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PubMed2002

Mastoid-obliteration surgery with cartilage for suppurative cholesteatomatous ears.

BACKGROUND: Autologous cartilage has been widely used as a material for tympanoplasty and mastoid-obliteration surgery. Since it remains vulnerable to an infectious condition, this study aims to evaluate if it can be used for a chronic suppurative cholesteatomatous ear to achieve single-stage tympanoplasty with mastoidectomy and obliteration of the cavity. METHODS: From January 1988 to August 1998, the records of patients with cholesteatoma who received cartilage-obliteration surgery performed by Dr. Lien were examined for any infection-associated problems within three months after the operation. The Fisher's exact test was used to compare the difference in the incidence of post-operative infection-associated problems between suppurative ears and non-suppurative ears. RESULTS: One hundred and seven surgical procedures performed upon 96 patients were included in this study, with 97 being primary surgical procedures and ten being revision surgery for previous open cavity with cholesteatoma recurrences. The average follow-up was 47.7 months. At time of surgery, there were 59 non-suppurative ears; 48 ears were suppurative and cultured. Granulations were found in the middle ear or mastoid for 42 ears (39.3%). Five ears (4.7%) exhibited infection-associated post-operative problems within three post-operative months. Three cases (5.1%) were non-suppurative ears and two cases (4.2%) were suppurative ears. There was no significant statistical difference when examined with the Fisher's Exact test. CONCLUSIONS: In an immunocompetent patient with a cholesteatomatous chronic suppurative ear, autologous cartilage could potentially tolerate an infection condition to serve as a material for mastoid-obliteration in a single-stage surgical procedure.

Cartilage↗
PubMedDate not supplied

Otogenic intracranial complications. a 7-year retrospective review.

OBJECTIVES: The objectives of this study were to review our experience on intracranial complications secondary to otitis media (OM), and to compare the results to those occurring 10-15 years ago. We also reviewed the timing of both otologic and neurosurgical treatments. MATERIAL AND METHODS: All patients with intracranial complications secondary to OM over a 7-year period were identified. A retrospective chart review was undertaken at Beaumont University Hospital, Dublin, Ireland. Clinical presentation, radiological findings, microbiology, surgical management, and antibiotic use were studied. We compare our findings to those of other international investigators. RESULTS: Twelve cases were identified. Five had brain abscesses, 4 had lateral sinus thrombosis, and 3 had petrous apicitis. Eight of these cases were secondary to chronic OM and 4 were secondary to acute OM. Malodorous otorrhea, otalgia, headache, fever, and vertigo were the primary symptoms. Anaerobic bacteria were the most commonly isolated organisms followed by Staphylococcus aureus, Proteus mirabilis, and Pseudomonas aeruginosa. Patients with cholesteatoma underwent modified radical or radical mastoidectomy, and those who did not have cholesteatoma underwent cortical mastoidectomy. Two brain abscesses were drained before mastoid surgery; 2 were drained after mastoid surgery and 1 at the same time as otologic surgery. All patients received broad-spectrum intravenous antibiotics targeted at individual culture and sensitivity results. The mortality rate was zero. CONCLUSION: Clinical presentation and the frequency of occurrence of intracranial complications are similar to those occurring 10 years ago. The choice of antibiotics should include adequate anaerobic cover. We recommend that otologic surgery be performed at the same time as intracranial surgery for patients with mature brain abscesses.

Adolescent↗
PubMed1988

Endolymphatic mastoid shunt surgery using the Denver inner ear shunt.

This study, merging data from two different clinics, was undertaken to evaluate the efficacy of endolymphatic mastoid shunt surgery using the Denver Inner Ear Shunt operation for Meniere's disease. This surgery was performed by the senior authors (C.G.J., J.R.E.D., and M.E.G.) between May 1984 and October 1986, after we attended the Colorado Otologic Research Center (CORC) instructional course. Sixty-six and thirty-four cases, respectively, were performed. Follow-up questionnaires were sent to this total of 100 patients. Fifty-six patients returned completed questionnaires, which formed the basis of this report. A retrospective chart study was also carried out. The results of surgery and questionnaires are reported as statistical data, and, where applicable, the 1985 AAO-HNS criteria for reporting vertigo and hearing results in the treatment of Meniere's disease are used. Preliminary analysis of these data is reported because of its profound effect upon our treatment protocol for patients with Meniere's disease. Results on use of the Denver valve do not appear to be significantly different than the results of other shunt surgery not using the valve.

Adolescent↗
PubMed1985

Acute mastoiditis: a review of 34 patients.

