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PubMed2002

Detection of postoperative residual cholesteatoma with delayed contrast-enhanced MR imaging: initial findings.

Our objective was to assess the value of delayed contrast-enhanced T1-weighted spin-echo MR imaging in the detection of residual cholesteatoma in patients who have undergone canal wall-up tympanoplasty procedure. The MR imaging was obtained prior to revision surgery in 18 patients with opacity of the post-operative cavity at CT examination 12-18 months after canal wall-up tympanoplasty. In each patient the following was performed: precontrast T1- and T2-weighted images; and early and delayed contrast-enhanced axial and coronal T1-weighted imaging. Early and delayed MR imaging results were separately compared with surgical second-look findings. Sensitivity, specificity, and predictive values were evaluated for early and delayed post-contrast MR imaging, compared with second-look surgery findings. A residual cholesteatoma was correctly identified in 8 of 9 cases with delayed contrast-enhanced T1-weighted MR imaging. Mean sensitivity, specificity, positive predictive value, and interobserver agreement (evaluated by kappa statistics) were, respectively, 85.2, 92.6, 92.6%, and kappa=0.78 for the delayed contrast-enhanced MR imaging technique. The same parameters were, respectively, 96.3, 33.3, 60.6, and 0.30 for the early contrast-enhanced T1-weighted MR images. We conclude that delayed contrast-enhanced T1-weighted MR imaging is reliable for the detection of residual cholesteatomas of the middle ear in patients who have undergone canal wall-up tympanoplasty.

Adolescent↗

PubMed2001

Surgical strategy for cholesteatoma in children.

OBJECTIVE: We reviewed our experience with childhood cholesteatoma in children under 15 years old. Based on cumulative postoperative data, we propose a modified canal-wall-up technique in conjunction with a planned, staged operation. METHODS: From 1982 to 1997, 56 children with cholesteatoma (58 ears, total) underwent surgery in our department. In the early period (1982-1990), canal wall-down mastoidectomy was performed in 52% (21 of 40 ears), and canal wall-up mastoidectomy in 48% (the remaining 19 ears). In the late period (1991-1997), 18 ears with cholesteatoma underwent surgery. The canal-wall up mastoidectomy was performed in 89% (16 ears), and canal-wall-down mastoidectomy in the remaining 11% (two ears). RESULTS: In the early period (1982-1990), cholesteatoma recurred more frequently in the canal-wall-up mastoidectomy group than in the canal-wall down mastoidectomy group (53 vs. 14%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, and perforation of the eardrum, occurred more frequently in the canal-wall-down mastoidectomy group than in the canal-wall-up mastoidectomy group. In the late period (1991-1997), in the canal-wall-up mastoidectomy group, ten ears underwent one-stage surgery. Planned staged tympanoplasty was completed in six ears. After one-stage surgery, four of ten ears experienced residual cholesteatoma. Two of the recurrent ears had undergone planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) images, 12 of 15 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. CONCLUSION: Our strategy for pediatric cholesteatoma in the future is to use canal-wall-up mastoidectomy when possible. If aeration in the attic and antrum is observed by preoperative CT-scan image and no erosion in the malleus and incus exists, the one-stage surgery will be chosen. If no aeration is observed by CT-scan and/or erosion exists in the surgical findings, planned staged tympanoplasty will be necessary. This strategy allows a high incidence of aeration of the attic and antrum, and prevents the formation of the attic retraction pocket while enabling the early detection of residual cholesteatoma by means of CT.

Adolescent↗

PubMed2000

Blood flow in the external auditory canal and tympanic membrane as assess by laser doppler blood flowmetry

INTRODUCTION: Procedures within the external meatus and tympanum constitute a large part of otological surgery. Successful healing after procedures on the tympanic membrane will in large part be dependent on the integrity of local blood flow. However, there appear to have been relatively few studies investigating blood flow in the external auditory meatus and tympanum in normal subjects and those with conditions requiring surgery, e.g. tympanoplasty. The aim of this study is to obtain such data using Laser Doppler Blood Flowmetry. METHOD: Control volunteers (n = 30) and patients requiring tympanoplasty (n = 20) were recruited for the study. Laser Doppler Blood Flowmetry was performed in all patients using a commercially available system (Periflux 5000, Perimed AB, Sweden) at four sites: (1) preauricular skin; (2) cartilaginous ear canal; (3) bony ear canal; and (4) tympanic membrane. Mesotympanic temperature was also measured using a Braun Infrared thermometer. Blood flow (flux) was measured as RBC density 'speed following internal calibration. RESULTS: Analysis revealed that in both the control subjects and pretympanoplasty patients, the ranking of blood flow at the sites was 3, 2, 1 and 4 (highest to lowest). Comparing matched sites, there were no significant differences between the two groups. The amplitude of flow was not found to be correlated with mesotympanic temperature. CONCLUSION: Grafts applied to repair perforations of the tympanic membrane are likely to obtain the majority of their blood supply from the bony external auditory meatus rather than that tympanic membrane. Further studies are ongoing to define local blood flow patterns in order to optimize the results of tympanoplasty.

