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PubMed1999

[Postoperative complication in stapedectomy: excessive introduction of the prothesis in the oval window].

Postoperative failures and complications detected in patients who undergo surgery for otosclerotic disease are not uncommon in stapes surgery. Prosthesis displacement and incus necrosis are the most common findings in review stapedectomy. We report the case of a patient who had tinnitus, vertigo, and non-recovery of air conduction thresholds without neurosensorial lesions after stapes surgery. The suspected diagnosis of excessive introduction of the prosthesis in the oval window was confirmed by computed tomography, which showed the radio-opaque image of the McGee metal prosthesis. The prosthesis replacement and literature review are discussed.

Female↗
PubMed1999

Supracochlear approach to the petrous apex: case report and anatomic study.

OBJECTIVE: The case of an 11-month old infant with petrous apex abscess drained through the supracochlear air cells prompted an anatomic study of the dimensions of this approach. Of the various approaches to the petrous apex, the supracochlear dissection has been the least described. STUDY DESIGN: Twenty temporal bones were dissected to completely expose the epitympanum. This required mastoidectomy, exenteration of zygomatic root and epitympanic air cells, and removal of the incus. Measurements were taken from three sides of a triangle described by the tegmen tympani (TT), tympanic facial nerve (TFN), and superior semicircular canal (SSCC). Similar measurements were obtained from standard coronal computerized tomographic (CT) scans from a random series of 20 patients. RESULTS: Mean lengths of the sides of the triangle were 7.0 mm (TT), 5.3 mm (TFN), and 4.8 mm (SSCC). The superior petrous apex air cells or marrow space was accessible through the supracochlear exposure in all specimens. Mean lengths from the coronal CT images were 4.2 mm (TT), 3.2 mm (TFN), and 8.45 mm (SSCC). CONCLUSIONS: The authors conclude that the supracochlear approach may provide adequate access to the superior petrous apex for drainage and biopsy in selected cases.

Abscess↗
PubMed1999

No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients.

OBJECTIVE: The objective of this study was to validate measures taken to reduce the number of cerebrospinal fluid (CSF) leaks after removal of vestibular schwannomas to 0. STUDY DESIGN: This study was a retrospective case review. SETTING: The study was conducted at an otology/neurotology tertiary referral center (Gruppo Otologico, Piacenza, Italy). PATIENTS: Three hundred thirty-one vestibular schwannoma patients were studied. INTERVENTIONS: The enlarged translabyrinthine approach (TLA) was used in all cases, with a number of modifications in the last 200 patients. It was extended in 22 patients with blind sac closure of the external meatus, removal of the posterior bony canal wall, and obliteration of the Eustachian tube and middle ear. MAIN OUTCOME MEASURES: Whether patients had a leak through the wound, the nose (rhinoliquorrhea), or the ear (otoliquorrhea) was assessed. RESULTS: In an early group, the percentage of CSF leaks was 6.9%. On the basis of the evaluated causes, as time went by, technical modifications evolved. They consisted of 1) the total conservation of the fascioperiosteal flap, 2) obliteration of all petrosal cells possibly communicating with the middle ear, 3) removing the incus in a correct way, 4) closing the attic with periosteum, 5) obliterating the surgical cavity, leaving strips of abdominal fat with their medial ends inside the cerebellopontine angle, 6) suturing the musculo-periosteal layer in a correct way, and 7) fixing the skin flap to the underlying surface. The application of these modifications resulted in a total absence of CSF leaks in 200 consecutive patients thereafter. Also, no cases of meningitis were encountered. CONCLUSIONS: To our knowledge, this is the first series of 200 consecutive vestibular schwannoma patients operated by means of the enlarged TLA without a single CSF leak. When the appropriate measures are taken, the number of CSF leaks after removing tumors through the enlarged TLA must and can be reduced to 0.

Adipose Tissue↗
PubMed1999

Two cases of Townes-Brocks syndrome.

Townes-Brocks syndrome (TBS) has been recognized as a dominant inherited syndrome. We report 2 cases of TBS. Case 1 was operated on for imperforate anus. Triphalangeal thumb and ear anomalies were remarkable. Deafness was diagnosed when the patient was 6 months old. Anomalies of the semicircular canals and the incus with inculomalleolar fusion were shown when the patient was 3.5 years old. During childhood, recurrent episodes of abdominal pain appeared. The diagnosis of hereditary angioneurotic edema (HANE) was made. HANE was familial as the father, the father's brother and the paternal grand mother were also affected. The parents of case 2, a female, are both mildly mentally retarded. This was the first pregnancy of the mother who had short stature. The child had an antepositioned anus, bifid right thumb, large toes, low set ears, microretrognathia and deafness. A (5, 16) translocation was observed in a child with TBS. At the breakpoint in 16q21.1, a gene coding for a transcription factor SALL1 has been identified and it was shown that mutations in the putative zinc finger of SALL1 cause TBS.

