conservative (modified) mastoidectomy. The procedure should aim at creating the smallest mastoid cavity possible. Small mastoid cavities, possessing a tympanic membrane, an adequate mastoplasty, and no recess behind the facial ridge, will be found to be dry in about 90% of cases. A technique for achieving a minimal mastoid cavity is described.

Cholesteatoma↗
PubMed1996

Surface and superficial surgical anatomy of the posterolateral cranial base: significance for surgical planning and approach.

We have performed an anatomic study, 15 using fixed cadaveric preparations, with the goal of identifying surface landmarks that will reliably locate the underlying transverse and sigmoid sinus complex. Simple morphometric relationships were first determined on both sides of each specimen to yield 30 sides measured. The following relationships were determined: 1) zygoma root-asterion, 2) asterion-mastoid tip, 3) zygoma root-suprameatal spine (Henle's spine), 4) asterion-suprameatal spine, 5) mastoid tip-suprameatal spine. The relationship of the asterion to the transverse-sigmoid junction was determined by bone removal. Also, the distances from the asterion to the sigmoid sinus-superior petrosal sinus junction and the superior margin of the transverse sinus were studied. Surface and marks were found to have definitive relationships to underlying anatomic substrates in all specimens studied. The critical relationships that were concluded from this study can be described in terms of two easily identified lines between bony surface structures. A line drawn from the zygoma root to the inion, i.e., the superior nuchal line, reliably located the rostrocaudal level of the transverse sinus in all specimens. Although the asterion did not consistently fall on this line, the transverse-sigmoid junction could reliably be placed at the anteroposterior level of the asterion. Further, a line drawn from the squamosal-parietomastoid suture junction to the mastoid tip reliably defined the axis of the sigmoid sinus through the mastoid. We also found that the junction of the squamosal and parietomastoid sutures lay over the anterior border of the upper curve of the sigmoid sinus. The anterior portion of the supramastoid crest correlated with the level of the middle fossa. These surface relationships all have significance for posterolateral approaches to the cranial base. Since performing this study, these relationships have been found reliable for operative planning in our clinical cases.

Cephalometry↗
PubMed1997

Long-term results of glass ionomer cement, Ionocem, in the middle ear of the rat.

Long-term results of glass ionomer cement, Ionocem, in the middle ear of the rat. An ionomeric cement (Ionocem), a new bone replacement material, was used for obliteration material of the mastoid cavity in the rat. Iononcem is biocompatible, biostable and in most of the cases well tolerated by bone and soft tissues. The bone cement was implanted in the left mastoid cavity of 17 rats. After periods of 3 and 12 months, 6 animals from each time interval were sacrificed and the mastoids were studied and compared with the unimplanted right ears. Five animals died of a middle ear infection. In the middle ears of the rats sacrificed after 3 months no abnormalities were observed but after 12 months in all implanted ears a granular tissue reaction around the glass ionomer cement was found. In some of these cases the cochlea was destroyed as well. The results of this animal experiment indicate that glass ionomer cement is not the material of first choice for obliterating the mastoid cavity.

Animals↗
PubMed2002

A staging system for congenital cholesteatoma.

OBJECTIVE: To develop a staging system for congenital cholesteatoma in predicting the likelihood of residual disease. DESIGN: Retrospective analysis of data from a case series, to identify predictors of residual disease. SETTING: Tertiary care pediatric hospital. PARTICIPANTS: Children undergoing surgical removal of congenital cholesteatoma. There were 156 patients, with 160 cholesteatomas; 4 children had bilateral disease. INTERVENTIONS: Each case was scored as to quadrants of the middle ear involved, ossicular involvement, and mastoid extension. MAIN OUTCOME MEASURE: Surgically confirmed residual disease at any time after the initial procedure. RESULTS: Four stages were defined as follows: stage I, disease confined to a single quadrant; stage II, cholesteatoma in multiple quadrants, but without ossicular involvement or mastoid extension; stage III, ossicular involvement without mastoid extension; and stage IV, mastoid disease. There was a strong association between stage and residual disease, ranging from a 13% risk in stage I to 67% in stage IV. CONCLUSIONS: This simple staging system may be particularly useful in standardizing the reporting of congenital cholesteatoma and in adjusting for severity in evaluating outcomes. It also provides information that is useful in counseling parents.