Journal Article↗

PubMed2004

The Yung percutaneous mastoid vent: results of a multicenter trial.

OBJECTIVE: The primary goal of the study was to find out whether the Yung vent would remain patent long-term. The secondary goal was to find out whether mastoid ventilation could overcome permanent ventilation disorder within the middle ear. STUDY DESIGN: The study was an open prospective investigation. SETTING: The study was a multicenter study involving three tertiary referral centers. PATIENTS: Twenty-three subjects older than 12 years were included. The inclusion criteria were complete atelectasis, failed tympanoplasty because of persistent eustachian tube dysfunction, and persistent otitis media with effusion in spite of repeated ventilation tube insertion. INTERVENTION: Tympanoplasty with insertion of the Yung percutaneous mastoid vent. MAIN OUTCOME MEASURES: Patency of the vent, adverse effects, patient acceptance, hearing results, and appearance of the tympanic membrane were assessed every 3 months up to 18 months postoperatively. RESULTS: : At 18 months, 20 of 23 vents were still patent. Overall, there had been no unacceptable adverse effect on any patient. Eighteen of 23 ears had improved hearing. The tympanic membrane had returned from a collapsed state to near normal in 13 of 17 completely atelectatic ears. There were five patients who had no benefit from the vent because of blockage within the epitympanum or middle ear effusion. CONCLUSION: The Yung percutaneous mastoid vent can maintain long-term patency. It is effective in the treatment of complete atelectasis as an adjunct to tympanoplasty.

Acoustic Impedance Tests↗

PubMedDate not supplied

Correlation between MRI findings and second-Look operation in cholesteatoma surgery.

Two-staged intact canal wall tympanoplasty is a common operation for treatment of middle ear cholesteatoma. MRI provides better tissue differentiation of the middle ear and/or mastoid, which often become occupied with soft density tissue after the first operation. If MRI was able to detect the presence of a recurrent or residual cholesteatoma with sufficient sensitivity and specificity, this may facilitate a decrease in the number of second-look procedures. This study compared MRI findings to surgical findings at second-look surgery and calculated the correlation rates between the two sets of findings. Thirty ears having undergone intact canal wall tympanoplasty for cholesteatoma at the initial operation were examined by MRI prior to the second look. Otoscopic findings of the tympanic membrane were nonsuspect in all cases. The true positive rate was 11/30 (37%) and the true negative rate was 10/30 (33%), leading to a radiosurgical correlation of 70%, whereas the false positive rate was 6/30 (20%) and the false negative rate was 3/30 (10%). This indicates that 30% of the MRI findings were incorrect. Therefore, at the present time, MRI does not appear as a likely replacement for second-look surgery in cases of intact canal wall tympanoplasty.

Adolescent↗

PubMed1976

[Experimental studies on the reaction of the immunological system during chronic otitis media and about the course of this disease (author's transl)].