Abnormalities, Multiple↗
PubMed2000

The effect of the "floating mass transducer" in the middle ear on hearing sensitivity.

OBJECTIVE: The Vibrant soundbridge is a semi-implantable hearing device; the transducer is implanted, coupled directly to the incus. The influence of the implant surgery and the presence of the transducer on hearing sensitivity was studied in six implanted subjects. STUDY DESIGN: Longitudinal case reports. SETTING: Tertiary referral center. Subjects. The subjects had bilateral sensorineural hearing loss with an average hearing loss of 40 to 70 dB HL. RESULTS: In five of the six subjects, no long-term effect of the surgery or the presence of the transducer on hearing thresholds was found. In the remaining subject, a deterioration in hearing thresholds was found of 20 dB, with a high and low frequency component. In the 2-kHz region, hearing sensitivity was not deteriorated. In addition, chronic negative middle ear pressure occurred after surgery. CONCLUSION: Hearing thresholds did not change significantly in five of the six patients after placement of the "floating mass transducer." It was speculated that the high frequency component of the hearing deterioration in the remaining patient was caused by cochlear damage caused by the surgery and that the low frequency component was caused by the chronic aeration problems indirectly related to the surgery.

Audiometry, Pure-Tone↗
PubMed2000

Imaging and clinical evaluation of isolated atresia of the oval window.

BACKGROUND AND PURPOSE: Congenital causes of hearing loss in children commonly are encountered, and imaging aids in diagnosis as well as presurgical evaluation. Atresia of the oval window not associated with atresia of the external auditory canal (EAC) is a rare cause of congenital hearing loss in children. We present the clinical and imaging findings in children with isolated oval-window atresia. METHODS: Atresia of the oval window was defined as the absence of the structure with the presence of a bony plate superimposed between the vestibule and middle ear. The bony plate is within the expected region of the oval window. Using a computerized database, nine patients with isolated oval-window atresia were found. All had been evaluated with high-resolution computed tomography (HRCT) and all had medical records available for review, including audiogram results. Imaging studies were interpreted by the consensus of two pediatric neuroradiologists. RESULTS: Atresia of the oval window was documented in all cases using HRCT criteria. The most common anomalies associated with oval-window atresia were inferomedial malposition of the facial nerve (n = 8), malformed incus (n = 6), and displaced stapes (n = 2). Four patients had symmetric bilateral involvement. Hearing tests were not specific, because conductive, sensorineural, and mixed patterns were found. CONCLUSION: Anomalies of the oval window should be sought in all patients with congenital hearing loss. Associated findings, such as facial nerve aberrancy and ossicular anomalies, are important in both diagnosis and surgical planning.

Adolescent↗
PubMed1975

[Facial paresis following stapedectomy (author's transl)].

An ususual complication after stapedectomy for otosclerosis is reported. After two vain attempts elsewhere, the tympanic cavity was opened for the third time. Since the incus was missing, a malleovestibuloplasty was undertaken, using the Schuknecht wire prosthesis. Hearing was very good. One day after the operation, a facial paralysis developed, and increased over the following days. After 18 days, the nerve was found to be oedematous and swollen above the fenestra ovale upto the level of the promontory and had forced the prosthesis out of the fenestra ovale. Six weeks later, nerve function was normal.

Facial Paralysis↗
PubMed2000

[Otosclerosis surgery: hearing results and complications].

A retrospective study was made of 183 stapedectomies performed at the Santiago de Compostela Hospital from 1989 to 1996. Sixty-seven percent (67.3%) of patients were women and 32.7% were men. Good results were obtained in 87% of cases (79% had an air-bone gap closure difference under 10 dB, and 8% 10-20 dB). Ten pefect had not change in air threshold and the rest deteriorated. There were no significant differences between stapedectomy and stapedotomy. The 4. 000-Hz improvement obtained was inferior to those in 500, 1,000 and 2,000 Hz. In 8.7% of patients with obliterated footplate, heaving outcome was significantly worse. In patients with exposed or overhanging facial nerve, floating footplate, middle ear fibrosis, and necrosis of the long incus process had better results. Total sensorineural hearing loss occurred in 1.1% of cases.