A review of 34 patients presenting with acute mastoiditis was undertaken. Prior treatment was noteworthy for lack of medical or surgical drainage at the time of initial otitis media. Typical findings, in hospital, included postauricular edema and tenderness, displaced auricle, and distorted tympanic membrane. X-rays were not diagnostic, nor were they helpful in determining who was a surgical candidate. Treatment was individualized. Patients with obvious subperiosteal abscesses, and those who did not respond rapidly to enteric antibiotics, underwent early mastoid surgery. The remaining patients received enteric antibiotics, had drainage established, and were carefully followed. Most resolved without mastoid surgery. Patients with a history of antecedent ear disease were examined separately from those without such history. The former group required mastoid surgery more often than the latter and had poorer outcome.

Acute Disease↗
PubMed1998

The facial ridge and the discharging mastoid cavity.

This study evaluates the causes for a persistently discharging mastoid cavity and attempts to weight the importance of each identified factor. It consists of a temporal bone dissection to evaluate the anatomy of the facial nerve and a clinical prospective study measuring the factors that contribute to a wet cavity. The factors measured were height of the facial ridge, the size of the meatus, state of the tympanic membrane, and size of the mastoid cavity. The height of the facial ridge and the kidney shape of the cavity were found to be the most significant factors contributing to the state of the cavity. The tympanic membrane and size of the meatus were also found to significantly influence the state of the cavity, whereas the size of the cavity was not significant. These results illustrate the importance of the facial ridge in mastoid surgery and that most poor results in mastoid surgery are due to the surgeon, not the disease.

Clinical Competence↗
PubMed1997

Endolymphatic mastoid shunt surgery in unilateral Menière's disease.

One-hundred endolymphatic mastoid shunt operations in patients with classic unilateral Meniere's disease were analyzed. The patients were carefully preselected with a comprehensive protocol of audiovestibular and metabolic investigations. All patients had definitive electrophysiologic evidence of endolymphatic hydrops with an enhanced negative summating potential on transtympanic electrocochleography. The surgical results were analyzed both by the original American Academy of Ophthalmology and Otolaryngology Guidelines (AAOO, 1972), and the more recent modifications of the American Academy of Otolaryngology-Head and Neck Surgery (AA-HNS, 1985). Control of vertigo was achieved in 79% of the patients overall, with 42% sustaining complete control and 37% substantial control. A significant hearing improvement was obtained in 15% of cases, there was no change in 56% of patients, and hearing became worse in 29%. Tinnitus improved following surgery in 35% of patients, was the same in 56%, and worse in 9%. Postoperatively, there was no disability in 42% of the patients, some degree of disability in 50%, and severe disability and inability to sustain gainful employment in only 8%.

Adolescent↗
PubMed2001

Transcanal atticoaditotomy and transcortical mastoidectomy for cholesteatoma: the Farrior-Olaizola technique revisited.

Conservative mastoid surgery in the management of middle ear cholesteatoma has been a subject of controversy for decades. Proponents of the combined-approach tympanoplasty for cholesteatoma do not entirely support the conservative approach in children, especially in the hands of an inexperienced surgeon. We describe here our experience with a modified technique of conservative mastoid surgery involving an atticoaditotomy and a separate simple mastoidectomy with lateral attic wall reconstruction (modified Farrior technique) that can be relatively safely used in the majority of cases of chronic squamous otitis media, even in children. This was a prospective analysis of the therapeutic effects and benefits of the technique used in 103 cases of cholesteatoma at Staffordshire General Hospital from 1991 to 1997. The follow-up was between 3 and 9 years. The study group consisted of 55 male patients and 48 female patients, including 28 children less than 16 years of age. The age ranges were 9 to 61 years in male patients and 10 to 48 years in female patients. After an audiological assessment, all patients underwent the described mastoid procedure, and some of them required revision surgery, mostly for a second look or for ossiculoplasty. The chief outcome measures used were complete eradication of disease, incidence of disease recurrence, and restoration of hearing. The steps of the procedure, its pros and cons, and the results of the series are presented. Also discussed is an overview of the literature pertaining to intact-canal wall mastoid surgery. Of the 103 patients, only 3 had a recurrence of disease, and 9 patients showed no hearing improvement. We conclude that this modified technique has several advantages over the previously described mastoidectomy procedures. It is a relatively simple and effective technique that can be performed even in children.

Adolescent↗
PubMed1979

[Otitis nigra: etiologic pathogenetic and clinical aspects (author's transl)].

