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The authors report on a series of 25 patients who, in the process of undergoing tympanoplasty, were noted to have erosion of the long process of the incus. This was repaired with bone pâté in an attempt to restore ossicular continuity. The methods and results are presented and the prospects for the future are discussed.
To obtain the best possible results of treatment of acquired cholesteatoma, we made a subdivision of cholesteatoma types into attic and pars tensa cholesteatomas, and subdivided the latter further into tensa retraction cholesteatoma and sinus cholesteatomas. Tensa retraction cholesteatoma is defined as arising from a retraction or perforation of the whole pars tensa, whereas sinus cholesteatoma is defined as arising from a retraction or perforation of the postero-superior part of the tensa. We present the long-term results obtained in tensa retraction cholesteatomas treated with one stage surgery from 1964 to 1980. Median observation time was 9 years, range 2 to 19 years. Sixty-one ears were treated without mastoidectomy, whereas 71 ears had canal wall-up mastoidectomy and 64 ears had canal wall-down mastoidectomy. The total recurrence rate was 13.3 per cent; 17 ears had residual cholesteatoma, and nine ears had recurrent cholesteatoma. The best results were obtained in ears with an intact ossicular chain where mastoidectomy was not performed. In 49 per cent of the cases, the cholesteatoma was confined to the tympanic cavity without reaching the aditus, antrum or mastoid process. About one-third to one-quarter of the ears had tympanoplasty only, with removal of the cholesteatoma through the ear canal.
Seventy-four patients undergoing bone pate repair of the long process of the incus as part of a tympanoplasty are presented. Mean follow-up time was 66 months (range 12-143 months). Hearing results are averaged over the frequencies 500, 1000, 2000 and 4000 Hz. Thirty-two per cent of the patients had hearing thresholds better than 30 dB pre-operatively. A significant improvement in hearing was seen (p < 0.001). The data were also analysed to assess the effect of the pre-operative state of the tympanic membrane on the final result. The pre-operative condition of the tympanic membrane was either perforated (35 ears) or atrophic (33 ears). Six tympanic membranes were intact but these were excluded from the final results. No difference in hearing result was found between patients who had an ossicular repair in combination with either a perforated tympanic membrane repair or an atrophic membrane repair. Average hearing gain in the perforated group was 13 dB, in the atrophic group 9 dB and in the intact group 7 dB.
The authors present their initial experience of a new sterile medical grade cyanoacrylate adhesive (Indermil) in otolaryngeal and head and neck surgery. Thirty-three patients who underwent a variety of head and neck operations consented to have their skin incisions closed using the adhesive and 10 of those also underwent repair of the tympanic membrane, either as part of tympanoplasty or mastoid surgery. The history of the use of this class of adhesive is presented with an explanation of the chemical properties of these compounds. Advantages of using cyanoacrylate adhesives and future possible applications in otolaryngology and head and neck surgery are discussed.
We performed tympanoplasty with reconstruction of the soft posterior meatal wall for the prevention of post-operative retraction pocket formation. Our method is characterized by the reconstruction of the soft posterior meatal wall, non-obliteration with permanent or temporary materials, including Gelfoam, no use of a Palva flap and the use of fibrin glue for attaching the fascia to the posterior meatal skin. None of the patients experienced post-operative narrow-neck retraction pocket formation, and whenever aeration of the middle ear was disturbed, a balloon-like retraction was observed. Not all the posterior meatal walls retracted. The final position of the posterior meatal wall varied among the subjects. No serious cavity or hearing problems have occurred since surgery. Due to the strong possibility of post-operative retraction pocket formation in cases with a large balloon-like retraction, we rejected adopting the canal wall up technique or hard posterior meatal wall reconstruction.
We have used human teeth for ossicular reconstruction in 20 tympanoplasties, the longest follow-up being over 2 years. The take of the graft and the hearing improvement have been very satisfactory and long-lasting. This preliminary report discusses the merits of the tooth as a prosthetic material for ossicular reconstruction. Our experience to-date indicates that the material satisfies all the criteria of an ideal prosthesis.