During chronic otitis media intact immunoglobulins are split due to the proteolytic activity of extracellular bacterial proteinases into fragments of different molecular weight. The most malignant bacterial proteinases are the proteinases of pseudomonas aeruginosa (pyrocyanea). These proteinases can only be inhibited by alpha-2-macroblobulin of human blood serum. Because of its high molecular weight we find this inhibitor only in a very low concentration in the middle ear secretion. The destruction of the immunoglobulins is certainly one of the factors of weakening the immunological system in the middle ear. The inhibitory system with alpha-1-antitrypsin, inter-alpha-trypsin inhibitor and alpha-1-antichymotrypsin is unable to inhibit these bacterial proteinases of pseudomonas aeruginosa. The only possibility to get a high concentration of alpha-2-macroglobulin in the middle ear secretion is the liberation of this inhibitory by injuring blood vessels during a tympanoplasty. By this procedure the proteinases of pseudomonas aeruginosa with maximum activity at pH 7.8 and with a high proteolytic activity are almost completely inhibited. By blocking these proteinases combined with an appropriate antibiotic therapy and with the reconstruction of the destroyed parts of the middle ear by a tympanoplasty we can produce a preponderance of the immunological system as compared with the proteolytic activity of the proteinases. This high proteolytic activity can be a cause of the destruction of the small processes of the ossicular bones, especially of the lenticular process of incus. In order to demonstrate that there are proteolytic splitting processes of intact immunoglobulins, a quantitative analysis of the immunoglbulins IgG, IgA and IgM was done pre- and postoperatively. By these studies we found postoperatively a much higher level of intact immunoglobulins, particulary in cases of chronic otitis media associated with cholesteatoma. The blocking of the proteinases and the increase of the level of intact immunoglobulins combined with the reconstruction of physiological conditions in the chronically inflamed middle ear by a tympanoplasty lead to a stabilsation of the immunological and inhibitory system and create the prerequisites for a healing process in chronic otitis media. It is the purpose of further studies to learn about the capability of the split-products of the immunoglobulines to attach and to absorb antigens and toxins during a chronic inflammation in the middle ear.

Enzyme Inhibitors↗

PubMed1981

[Reconstruction of the ossicular chain: Plastipore prosthesis compared with autogenous and allogenic ossicles (author's transl)].

Morphological and audiological early and late results after reconstruction of the ossicular chain with Plastipore prosthesis (TORP's and PORP's) were compared with those achieved by using autogenous or allogenic ossicles. In particular 32 tympanoplasties with TORP's were compared with 25 cases of columella and 29 PORP cases with 75 interpositions. Only Plastipore prostheses were extruded, up to now in 11.4% of cases. The final extrusion rate will be even higher since perforations of the fascia graft or the drum over the head of the prostheses as signs of imminent extrusions were noted in 9.8% of tympanoplasties at the end of the 2-year follow-up period. However, only in one third of tympanoplasties cartilage had been interposed between the head of the prosthesis and the fascia graft or drum. Audiological results, early as well as late ones, using the mean postoperative air-bone gap as criterion of success, showed no statistically significant differences between the compared groups. Only the comparison of the mean air-bone gaps in late results versus the preoperative values seemed to favour the PORP group over the interposition group. In some PORP cases, however, greater reduction of the air-bone gap was caused by postoperative deterioration of the bone conduction threshold level. In addition, hearing gains were more lasting in the interposition than in the PORP group. Because of the high extrusion rate and the fact that the audiological results were not significantly better than in the compared groups we will cease using PORP's and will employ TORP's only with careful interposition of cartilage and then only in selected cases with good tubal function.

Audiometry↗

PubMed1993

[Development of the surgery of chronic otitis].

For on a strictly conceptual level, today as well as yesterday we find the two main streams of thoughts shared by otologists. Some put the emphasis on the exeresis of lesions which are mainly cholesteatoma, at the agreed expense of hearing. Others are anxious to conciliate lesion exeresis and conservation, even restoration of hearing. The first streams of thoughts outnumbered the others during the first half of the century. Thus that was the triumph of the radical mastoïdectomy, due to the works of Kurster, Laufal and Stacke, then those of Bergman, Barany, Bondy, Beyer and Voss. Today the heirs to that philosophy have converted this surgery, in open technique tympanoplasty. In the second streams of the ... there was Heath in 1904, then Bondy in 1908, and especially Sourdille in France, who in his thesis, described antro-atticotomy with conservation of the ossicular chain. The state of mind he was in as early as 1918 makes him one of the fathers of tympanoplasty, at least so we think. Unfortunately for him, he was ahead of his time and it wasn't until the second half of the century that the heirs to his philosophy could fulfill the vow which was to conciliate lesion exeresis and restoration of hearing. To be frank, they enjoyed the use of antibiotics and surgery microscope, without which tympanoplasty whose initiators were Zollner and Wullstein would have never been possible. A lot of improvement remains to be done as far as chronic otitis surgery is concerned.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholesteatoma↗

PubMed1998

Management of labyrinthine fistula in middle ear cholesteatoma.