The clinical picture of otitis nigra (idiopathic sero-hemmorrhagic otitis media) as independent clinical entity is shown, presenting 5 cases requiring mastoid surgery. Samples of mastoid mucosa were investigated by light- and electron-microscopy employing histochemical, immunofluorescent and virological techniques. Pathological changes of the small vessels in the subepithelial connective tissue with increased vascular permeability and extravasation of red blood cells and serum play a central role in the pathogenetic course of the disease. Disintegration of erythrocytes leads by catabolism of hemoglobin to formation of hemosiderin and ferretin, whereas by processing of phospholipids of the cell-membrane cholesterin cristals are deposited in the connective tissue. These cholesterin deposits in turn induce a foreign body reaction with formation of typical cholesterol granulomas. The mucosa shows secretory activity in intraepithelial secretory cells and glandlike structures in the subepithelial connective tissue. Neutral and acidic mucopolysaccharides are demonstrated in the secretory product. As possible cause for the vascular lesion that in turn sets off the pathomechanisme of otitis nigra a subclinical viral infection is discussed. This conjecture is supported by demonstration of virus-like inclusion bodies in macrophages and fibrocytes and of virus-like particles in antral smears. In addition myxoviruses of the parotitis-epidemica group could be identified in these smears by serological methods. Furthermore, the stimulation of the local immunological defense system, evidenced by the presence of numerous immunoglobulin-producing plasmacells in the tissue, is in concord with a viral infection. Therapy requires mastoidectomy in combination with posterior tympanotomy in order to eradicate completely the intractably diseased mastoid mucosa.

Adolescent↗
PubMed2006

A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children.

OBJECTIVE: To explore factors influencing hearing outcomes in children treated by canal wall up (CWU) and canal wall down (CWD) mastoid surgery. METHODS: Retrospective cohort study including three units in Bristol and Bath, UK. Ninety consecutive children underwent cholesteatoma mastoid surgery, with the first procedure between 1998 and 2001; minimum follow up was three disease-free years. RESULTS: The CWU and CWD cohorts significantly differed in pre-operative stage and hearing. After disease eradication, air conduction (AC) thresholds changed by +4.0 dB (95 per cent confidence intervals (95% CI) -2.0, 10.1) in the CWD group and -5.3 dB (95% CI -9.3, 1.3) in the CWU group (p=0.029). Using multiple linear regression to account for cohort differences, AC thresholds were increased by: pre-operative AC threshold (p<0.0001), initial ossicular stage (p=0.013), and CWD-surgery (p=0.005). CONCLUSION: Disease-free hearing was better with CWU-surgery, less initial ossicular damage, and better pre-operative hearing. Worse initial disease increased the likelihood of CWD surgery. Wider use of ossiculoplasty in the CWU cohort (51 per cent vs 5 per cent) may partially explain the superior results.

Adolescent↗
PubMed2003

[Ceramic model for temporal bone exercises--an alternative for human temporal bones?].

BACKGROUND: The complexity of the temporal bone anatomy makes it necessary to train in a model before starting middle ear surgery. The classical object are human cadaver temporal bones, but these are not always available for different reasons. Alternatively in cooperation between the department of otolaryngology, head and neck surgery of the University of Jena and the 3di company Jena, Germany, a calcium sulfate based model was developed. METHODS: During a temporal bone course at the Bugando Medical Centre, Mwanza, Tanzania, these ceramic temporal bone specimens were used for training. Because of the lack of drills, the specimens were worked on in chisel and carving technique. All participants were beginners in ear surgery. Classical procedures in mastoid surgery were performed: Exposing of sigmoid sinus, facial nerve, labyrinth, dura, jugular bulb and internal carotid artery. RESULTS: The temporal bone models were very useful for these exercises. Good exposure was possible for the dura, the facial nerve and the major blood vessels. The possibility of exposing tinier structures like the labyrinth was still insufficient. Nevertheless the understanding of the 3-dimensional anatomy of the temporal bone using the ceramic model was excellent. The relationship of all important anatomical structures could be taught intensively. CONCLUSIONS: Particularly for beginners or in cases where human temporal bones are not available the calcium sulfate based temporal bone is an alternative training model for mastoid and middle ear surgery.

Calcium Sulfate↗
PubMed1993

The value of head dressings for middle ear surgery.

A prospective trial was performed to ascertain the value of head dressings in the post-operative management of patients undergoing middle ear and mastoid surgery. One hundred consecutive patients were randomly allocated to a head dressing or no head dressing group after wound closure. Nine patients in the head dressing group developed a wound complication as opposed to four patients in the no head dressing group. The application of a pressure dressing following middle ear and mastoid surgery is unnecessary and may contribute to increased wound morbidity.

Adolescent↗
PubMed1997

Intracranial complications of temporal bone osteoradionecrosis.

OBJECTIVE: To present four cases of life-threatening intracranial complications associated with temporal bone osteoradionecrosis. STUDY DESIGN: This study was a retrospective case review of four patients combined with a literature review. SETTING: All patients were treated at Loyola University Medical Center, which is a tertiary care facility. PATIENTS: The four patients were retrospectively reviewed without demographic constraints. INTERVENTIONS: All patients underwent preoperative radiographic assessment (magnetic resonance imaging/computed tomography scan), and three of the four patients underwent surgery. MAIN OUTCOME MEASURE: The role of surgical intervention in the management of advanced temporal bone osteoradionecrosis. RESULTS: Three patients underwent mastoid surgery after medical treatment of intracranial complications associated with temporal bone osteoradionecrosis. All three patients had dry, epithelialized mastoid cavities. One patient died as a result of meningitis. CONCLUSIONS: Mastoid surgery should be used in the overall management of patients with advanced temporal bone osteoradionecrosis to prevent secondary intracranial complications.