A rare facial nerve anomaly was incidentally discovered whilst performing a tympanoplasty and ossicular reconstruction on a patient with an acquired unilateral conductive hearing loss. The nerve was seen to bifurcate and straddle a normal stapes superstructure as it ran posteriorly through the middle ear, a unique and as yet unreported combination. This case highlights the importance of vigilance regarding facial nerve anatomical variations encountered during middle-ear surgery thus avoiding inadvertent damage. The purported embryological mechanism responsible for such anomalies of the intra-tympanic facial nerve is discussed.
We report two cases of carcinoma in situ in the external auditory canal (EAC), presenting with symptoms such as pain, long-term itching of the ear, easy contact bleeding, canal otorrhea and hearing loss. Otoscopic examination revealed granulation tissue and a greyish-black tumour with irregular surface. The first patient had previously been diagnosed with otitis externa with persistent ear itching for the past three years. The second patient had received tympanoplasty for treatment of chronic otitis media on the right ear ten years ago. The first case was treated with wide excision, whereas the second patient received resection of the skin of the EAC together with its adjacent soft tissue, followed by skin grafting. No tumour recurrence was noted in the fourth and third post-operative year for the first and second patient respectively. We suggest that EAC carcinoma can be detected early and treated.
The aim of this study was to assess and quantify the current surgical practice of ossiculoplasty among British otolaryngology consultants, using a postal questionnaire. Ossiculoplasty is not a very common procedure. It is only performed by otologists with a special interest in ossiculoplasty. Among the 280 respondents (response rate 51.9 per cent), only 179 (63.9 per cent) performed ossiculoplasty. The majority of the consultants (86.5 per cent) used artificial prostheses, and 63.7 per cent used patients' own ossicles (autografts). Most of the consultants (77.6 per cent) performed ossiculoplasty with primary tympanoplasty surgery rather than with primary cholesteatoma surgery (46.3 per cent). The majority of the consultants (50.8 per cent) performed less than 10 ossiculoplasties per year. This is the first survey on ossiculoplasty surgery in the United Kingdom.
A retrospective study was undertaken of the results of surgery in a series of 782 patients with chronic otitis media. The recurrence rate of cholesteatoma was 20% of patients operated on by trainees and 12% operated on by the faculty. In ears with granulating otitis media, control of infection was achieved by trainees as often as by the faculty. The tympanic membrane healing rate of myringoplasty and tympanoplasty operations was 78% for trainees and 95% for the faculty (P < 0.001). Major surgical complications were relatively rare. It is concluded that the performance of trainees was fairly safe and better than expected, but some failures might have been prevented by closer supervision. Because of the decline in available patients for chronic ear surgery, it is suggested that the training programme should be restructured so that only those trainees who wish to pursue otological surgery as a career are trained in this field.
Hearing impairment is the most prevalent sensory deficit in the human population. Otosclerosis and chronic otitis media are two of the most frequent causes of hearing loss of the Western world and both benefit from middle ear surgery. The success rate is high for both operations, in expert hands, but, in our clinic and in every ENT clinic, there remains a percentage of failure. Some of the most frequent post-operative complications can lead to tubal dysfunction. We believe that a correct and complete evaluation of the rhino-pharyngeal-tubal unit is very important before tympanoplasty and stapedioplasty in order to further reduce the incidence of some post-operative complications and to increase the success rate of middle ear surgery. What is well known in medicine, 'prevention is the best therapy', seems not oddly observed in ear surgery, where is usually operated the effect, while the evaluation and therapy of the causes seems to be underestimated.
BACKGROUND: The hearing results of otosurgery are still unsatisfactory. Even after successful implantation of middle ear prostheses there often remains an air bone gap of 30 dB or more. As possible reasons dislocation of the prostheses due to scar growth, changes in prostheses' attachment or ventilation disorders are being discussed. Decreased stapes mobility, which has been judged only manually up to now, is supposed to be a further reason. METHOD: We are introducing a new electromagnetic probe. The output signal of this device is proportional to the impedance of the stapes-annular ligament cochlear fluid system at the sensor's resonance frequency (2.4 kHz). The advantage of this system is characterised by its hand-guidance. Injury of the sensitive stapes-annular ligament due to tremor movements of the surgeon can be excluded using a special construction of the sensor head. The maximum force of the sensor's tip onto the stapes during measurement is limited to below 5 mN. RESULTS: Preliminary measurement results of 20 patients are presented with normal and abnormal stapes mobility. These results are compared to the subjective impression of the surgeon, who usually tested the stapes mobility by hand. As a result of our investigations probe measurements can detect more exactly decreased mobility of the stapes than the surgeon. CONCLUSIONS: Our device may help to detect latent stapes fixation caused by chronic inflammation of the middle ear. The intraoperative measurement of stapes mobility may influence the strategy of the surgeon. Furthermore it would be helpful in patient consulting prior to a revision-tympanoplasty with predicting the potential hearing improvement.
