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PubMed1994

Spontaneous cerebrospinal fluid leaks in congenital and acquired temporal bone defects-a long-term follow-up.

Twelve patients presenting with tegmen defects and requiring surgical repair were retrospectively reviewed from 1982 to 1993. One half of the patients presented with a cerebrospinal fluid leak at some time in the course of their illness. Nine cases were considered to be acquired, secondary to previous mastoid surgery or trauma. All 9 had encephalocoeles. Three spontaneous leaks were considered congenital; 2 of these patients had encephalocoeles. This report represents a long-term follow-up of these cases, with an average follow-up of 7,6 years. Computed tomography and magnetic resonance imaging technology, as well as contrast studies, have tremendously aided in diagnosis and planning of surgical repair. Nine repairs were done through a dual transmastoid and middle fossa approach, with the other 3 done via a transmastoid approach only. We favored temporalis muscle flaps and temporalis fascia over synthetic materials for defect repairs. The long-term results and complications are discussed.

Journal Article↗
PubMed1988

Current management of chronic suppurative otitis media in infants and children.

Most children who have chronic suppurative otitis media require: (1) a thorough examination of the external canal and tympanic membrane with the otomicroscope (under general anesthesia, if necessary); (2) a Gram stain and culture obtained directly from the middle ear; (3) thorough aspiration of the ear canal and, if possible, the middle ear, i.e. "aural toilet"; (4) treatment with an orally administered antimicrobial agent and an ototopical medication, if the organisms are susceptible; and if the suppurative process is unresponsive to this management, hospitalization and the parenteral administration of an antimicrobial agent. Parenteral antimicrobial therapy should be selected following microbiologic assessment of the discharge. If the infection can be eliminated using the methods described above, prevention of recurrence can be achieved by the following options: (1) prophylactic antimicrobial therapy; (2) removal of the tympanostomy tube; or (3) surgical repair of the tympanic membrane defect. The choice of these options depends on the age of the child and the status of the function of the eustachian tube. Middle ear and mastoid surgery should be reserved for those children who fail to respond to intensive medical therapy.

Child↗
PubMed1993

The role of CT imaging in the management of chronic suppurative otitis media.

CT imaging of the temporal bone is highly predictive of the presence of cholesteatoma but its value in the routine management of cholesteatoma has not been assessed. We aimed to establish the indications for CT imaging in CSOM by a prospective study of patients suspected of having cholesteatoma. The patients were assessed clinically and a management plan chosen; this was later adjusted, if indicated, on the basis of radiological findings. Surgical findings were recorded and correlation with CT appearances evaluated. Twenty patients completed the study. CT altered the management plan in 10 and was considered helpful in a further 6. We recommend its routine use in children, medically unfit patients, only or better hearing ears, patients in whom the tympanic membrane cannot be adequately visualized, patients who have had previous mastoid surgery whose operative records are available and patients with intratemporal or intracranial complications of disease.

Adolescent↗
PubMedDate not supplied

Blue ear drum and its management.

The "blue ear drum" generally refers to a condition in which blood or blood products are found in the middle ear. After all possible causes for hemotympanum, including blood dyscrasias and trauma are searched for and ruled out, the patient may have chronic serous otitis media accompanied by bloody effusion. Treatment for all of these patients is conservative, consisting of medical therapy and, if need be, myringotomy and insertion of ventilation tubes. In spite of proper treatment, rarely the condition may progress, over a long period of time, to a state of intractability. Characteristic findings are a hypocellular mastoid, hyperplastic and metaplastic mucoperiosteal lining, including the presence of glands and cysts and cholesterin granuloma. The recommended procedure is a modified radical mastoidectomy, placement of silicone rubber sheeting in the middle ear and insertion of a ventilation tube. It is to be emphasized that mastoid surgery is rarely indicated for these patients and only after all else has failed.

Ear Diseases↗
PubMed1989

Long-term results of transmeatal cochleovestibular neurectomy: an analysis of 100 cases.