Adult↗
PubMed1998

The role of endolymphatic mastoid shunt surgery in the managed care era.

OBJECTIVE: Ongoing controversy regarding the surgical management of Meniere's disease has prompted us to review the effectiveness of the endolymphatic mastoid shunt procedure in the control of vertigo. In the current managed care environment in which outcome measures, cost effectiveness, and procedural efficacy must be demonstrated, the surgeon can no longer rely on anecdotal or empirical observations regarding the effectiveness of a treatment paradigm. STUDY DESIGN: Retrooperative case review. SETTING: A tertiary care center. PATIENTS: The records of 327 patients with presumed Meniere's-related vertigo referred to the University of Cincinnati Medical Center were reviewed. One hundred nine patients underwent endolymphatic mastoid shunt. Our study population consists of 96 of these patients that were available for 5 years follow-up. INTERVENTIONS: Endolymphatic mastoid shunt for the control of medically refractory vertigo. MAIN OUTCOME MEASURE: Control of vertigo. RESULTS: Using the Arenberg anatomic classification system, patients with a type I endolymphatic sac achieved 68% control of vertigo, those with a type II endolymphatic sac had a 92% control rate, and patients with a type III endolymphatic sac achieved 78% relief. CONCLUSIONS: Based on an assessment of outcome variables, we conclude that there remains a definite role for endolymphatic shunt surgery in the contemporary approach to patients with Meniere's disease.

Adult↗
PubMed2000

Acute mastoiditis: predictors for surgery.

To estimate the incidence of acute mastoiditis and identify predictors for mastoid surgery, a retrospective case record study of 38 children hospitalised for acute mastoiditis in Oslo from 1989 to 1998 was performed. Median age at diagnosis was 18 months and 13 (34%) of the children received mastoidectomy. Compared to the period 1970-1979, the incidence of mastoidectomy was significantly reduced. Only seven children (18%) had experienced acute otitis media prior to the current episode. Symptom duration of 6 days or more prior to hospitalisation and elevated white blood cell counts and C-reactive Protein were predictive for mastoidectomy ((OR = 5.0 (1.0-22.8), (OR = 24.5 (2.5-240) and OR = 10.5 (1-108.8)). Furthermore, total time from symptom onset to hospital discharge was significantly higher in children who received mastoidectomy. We suggest early referral to an otolaryngologic department in children suspected of acute mastoiditis.

Acute Disease↗
PubMed1996

Hearing levels of young patients 10 years after mastoidectomy.

In several reports, the functional results of mastoid surgery in children have been stated to be disappointing. In this study, a series of 49 child patients who underwent mastoid surgery for chronic suppurative otitis media were examined 10 years postoperatively. At surgery, a cholesteatoma was detected in 49% of the patients. During the observation period, 33% of the patients were subjected to a second operation. At the last follow-up examination, 57% of the operated ears showed hearing levels of 20 dB or better, but in 16% hearing levels were worse than 40 dB. In 16% of the patients, contralateral disease had required surgical treatment and in only 39% of the patients, contralateral ear was found to be normal in otoscopy. Still, at the last follow-up examination, 90% of the better hearing ears had hearing levels of 20 dB or better and only one patient had hearing levels worse than 30 dB in both ears. Compared with an age-and sex-matched control group, hearing levels of the patients were significantly worse but the difference in the mean hearing levels of the better hearing ears was as little as 5 dB. Thus, 10 years after mastoidectomy, hearing levels of child patients were found to be better than expected.

Adolescent↗
PubMed2000

CT scanning in "second look" combined approach tympanoplasty.

One of the main disadvantages of intact canal wall mastoid surgery for cholesteatoma is the necessity of the "second look". The morbidity of a second procedure can be reduced, however, with the aid of a rigid endoscope. Fifty-five consecutive patients undergoing a re-exploration were included in this study. Prior to surgery computerized tomography (CT) was performed in order to assess both the anatomy and degree of pneumatisation of the middle ear cavity and mastoid bowl. The operative findings at the time of the "second look" were correlated with the pre-operative scans. An otoendoscopic approach was possible in all cases. In the diagnosis of residual or recurrent disease, the CT scan had a sensitivity of 43.8%. The specificity of the CT scan was 51.3%. The explanation for these findings is that it is impossible to differentiate between recurrence, scar tissue or inflammation on CT images in patients who have undergone previous mastoid surgery.

Adolescent↗