BACKGROUND: Middle ear surgery has reached an advanced stage of development over the last few decades. The use of biocompatible materials offers new possibilities in ossiculoplasty. The exact calculation concerning the length of the implant to be used, however, still poses considerable difficulties and is an additional cause for a remaining air conduction difference or a further surgical intervention. METHODS: Optical coherence tomography (OCT) is a non-invasive imaging procedure for the imaging of tissue structures with a resolution accurate to micrometres. OCT can be operated touch-free and for this reason does not require any means of contact between applicator and sample. In the present study an optical coherence inferometre was coupled to an operating microscope and used in 5 stapedoplasties and 5 tympanoplasties type III in order to determine the length of the prosthesis to be used. RESULTS: The use of OCT implies an intraoperative measuring time of only a few seconds. The coupling in the optical path of an operating microscope allows trouble-free handling. The measurement of middle ear structures has an accuracy of 30 micrometer. The postoperative audiological results show a good auditory performance. CONCLUSIONS: Initial experience with OCT indicates that the technology will be extremely interesting for otosurgery. Improvements in functional pattern will enable routine intervention in connection with an operating microscope. Further OCT applications for tissue differentiation will have to follow.
BACKGROUND: Sufficient ventilation of the tympanic cavity is a decisive factor for the success of the therapy and the prognosis after tympanoplastic surgery. With the postoperative use of the Valsalva- and Politzer-maneuver the patient is able to influence the aeration of the tympanic cavity in a positive way by autoinsufflation. However this implicates the risk of a dislocation of the transplant, which is possibly caused by high middle-ear pressure-peaks during the maneuvers mentioned. METHODS: The actual increase of pressure in the tympanic cavity respectively auditory canal during the Valsalva- and Politzer-maneuver is examined in 22 patients with chronic-mesotympanic Otitis media and additionally by using an experiment with a model of a reconstructed middle-ear. The risk of a transplant-dislocation after tympanoplasty type I is estimated. RESULTS: The increase of pressure in the middle ear respectively auditory canal -- and with that the possibility of a dislocation of the transplant -- is lower after Politzer- compared with Valsalva-maneuver. If the transplant is secured through silicon sheets and packings in the auditory canal, the probability of "blowing away" the newly created cover of the tympanon will be very small. CONCLUSIONS: Because of the benefits for the aeration of the tympanic cavity, an early post-operative insufflation of the middle-ear -- using the Politzer- and/or "cautious" Valsalva-maneuver -- is recommended.
BACKGROUND: Myospherulosis is a chronic-inflammatory lesion that is most commonly iatrogenic of origin and occurs in tissues exposed to petrolatum-based products. The disease does not exhibit characteristic symptoms and is therefore not diagnosed in some instances. In previous otorhinolaryngological studies, myospherulosis was mainly found in paranasal sinuses, while only four otitic cases have been reported. METHODS: A 48-year-old female Egyptian patient suffered from bilateral chronic otitis media that had been treated in Egypt by tympanoplasty. The patient presented few months later at the university ENT department (Mainz) with deteriorated otorrhea and otalgia. Clinical, otoscopical, and radiological examination led to the diagnosis of cholesteatoma. During revision surgery of the right side, ointment-like material was found, which was embedded in granulation tissue. Middle ear biopsies were taken from both sides and routinely processed for standard histological examination and transmission electron microscopy. RESULTS: Histological examination of the right middle ear biopsy showed cystic tissue spaces lined by histiocytes and foreign-body giant cells in a fibrous stroma. In the tissue spaces, scattered debris and sac-like structures containing round spherules of aggregated erythrocytes were found. In addition, erosion of adjacent bone matrix was seen. Diagnosis of myospherulosis was made. By contrast, histological evaluation of the left middle ear biopsy revealed cholesterol granuloma. CONCLUSION: Myospherulosis of the middle ear has been hitherto diagnosed in a very few otitic cases, but might be overlooked as it mimicks other chronic proliferative and inflammatory lesions such as cholesteatoma in the present case. Thus myospherulosis should be considered in otitic cases with a suspicious history (exposure to petrolatum-based products). Furthermore, patients with myospherulosis have a significantly higher likelihood of developing postoperative complications. Since the lesion exhibits distinct histological findings, microscopy plays a central role for the diagnosis of this important disease.