Child↗
PubMed1995

Delayed diagnosis and fate of congenital cholesteatoma (keratoma).

OBJECTIVE: To analyze clinical presentation, modes of detection, growth pattern, operative findings, and results of surgery in children 3 years old or older who had extensive congenital cholesteatoma (keratoma). DESIGN: Survey, case series. SETTING: Two academically affiliated medical centers: a children's hospital and an eye, ear, and throat hospital, both located in major metropolitan cities. PATIENTS: Twenty-five children selected according to specified criteria. INTERVENTION: Tympanomastoid surgery, ie, canal wall up and canal wall down, some with ossicular reconstructive surgery. MAIN OUTCOME MEASURE: Audiologic assessment (speech reception threshold) and recurrence (recidivism) of cholesteatoma. RESULTS: Incidence of recidivism, 52%. Hearing maintained within the range of normal to mild hearing impairment postoperatively in 91% of the patients for whom complete data are available. CONCLUSIONS: Congenital cholesteatoma may grow for years without causing signs or symptoms and, having grown without early detection, can extend to involve the epitympanum and mastoid antrum, cause ossicular erosion, and even extend to the middle cranial fossa. To adequately remove a congenital cholesteatoma that has gone undetected for many years, exposure of the anterior epitympanum is often necessary and removal of both the body of the incus and the head of the malleus often is required. Since congenital cholesteatoma usually develops in a child with a well-pneumatized mastoid that would create a large mastoid bowl if exteriorized, the otologic surgeon is likely to hesitate in using the canal wall down mastoidectomy technique. Alternatives to the canal wall down mastoidectomy technique, which can achieve reasonably good hearing results and avoid creation of a large mastoid bowl, include planned two-stage canal wall up surgery or canal preservation with primary reconstruction and close follow-up with otomicroscopy and serial computed tomographic scans.

Adolescent↗
PubMed2000

Antibiotics for acute otitis media in children.

BACKGROUND: Acute otitis media is one of the most common diseases in early infancy and childhood. Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for children with acute otitis media. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE, Index Medicus, Current Contents and reference lists of articles from 1958 to January 1999. SELECTION CRITERIA: Randomised trials comparing antimicrobial drugs with placebo in children with acute otitis media. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Nine trials were eligible but only six trials, with a total of 1,962 children, included patient-relevant outcomes. The methodological quality of the included trials was generally high. All trials were from developed countries. The trials showed no reduction in pain at 24 hours, but a 34% relative reduction (95% confidence interval 16% to 48%) in pain at two to seven days. Since approximately 85% of patients will have settled spontaneously in this time, this means an absolute reduction of about 5% or that about 20 children must be treated with antibiotics to prevent one child having some pain after two days. There was no effect of antibiotics on deafness, as measured by subsequent tympanometry, other complications, or recurrence. However, audiometry was done in only two studies and incompletely reported, and there were few serious complications seen in these trials: only one case of mastoiditis occurred (in a penicillin treated group). One semi-randomised trial in Sweden in 1954 reported a rate of 17% in the untreated group versus none in the penicillin treated groups. REVIEWER'S CONCLUSIONS: Antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions. Antibiotic treatment may play an important role in reducing the risk of mastoiditis in populations where it is more common.

Acute Disease↗
PubMed1995

Cerebrospinal fluid leak after acoustic neuroma surgery.

BACKGROUND: CSF rhinorrhea is a common complication of acoustic neuroma surgery. METHODS: Twenty cases of persistent cerebrospinal fluid rhinorrhea, 2 of transient leaks, and 2 of late meningitis occurring in a series of 156 posterior fossa acoustic neuroma removals were studied. Prophylaxis of leaks was usually attempted by filling opened air cells in the drilled internal auditory canal (IAC) with bone wax. Communications were repaired by rewaxing the IAC, or by fat packing of either the mastoid or the eustachian tube, middle ear, and mastoid. RESULTS: Most leaks were diagnosed within 1 week of surgery, although 1 occurred 4 years postoperatively. Those seen later were usually recurrences of a previously repaired leak or cases of meningitis. Leaks were more common later in the series when a more lateral unroofing of the IAC was used. The communication usually occurred through air cells opened while unroofing the canal, but two were via the vestibule and oval window. Treatment failed in 38% of cases in which canal rewaxing was used. There were no failures when the communication was sealed by fat obliteration of the eustachian tube, middle ear, and mastoid. CONCLUSIONS: Leaks are more common with a more lateral unroofing of the IAC. A leak may occur into the middle ear via the oval window. Optimal treatment is packing of the middle ear and mastoid with fat.