Adolescent↗
PubMed1999

[Imaging of post-traumatic tinnitus, vertigo and deafness].

Tinnitus, hearing loss, and more rarely disequilibrium are common sequela of temporal bone trauma. Hemotympanum may cause a transient and immediate conductive hearing loss. HRCT depicts ossicular dislocation (most frequently incus), producing a long-term conductive hearing loss. Labyrinthine trauma causing neurosensory hearing loss or/and acute vertigo may be depicted by MRI, showing an abnormal non-enhancing high signal T1 of the membranous labyrinthine fluid. MRI also may show low signal T1 and T2 fibrotic areas of the membranous labyrinth, especially of interest if cochlear implant surgery is planned. Perilymphatic fistulas are to be searched in case of fluctuant hearing loss. Both HRCT and MRI may show window damage: filling of the tympanic recess, rupture of the window membrane, intra-vestibular luxation of the stapes, or occasionally pneumolabyrinth.

Ear Ossicles↗
PubMed2000

Virtual endoscopy of the middle and inner ear with spiral computed tomography.

OBJECTIVE: To evaluate the inner anatomy of the auditory apparatus by means of virtual endoscopy of spiral computed tomography (CT) data sets. BACKGROUND: Virtual endoscopy permits simulation of the fiberoptic endoscopy perspective by processing CT or magnetic resonance images. METHODS: Seven formalin-fixed specimens of human mastoid were scanned with spiral CT with the following protocol: beam collimation 1 mm, pitch ratio 1, reconstruction spacing 0.2 to 0.5 mm, field of view 90 mm. For the generation of endoscopic views of the auditory spaces, the axial images were processed with Navigator software 2.0 running on UltraSparc I workstation. RESULTS: Virtual endoscopy allowed the demonstration of the external auditory canal, the head and handle of the malleus, the stapes and incudostapedial articulation, the corpus, the long process of the incus with its lenticular process and the short limb, the malleoincudal articulation, the rounded promontory, the round and oval windows, and Prussak's space. From inside the basal turn of the cochlea, virtual endoscopy showed the orifices of the fenestrae cochlea and vestibuli, the origin of the lateral and the anterior semicircular canals, and the basal turn of cochlea. The optimal perspectives that allowed demonstration of the anatomical details of the middle and inner ear are described. CONCLUSION: Virtual endoscopy allows the generation of inner views of the auditory spaces. This new method of image processing can be proposed as an integrative tool of spiral CT imaging.

Culture Techniques↗
PubMed2000

[Revision surgery of otosclerosis: a review of 26 cases].

OBJECTIVES: The aim of this study was to identify causes of primary stapedectomy failures and to evaluate hearing results in revision stapes surgery. MATERIAL AND METHODS: We retrospectively reviewed a series of 26 revision stapedectomies. Patient characteristics, preoperative findings, causes of failure and complication of primary stapedectomy and postoperative hearing results were noted. RESULTS: Conductive hearing loss was the most common reason for revision surgery (77 %). Leading causes of stapedectomy failure included prosthesis malfunction (42 %), fibrous adhesions (37,5 %), incus erosion (12,5 %) and otosclerotic regrowth (12,5 %). When revision was indicated because of cochleo-vestibular complication, middle ear exploration revealed 3 problems: oval window granuloma or excessively long prosthesis or perilymphatic fistula. In this series, postoperative air-bone gap was closed to less than 10 dB in 57 % of cases, to less than 20 dB in 71 % of cases and we did not observed any sensorineural hearing loss. CONCLUSION: The results of this series are comparable with previously published studies. Revision stapes surgery is not as successful as primary stapedectomy, but the risk of sensorineural hearing loss does not appear to be higher than in primary surgery. Revision surgery is a challenging problem that must be performed by an experienced surgeon.

Adult↗
PubMed1998

[Otogenic relapsing meningitis with 5 case reports].

Otogenic relapsing meningitis are rarely seen clinically, most of them are caused by congenital anatomical deformity of internal ear. 5 cases are reported in this thesis. The etiology, diagnosis and therapy of the disease are explained in our study. The operating method is introduced that the temporal fascia and incus are impacted into the vestibular window and the fistula is blocked after the pressure of cerebrospinal fluid is lowered. All 5 cases are primarily successful.