One hundred patients have been treated over a 13-year period with a transmeatal approach to the internal auditory canal for cochleovestibular neurectomy. Ninety-one of these patients have followup of more than 3 months (average, 4.67 years). The most common indication for the procedure was Meniere's disease (71%). Chronic labyrinthitis, usually following stapes, middle ear, or mastoid surgery, was the next most common indication. Patients with the preoperative diagnosis of Meniere's disease had better results in the curing of vertigo (89%) than those having chronic labyrinthitis (68%). Overall, vertigo was cured in 84% of patients and markedly improved in another 15.1%. Tinnitus was relieved or improved in 65% of all patients and in 67% of patients with Meniere's disease. Mild unsteadiness was commonly noticed postoperatively, but only 11% described this as severe. Eighty percent of these latter patients reported unsteadiness preoperatively. Complications were uncommon and temporary: one case of delayed facial paresis that recovered completely, one CSF leak, and one wound infection. There were no cases of permanent facial paralysis or meningitis. The advantages of the transmeatal approach to the IAC for CVN over labyrinthectomy without CVN are assurance of complete labyrinthine denervation, increased likelihood of improved tinnitus, practice at sectioning the posterior ampullary nerve (PAN), and the ability to inspect the internal auditory canal for a small tumor or other pathology. We recommend this procedure for treatment of unilateral vestibular dysfunction in patients with no serviceable hearing.

Adult↗
PubMed1984

Occult encephaloceles and temporal lobe epilepsy: developmental and acquired lesions in the middle fossa.

Three patients with medically refractory partial complex seizures were shown to have small and initially unsuspected encephaloceles of the middle fossa. All had bitemporal, independent, interictal epileptogenic abnormalities, and the side of origin of the seizures could not be determined by surface EEG alone. The encephaloceles were missed on the initial radiologic studies and were found retrospectively in two patients; the third was found at operation and was not demonstrable radiologically, even in retrospect. One was the sequel of remote mastoid surgery, another was neoplasm-related, and the third, developmental. In all, bony defects of the middle cranial fossa were associated with temporal lobe herniation. The patients were treated surgically and have had no further partial complex seizures since operation.

Adult↗
PubMed2003

Computed tomography in suppurative ear disease: does it influence management?

The value of high resolution computerized tomography (CT) prior to routine mastoid surgery for cholesteatoma remains controversial. Doubts about sensitivity and specificity, in detecting the extent of underlying pathology and in predicting asymptomatic complications, prevent widespread adoption. This retrospective study looks at the influence of pre-operative scanning on the surgical management of chronic suppurative otitis media over an 18-month period. The radiological findings determined the choice of surgical approach, but contributed less to the decision to operate and the prediction of potential hazards. CT is of most value when the otologist can be flexible in surgical technique, tailoring it to imaging findings.

Cholesteatoma↗
PubMed1982

Myringotomy and ventilation tubes: a report of 1,568 ears.

We reviewed the records of all patients who had a myringotomy and insertion of a ventilation tube at Otologic Medical Group during a 6-year period; there were 2,266 intubations on 1,568 ears. Uncomplicated serous otitis media was the indication in 1.055 ears; 19% developed brief episodes of otorrhea. Persistent otorrhea necessitated tube removal in 9 ears, all but 2 of which became dry. These 2 patients required mastoid surgery. We conclude that myringotomy and insertion of a ventilation tube in serous otitis media is associated with infrequent complications, and these complications are probably related more to the underlying disease process than to the ventilation tube.

Adolescent↗
PubMed1990

Tympanoplasty: review of 400 staged cases.

Staging of tympanoplasty is important in the management of patients with chronic otitis media. It allows establishment of an air-containing middle ear space and adequate postoperative hearing levels in a large proportion of patients with severely diseased ears. The results of 400 staged procedures performed over a 3-year period at the House Ear Clinic, Los Angeles are reported. Staging was performed in 75% of tympanoplasty with mastoidectomy cases and in 15% of ears not requiring mastoid surgery. Closure of the air-bone gap to 20 dB or less occurred in 68% of patients with intact stapes. Mucous membrane problems were the most common reason for staging. Almost one third of cases with middle ear cholesteatoma at the first stage had residual disease on reexploration. Staging of tympanoplasty continues to be an important technique in management of severely diseased ears.

Adolescent↗
PubMed1994

Juxtaposition lipoma to the mastoid seventh nerve.