Cerebrospinal Fluid Rhinorrhea↗
PubMed1985

Further investigation of visual evoked potentials elicited by lateralized stimuli: effects of stimulus eccentricity and reference site.

Visual evoked potentials (VEPs) to small lateralized flashes were recorded from the parietal midline, homotopic lateral central and occipital electrodes, and from left and right mastoid processes, all referred to a balanced non-cephalic reference. Two stimulus eccentricities, 4 degrees and 10 degrees, were employed, and a comparison made between the non-cephalic and linked mastoid references. P120 (measured at lateral occipital sites only) peaked earlier and was of smaller amplitude at the electrode contralateral to the visual field of stimulus exposure. N160 peaked earlier at central than occipital sites, was larger from electrodes over the contralateral hemisphere, and at the occipital sites only, peaked earlier in the electrode contralateral to the visual field of stimulus exposure. These effects were virtually unaffected by the eccentricity manipulation and it is concluded that light scatter across the visual midline is unlikely to be responsible for the observed pattern of ipsilateral-contralateral VEP asymmetries. The mastoids were found to detect significant stimulus-locked activity in the same latency range as the occipital N160 component. However, comparison of the non-cephalic and linked mastoid references revealed only non-specific effects, and no sign of any change in the pattern of ipsilateral-contralateral VEP asymmetries, or the magnitude of the associated latency differences. It is concluded that these effects may be of value in the study of callosal transfer.

Adult↗
PubMed1991

Development of auditory brainstem evoked potentials in newborn infants: a three-channel Lissajous' trajectory study.

Auditory brainstem evoked potentials (ABEP) were recorded from 50 newborns (35-43 weeks gestational age), using three orthogonal differential electrode pairs, in addition to the widely used vertex-mastoid derivation. Potentials were evoked by alternating polarity, 75 dBnHL clicks presented monaurally at a rate of 10/s. From the records of the three orthogonal electrode pairs (nasion-inion; vertex-spinous cervical process VII; left-right mastoids), Three-channel Lissajous' trajectories (3CLT) were derived and analyzed. 3CLT point-by-point, as well as segmental descriptors were compared with peak latencies of the vertex-mastoid derivation. Point-by-point 3CLT descriptors included apex amplitude, latency and orientation. Segmental descriptors included planar segment beginning latencies, duration and orientation. The interpretation of these results in relation to developmental aspects of the auditory system, as well as to the question of ABEP generators, is enhanced by using 3CLT descriptors of ABEP, which are more comprehensive than their single-channel counterparts. 3CLT apices correlated well with the Vertex-Mastoid defined peaks. Both peak and apex latency changes indicate that at the developmental stages surveyed in this study, development takes place in the more central portions of the pathway, whereas the peripheral portion is already relatively mature. The results also indicate a maturational change in the relative contributions of constituent generators of ABEP components.

Brain Stem↗
PubMed1990

Histological examination of the temporal bone in medicolegal cases of asphyxia.

Histological findings of the temporal bone in 23 autopsy cases of various asphyxial fatalities were studied. The temporal bones of 12 cases who died of tumors including mammary cancer, gastric cancer, myxoma of heart and craniopharyngioma, the bones of 3 cases of heart attack and the bones of 17 cases who died of various poisoning (barbiturate, amphetamine, paraquat and alcohol) were used as controls. In drowning, the primary finding was hemorrhage in the mastoid air cells of the bilateral temporal bones. In cases of strangulation by ligature, hemorrhage and edema of the cochlear duct in the inner ear as well as hemorrhage in the mastoid air cells were demonstrated bilaterally. In contrast, congestion and edema in the mastoid air cells and inner ear were found in cases of manual strangulation but there was no hemorrhage. From these results, the histological examination of the temporal bone is useful as an adjunct procedure for diagnosing the cause of asphyxia. Differentiation between drowning, strangulation by ligature and manual strangulation may be possible by observing hemorrhages or their absence in the mastoid air cells and inner ear.