Adolescent↗
PubMed2000

What future in the 21st century for tibial bone allografts in ossicular chain reconstruction: the state of the issue.

After using tibial cortical bone allografts in reconstructing the middle ear over a period of ten years, the authors analyze their results. They compare the functional and anatomical outcome at 4 years of 24 patients who received this allografts with a series of 25 patients who underwent incus transposition. Results were analyzed in two different ways: the Air Bone Gap and the Glasgow Benefit Plot. The discussion addresses the techniques used to reduce risks of iatrogenic transmission of viruses and prions, the current legislation in Belgium and the comparative costs, after refunding of the various reconstruction materials. The authors conclude that, because the present-day preparation techniques offer a certain security with regard to transmission risks and because of its numerous advantages (mechanical properties, tolerance, cost and availability), tibial cortical bone still has a promising future.

Adult↗
PubMed2001

Pars tensa and pars flaccida retractions in persistent otitis media with effusion.

OBJECTIVE: In children with otitis media with effusion (OME), to investigate the incidence of, and any association, between retractions of the pars tensa and pars flaccida; to assess the effect of pars tensa and pars flaccida retractions on the hearing; to investigate risk factors for retractions; and to document the natural history of such retractions over a 12-week 'watchful aiting" period. STUDY DESIGN: Prospective, observational study. SETTING: Sixteen departments of otolaryngology in hospitals in the U.K. PATIENTS: A cohort of 1,267 children aged 3.25 to 6.75 years with confirmed OME. None had previously received surgical intervention. INTERVENTIONS: Follow-up over a "watchful waiting" period of 12 weeks. MAIN OUTCOME MEASURES: Otoscopy and pure-tone audiometry. RESULTS: Retraction of the pars tensa to the incus or promontory occurred in 8% of the better-hearing ears and 10% of the poorer-hearing ears. Pars flaccida retraction to the malleus or farther occurred in 4.5% of the better-hearing ears and 5.5% of the poorer-hearing ears. Retractions were not associated with a longer history of hearing problems. Pars tensa or pars flaccida retraction in association with OME did not materially affect the hearing. Pars tensa retractions, followed up over a 12-week period, resolved in 69% of the better-hearing ears and 65% of the poorer-hearing ears. In 14% and 10% of ears, respectively, the OME had also resolved. CONCLUSIONS: There is minimal evidence to support the concept that pars tensa or pars flaccida retractions are a strong or relevant marker for the severity or evolution of OME in children. Prospective studies over a longer period of follow-up are required to confirm this.

Acoustic Impedance Tests↗
PubMed2001

The value of pre-operative high resolution CT scans in cholesteatoma surgery.

INTRODUCTION: Cholesteatoma is traditionally diagnosed by otoscopic examination and treated by explorative surgery. The need for imaging in an uncomplicated case is contentious. This study assesses the usefulness of a pre-operative high-resolution CT scan in depicting the status of the middle ear structures in the presence of cholesteatoma. MATERIALS AND METHODS: The surgical findings of 36 ears with cholesteatoma operated on by the first author were retrospectively compared with the CT findings reported on by the second author. The following were analysed: diagnostic features of cholesteatoma on CT, status of the middle ear structures (ossicles, facial nerve canal, semicircular canals and tegmen tympani), and presence of any anatomical variations and disease complications. RESULTS: All cases had at least 1, and 30 cases (83.3%) had all, of the following radiological features: (a) a non-dependent tissue mass, (b) a location typical for cholesteatoma and (c) bony erosion. The radiosurgical agreement was excellent for the malleus (kappa statistics, k=0.83), stapes (0.94) and semicircular canals (0.8), good for the incus (0.62) and tegmen (0.65), but poor for the facial nerve canal (0.3). 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 good to excellent radiosurgical correlation in cholesteatoma for most middle ear structures except for the integrity of the facial canal. The scan alerts the surgeon to potential surgical dangers and complications of disease. High-resolution CT scan is an important investigative tool prior to cholesteatoma surgery.

Cholesteatoma, Middle Ear↗
PubMedDate not supplied

[Congenital fistula of the stapedial footplate as an avenue for recurrent purulent meningitis].