The Apert syndrome (Acrocephalosyndactyly) is one of the craniosynostotic syndromes, which is often associated with congenial malformation in the temporal bone. We present a case of a 13 year old girl with Apert syndrome. By planning a tympanoplasty we arranged a CT-scan of the temporal bones. It demonstrated next to some other malformations a high jugular bulb on both sides, on the right side just with a membraneous bound to the external ear canal. In a recherche we did not find a higher incidence of high jugular bulb in Apert-syndrome and other craniosynostotic syndromes. However as we expect different malformations of the temporal bone in Apert syndrome we recommend an otorhinolaryngeal examination in each of these patients and a ct scan of the temporal bone before any operation of the middle ear.
BACKGROUND: This paper will discuss whether long term conductive hearing loss leads to late onset auditory deprivation as described in the literature in patients suffering from bilateral sensorineural hearing loss and fitted with monaural hearing aids. METHOD: The patients were examined using the Freiburg speech test in the undistorted and distorted forms (according to Dieroff 1985), and the pure tone threshold was ascertained for each patient. Thirty-six preoperative und postoperative results after tympanoplasty and stapes surgery were evaluated. Follow-up was performed six weeks and six months postoperatively. Twenty-one test persons with normal hearing were investigated. RESULTS: Comparison showed that the quotient obtained from undistorted and distorted tests is significantly higher in the affected patients. We even observed a highly significant improvement of this quotient, the speech recognition score (according to Bönninghaus/Röser), and the pure tone threshold after surgery. Seventy-eight percent of our patients showed an improved quotient, and 73% attained a normal value. But in only 29% of all cases did we see a symmetrical quotient in both ears in this period of time. In the statistical evaluation, we were unable to demonstrate a correlation between the patient's age at that moment, the age at the beginning of hearing loss, and this echo quotient. There is also no correlation between the absolute and relative change of the echo quotient and the duration of hearing loss. CONCLUSION: It was evident that the distorted Freiburg speech test is a good method to demonstrate the deprivation of the auditory system. We observed the improvement of the distorted Freiburger speech test at postoperative intervals of six weeks and six months. Hearing training should be applied after surgery in an effort to improve the hearing results.
The Erbium:YAG-laser is a good tool for microresection of bone and soft tissue from the ear drum, to the ossicles and extending to the footplate. The mechanism of ablation is based on the fact that the emission of infrared light is of the same wavelength at which water has its peak of optimal light absorption. 14% of bone is water, just sufficient force for ablation. At 50 mJ impulses the temperature in the centre stays below the coagulation point. 500 impulses of 50 mJoule definitely remain below the acoustic risk. In 44 guinea pigs 500 x 50 mJ caused a temporal threshold shift of maximal 38 dB at 2000 cps which recovered after 90-135 min. In 60 tympanoplasties neither tinnitus nor audiological side effects of the laser application were measured. The ear drum is perforated by 1 (-3) impulses. This can be done even in children after superficial anaesthesia (2% pantocaine drops) to drain the middle ear. The laser perforation of 0.3 mm [symbol: see text] will close after a day and has to be re-opened in the office to avoid tubes. We do not yet know how often general anaesthesia and removal by suction of too viscous mucus remain nevertheless necessary. With the Er:YAG laser parts of the ossicles can be cut out of the intact chain, without contact and trauma, nearly without loss of bone tissue. This allows better radicality in removing cholesteatomas or scars with less destruction. 500 impulses of 50 mJ ablate 32 mg of bone, i.e. the weight of an incus.(ABSTRACT TRUNCATED AT 250 WORDS)
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