Adolescent↗
PubMed2003

Anthropometric growth study of normal human auricle.

OBJECTIVE: The aim of this study was to reveal the anthropometric growth of auricula from birth to the age of 18 years and to bring out the dynamics of ear growth. MATERIAL AND METHODS: A total of 1552 children in 50 groups were evaluated. Six surface measurements were performed directly on the right auricle of the subjects: the length from the superaurale to subaurale, the width from the tragus to helix, the width from the tragus to antihelix, the conchal depth, the height from the helix to mastoid at superauraler level, and the height from the helix to mastoid at tragal level. The frequency of prominent ear deformity and the degree of attachment of the lobule were also noted. RESULTS: Vertical auricular growth was complete in girls at the age of 11 and in boys at the age of 12, whereas the auricular width from the tragus to helix, the height from the helix to mastoid at superauraler level and the height from the helix to mastoid at tragal level were found almost complete at the age of 6. The auricular width from the tragus to antihelix attained its full size at 6 months for girls and 12 months for boys. The conchal depth was found almost complete at the age of 5 in both sexes. The incidence of prominent ear deformity and attached lobule was 9.8 and 26.5%, respectively. CONCLUSIONS: Different ear growth pattern and maturation size from previously published reports are obtained in different populations. There is still need for future studies comparing populations with different social and ethnic background to interpret common knowledge about the size of the ear. This study gives dimensional information and the growth pattern of the auricle, and therefore may reveal important implications for the adequate timing of the surgical treatment of auricular deformity.

Adolescent↗
PubMed2001

A unique area of the homonculus: the topography of the primary somatosensory cortex in humans following posterior scalp and shoulder stimulation.

We recorded somatosensory evoked magnetic field (SEF) to investigate the differentiation in the receptive area for the face, lower part of the posterior scalp (mastoid) and shoulder, which occupy an unique area in the homunculus. We analyzed the location of the equivalent current dipole (ECD) of SEF following electrical stimulation of the skin at the face, mastoid and shoulder in 20 normal subjects. Three deflections (1M, 2M and 3M) were obtained within 50 ms of the stimulation in 16 of 20 subjects. The peak latency of the 1M and 2M was not significantly different at any stimulus sites. The amplitude of the 1M was significantly larger following the face than mastoid stimulation (p<0.05). The 16 subjects were classified according to the locations of the ECD on stimulation of the mastoid: close to that for shoulder stimulation, but significantly (p<0.05) more superior and medial to that following the face stimulation (Type 1, eleven subjects); close to that for face stimulation, but significantly (P<0.05) more inferior and lateral to that following the shoulder stimulation (Type 2, five subjects). The site of the receptive area for the posterior scalp shows interindividual variation, possibly due to anatomical differences.

Adult↗
PubMed2003

Micro macroporous biphasic ceramics and fibrin sealant as a moldable material for bone reconstruction in chronic otitis media surgery. A 15 years experience.

Bone reconstruction is still a matter of concern in middle ear surgery despite the large number of surgical techniques proposed. Combination of biphasic calcium phosphate bioceramics with human fibrin sealant forms a moldable material easy to apply for bone reconstruction. Since 1986, we have been using this composite for reconstruction of mastoid cavities during chronic otitis media surgery. Granules of ceramic provide immediate mechanical stability and later on, promote osseoinduction when fibrin sealant forms a strong bond between granules enhancing the wound healing process. After checking feasibility, efficacy and tolerance through a controlled study on dogs by filling mastoid cavities, we started a clinical series comprising yet 66 mastoid reconstructions. A retrospective data analysis on 63 patients with an average follow up of 42 months including 12 histological controls confirms the stability of bone reconstruction with a remarkable tolerance of the skin in contact. Biopsies confirmed progressive replacement of material by lamellar newly formed bone. Mastoid cavities have a randomed shape making complex bone reconstruction procedure and their filling by the composite constitutes an easy way and represents a highly satisfactory procedure. The authors considered that this should be explored in other indications of bone surgery.

Journal Article↗

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