The precise embryological source for fat in juxtaposition to the vertical portion of the seventh nerve in the mastoid is unknown. Seventeen percent of 240 temporal bones disclosed various amounts of fat adjacent to this portion of the nerve. Shiny areas of fat granules are occasionally seen around, and perhaps at first glance mistaken for, the seventh nerve during mastoid surgery. The radiographic appearance of fat in this area has not been described. Bilateral 1-cm ovoid images were interpreted in a 16-year-old girl as seventh nerve neuromas or perhaps hemangiomas, but were surgically proven to be a lipoma in the only ear operated on. Lipoma should be considered in the differential diagnosis for a mass in this location which demonstrates increased T1 signal, progressive decreased signal on T2-weighted images, and has signal intensity isodense with that of fat.

Adipose Tissue↗
PubMed2003

[Spontaneous otogenic pneumocephalus].

Otogenic pneumocephalus is uncommon. Typical causes include trauma, tumor, infection, and nasosinusal or mastoid surgery but spontaneous otogenic pneumocephalus is very exceptional. We report a case of spontaneous otogenic pneumocephalus located in the left temporal lobe revealed by sudden onset aphasia. The temporal pneumatocele was cured through an epidural subtemporal approach with needle puncture of the aeroma and duroplasty. Two years after surgery, no recurrence was observed and the patient remained symptom free.

Aphasia↗
PubMed2004

[The role of high-resolution CT in the preoperative assessment of chronic otitis media].

OBJECTIVE: To assess the high-resolution CT scan in depicting the middle ear structures. METHOD: The surgical findings of 51 ears operated on were retrospectively compared with the CT findings. The followings were analysed: diagnostic features of chronic otitis media (COM) on CT status of the middle ear structures (ossicles, facial nerve canal, semicircular canals and tegmen tympani), and anatomical variations. RESULT: The radio-surgical agreement was excellent for the malleus (kappa statistics, k = 0.840) and tegmen (0.788), good for the incus (0.700) and semicircular canals (0.56), but poor for the stapes (0.366) and facial nerve dehiscence (0.310). Potential surgical hazards detected by the scans included: Low lying dura, high jugular bulb, anterior lying sigmoid sinus, facial nerve dehiscence and other situations brought about by the destructive nature of the lesion. CONCLUSION: There is a good radio-surgical correlation in COM for most middle ear structures except for the integrity of the facial canal and stapes. The scan alerts the surgeon the potential surgical dangers and complications of disease. High-resolution CT scan should be a routine examination prior to middle ear and mastoid surgery.

Adolescent↗
PubMed2006

Correlation of clinical and surgical findings to histological features (koilocytosis, papillary hyperplasia) suggesting papillomavirus involvement in the pathogenesis of cholesteatoma.

BACKGROUND: The clinical course of cholesteatoma is rather unpredictable, as some cases show aggressive development, while others have a mild, more 'benign' nature. The aim was to correlate the clinical course and surgical findings of cholesteatomas with histological features. MATERIAL/METHODS: The study included 45 patients with cholesteatoma, 29 of whom had surgically aggressive and 16 simple (not surgically aggressive) cholesteatoma. All patients underwent mastoid surgery and the cholesteatoma specimens were sent for histological examination. RESULTS: The clinical course of the cholesteatomas had a statistically significant association (p < 0.001) with the 'aggressiveness' found in surgery, suggesting that clinical history correlates well with surgical findings. All 29 specimens of patients with surgically aggressive cholesteatoma had characteristic papillary hyperplasia of the epithelium and marked koilocytosis, suggesting papillomavirus-incduced lesions. In contrast, none of the specimens of the 16 patients with simple (non-aggressive) cholesteatoma had papillary hyperplasia and there was no marked koilocytosis, as few koilocytes could occasionally be found. The difference was statistically significant (p < 0.001). In situ hybridization for human papillomnavirus (HPV) was performed in 14 specimens (7 each with aggressive and simple cholesteatomna). Positive staining was found in three aggressive cholesteatomas. All seven simple cholesteatomas were negative for HPV. CONCLUSIONS: The results of the present paper suggest that papillomaviruses may play an important role in the pathogenesis of cholesteatomas. Further studies with controls and the development of new methods to identify known and unknown types of papillomavirus are needed to explore their exact role.

Adult↗
PubMed1991

Ruptured petrous carotid aneurysm presenting with otorrhagia and epistaxis.