INTRODUCTION: Congenital fistula of the stapedial footplate is a rare cause of recurrent purulent meningitis and a diagnostic and therapeutic problem as well. CASE REPORT: We report a case of a stapedial fistula diagnosed intraoperatively in a 4-year-old boy, after recurrent meningitis. The boy was hospitalized at the Pediatric Clinic three times in a 6-month period because of recurrent meningitis. The applied anti-meningitis therapy presented with good general state of the child, but the main target was to discover the cause of recurrent meningitis. Immunologic and genetic investigations were performed. Otorhinolaryngologic findings nearly normal, except minimal asymmetry in the otoscopic finding. Eardrum was reddish with all other characteristics of a normal drum. The tympanometric curve was of type B/C on the right ear. MRI revealed hydrocephalus internus with signs of inflammation of mastoid cells and cavum tympani indicating explorative myringotomy and antrotomy. Intraoperatively, we found cerebrospinal fluid in the antrotympanic cavity, including malformation of the incus without contact with stapes and fistula on the middle part of the stapedial footplate with flow out of the perilymph. CONCLUSION: Perilymphatic fistula is a rare cause of recurrent meningitis, whereas congenital ear malformation may be a cause of recurrent meningitis, particularly in children. The diagnosis is intraoperative. The surgical treatment may be very difficult, often requiring revision of procedures especially if cerebrospinal fluid pressure is increased.

Child, Preschool↗
PubMed2001

[Predictive factors of outcome in 220 ossiculoplasties in adults].

OBJECTIVE: To define factors predictive of outcome after ossiculoplasty in adults. MATERIAL AND METHODS: From 1992 to 1998, 220 ossiculoplasties were performed for chronic otitis media in 200 patients (100 men and 90 women), average age 53 years, age range 17 - 82 years. Ninety-four patients (47%) had not undergone prior surgery (99 ossiculoplasties) and 106 (53%) underwent revision procedures (121 ossiculoplasties). Average follow-up was 20 months. All patients were reexamined at consultations 3 and 12 months after surgery and 100 patients (50%) were reexamined at two years. The operations were classified in type II tympanoplasty when the patient presented a normal stapes (n=120), and a type III tympanoplasty when the stapes arch was absent (n=100). Perforations (n=200) were repaired by temporal aponeurosis in 160 cases (80%) and a tragal perichondrium in 40 cases (20%). The materials used included 23 incus autografts (10%), 105 hydroxyapatite composite Goldenberg prosthesis (48%), 55 all-hydroxyapatite Xomed prosthesis (25%) including 20 covered with a thinned tragal cartilage, 19 teflon Klein prosthesis (9%), 12 Ionos prosthesis (5%) and 6 Malleus prosthesis (3%). The results were analyzed from the microscopic aspect and audiometric data for frequencies 0,5 to 3 KHz. RESULTS: Twenty prosthesis luxed or extruded (9%) within an average of 6 months, 15 (12.4%) after a revision procedure and 5 (5%, p<0,05) after an initial procedure. Fifteen perforations (15/200, 7.5%) occurred, 9 with temporal aponeurosis grafts (9/160, 5.6%) and 6 with perichondrium grafts (6/40, 15%, NS). The residual air-bone gap (ABG) was equal to 23 +/- 12,5 dB with 57% of ABG<20 dB at 12 months follow-up. The gain in air conduction was 14 +/- 16,5 dB and the change in air-bone gap 13 +/- 12,3 dB. Some factors could significantly improve functional results: presence of the stapes arch (n=120, p<0,05), first-intention procedure (n=99, p<0,05), and use of all-hydroxyapatite prosthesis in type II (p<0,05) or type III tympanoplasties. CONCLUSION: Ossiculoplasty with all-hydroxyapatite prosthesis produced satisfactory results in type II or III tympaonoplasties.

Adolescent↗
PubMed2001

[Study of the middle ear. Value of multiplanar reconstructions in spiral tomodensitometry].

We point out the interest of computed tomographic reconstructions from spiral acquisition--particularly sagittal reconstructions--in the study of middle ear anatomy and adjacent structures: the facial canal and the chorda tympani. The reference reconstructions are axial and coronal reconstructions. So, we demonstrate the superiority of sagittal reconstructions for the visualization of the lateral process of the malleus, the body and long process of the incus, the third portion of the facial canal, and the chorda tympani. For the other structures of the middle ear and the other parts of the facial canal, these sagittal reconstructions are complementary. Besides, the best type of reconstruction to visualize the stapes and the vestibular window is the axial plane parallel to the stapes axis.

Ear, Middle↗