Aneurysm formation and rupture within the petrous internal carotid artery (ICA) is an extremely rare occurrence with approximately 10 such cases in the literature. Etiologies of petrous ICA aneurysms include atherosclerosis, closed head trauma, iatrogenic injury during mastoid surgery, chronic middle ear infections, and congenital causes. Therapeutic options include carotid artery ligation, aneurysm resection with or without reconstruction, and radiographically controlled vessel occlusion. The case of a patient who presented with otorrhagia, epistaxis, and transient focal neurologic signs due to a ruptured petrous ICA aneurysm is presented. The incidence, etiology, and anatomy of these aneurysms is reviewed, and the various tests for determining adequacy of collateral cerebral blood flow are described. Factors that affect the selection of surgical versus radiologic control of these lesions are also discussed.

Adult↗
PubMed1984

"Congenital cholesteatoma" of the middle ear. A report of 11 cases.

This article is based on a report presented at the Second International Conference on Cholesteatoma and Mastoid Surgery, in Tel Aviv, in March 1981. The principal aim is to illustrate our personal experience with the so-called congenital cholesteatoma of the middle ear, that is, a cholesteatoma growing inside the tympanic cavity affecting subjects with no inflammatory processes in their clinical history and a perfectly normal eardrum. Eleven cases out of a total of 429 cases with cholesteatoma (2.56%) operated on at the Otorhinolaryngology Clinic II of Parma are reported. All patients--nine children and two adults--underwent a combined-approach closed tympanoplasty. The diagnostic stages are analyzed in particular, as well as the clinical and impedance audiometric data, which are correlated with surgical findings. Pathogenetic mechanisms are discussed briefly. The need for screenings to be carried out in schools and an accurate evaluation of all unilateral impairments in hearing conduction are emphasized with a veiw to early diagnosis.

Adult↗
PubMed2002

Tuberculous mastoiditis: when is surgery indicated?

Mycobacterium tuberculosis is a rare cause of mastoiditis, but diagnosis is often delayed, with potentially serious results. We present the case of a 7-year-old child who failed to improve even once the diagnosis was made and appropriate medical treatment initiated. At mastoidectomy, a bony sequestrum was found which had not been evident on CT scanning. We review the diagnosis and management of this condition and suggest that failure to respond to drug therapy even in the absence of demonstrable complications be added to the list of indications for surgical intervention.

Antitubercular Agents↗
PubMed2001

[Vertigo in suction of open mastoid cavities ("radical surgery cavities")].

BACKGROUND: Vertigo during suction-cleaning of open mastoid cavities is caused by cold stimulation of the vestibular organ. In clinical and model-experimental measurements we tried to estimate the physical background and the dimension of this temperature drop. METHODS: Using different techniques like thermo-probes, thermovision, or additional model experiments temperature changes during suction were measured in 5 volunteers with open mastoid cavities. These registrations were carried out with special regard to the moisture of the cavity-walls. RESULTS: Distinct temperature changes during suction were observed. In moist cavities superficial temperature decrease was much higher than in dry ones. Using additional model experiments, temperature conduction towards e.g. the horizontal semicircular canal could be simulated. DISCUSSION AND CONCLUSIONS: Among other mechanisms like replacement of sucked-off air by colder air, or taking away warm air close to the cavity walls, effects of evaporative cold seem to be very significant. This could be demonstrated by moistening cavity walls in patients as well as in model experiments. The conclusion to keep the cavity walls as dry as possible is already a clinical demand. In this paper, the physical background and the dimensions of thermal effects during suction-cleaning could be elucidated.

Body Temperature Regulation↗
PubMed1985

The exenterated mastoid: a problem of ear surgery.

The exenterated mastoid behind an intact posterior ear canal wall is one of the preconditions for the development of hidden cholesteatoma recurrences. Retraction pockets can develop into the cavity owing to persisting malfunction of the eustachian tube. Matrix inadvertently left in the tympanic space or in the mastoid process can grow into or in the cavity unnoticed. The way to avoid this nesting site is permanent obliteration of the mastoid process immediately after the eradication of the disease. Furthermore, the disadvantages of old radical operation cavities can be eliminated by secondary obliteration, connected with a revision and repair of the sound pressure transfer mechanism if necessary. It is important to use a nonresorbable obliteration material. We use methacrylate (Sulfix-6) for this purpose, so far without any negative consequences in the ears.

Bone Cements↗