Labyrinthine fistula is a complication of chronic otitis media with cholesteatoma. Canal wall down tympanoplasty with partial mastoid cavity obliteration and complete removal of cholesteatoma matrix was adopted in five cases of labyrinthine fistula. The operation resulted in elimination of vertigo. Sensory hearing has been saved in two cases. Air conduction hearing improved in one case. In three cases whose air conduction deteriorated post-operatively, bone conduction worsened in two cases and remained unchanged in one case (Tympanoplasty type 0 was performed in the other one case.) During the follow-up period, otorrhea improved in all cases and there was no evidence of recurrence of cholesteatoma. If the hearing of the other ear is acceptable, we suggest one-stage canal wall down tympanoplasty with complete removal of cholesteatoma matrix and partial mastoid cavity obliteration. It provides low recurrence rate of cholesteatoma and there is no need of re-operation.

Adolescent↗

PubMed1975

Reconstructive procedures for congenital aural atresia.

The three surgical methods currently in use to improve hearing for patients with congenital aural atresia are fenestration of the lateral semicircular canal, canal plasty, and type III tympanoplasty. Because the surgery is difficult and the functional rewards are modest, it should ordinarily be reserved for patients with bilateral atresia. Of the 12 ears operated by the technique of type III tympanoplasty, the average gain in hearing was 22 dB, with seven attaining a 30 dB or better air-conduction threshold. When aural rehabilitative and cosmetic surgery are contemplated, coordinated planning by the surgeons is necessary to acquire the best end result.

Auditory Threshold↗

PubMed1980

Secondary neotympanic membrane and total ossicular chain reconstruction. A preliminary report.

This new tympanoplasty technique with homo-ossicles (25 cases) has evolved as a reliable, effective, and durable technique to construct the middle ear conduction system when the total ossicular chain is missing. The isolated footplate is driven by two (primary and secondary) neotympanic membranes; hence this new technique is designated as "twin tympanoplasty." The initial hearing results (air-bone gap closure to 10 dB or less in 88% of the cases) have been good, and follow-up (six to 14 months) audiograms suggest that the hearing gain may survive the test of time. Toenail autograft could be one substitute for the ossicle as proved by satisfactory results in five cases.

Ear Ossicles↗

PubMed1991

The influence of ventilating tubes on the surgical treatment of atelectatic ears.

Forty children and 53 adults having 111 atelectatic ears were operated on and followed up. All patients underwent a tympanoplasty operation, while 27 patients underwent concomitant various mastoid operations. A ventilating tube was inserted in 55 out of the 111 atelectatic ears, while in 56 ears the tympanoplasty was left without a ventilating tube. After an average of 53.1 months of post-operative follow-up we found that all ears were adequately aerated as long as a ventilating tube was in place. However, at the final check, once all ventilating tubes extruded, it was found that insertion of a ventilating tube at operation did not change the natural evolution of the atelectatic condition after surgery. Our conclusion is that the only way to overcome the atelectatic prone condition is to reinsert a ventilating tube whenever atelectasis reformation occurs.

Adolescent↗

PubMed2006

["Ear camp" for children in Namibia. A field report].

BACKGROUND: Ear surgery is urgently needed in northern Namibia as many children cannot even be provided with hearing aids due to chronically discharging ears, not to forget possible complications of untreated cholesteatoma. METHODS: During the two "ear camps" in 2003 and 2004, 61 children (median age 12 years) and one adult were operated, mainly for (sub)total defects of the tympanic membrane (81 tympanoplasties). PATIENTS AND RESULTS: We performed tympanoplasty type I in 33 cases and type III in 48 cases, mostly using autogenous ossicles and titanium prostheses. In 39 cases, an antrotomy or mastoidectomy was also performed, while in six cases an open cavity had to be created because of a cholesteatoma. The tympanic membrane was reconstructed using tragal cartilage with overlapping perichondrium in an "underlay-technique". The closure rate after 6 months was about 80%, the average improvement in air conduction thresholds in the frequencies between 250 and 4,000 Hz was 13 dB. CONCLUSIONS: An "ear camp" can only be realised with the financial and material help of companies and private supporters. Therapy must be adapted to the limited local possibilities. The use of tragal cartilage with overlapping perichondrium is a safe technique for the reconstruction of a stable tympanic membrane. We have started to instruct local doctors in pre- and postoperative care in ear surgery in order to develop local competence. This will be continued in the next "ear camp".

Child↗

PubMed1998

[Histological studies of tympanic membrane rim defects in chronic otitis media mesotympanalis].

In the present study we investigated resected tympanic membranes taken during tympanoplasty. Tissue from 111 patients with chronic otitis media was analyzed after being embedded in paraffin and stained with hematoxylin and eosin. In 67 patients (60%) the tympanic membrane epidermis did not extend beyond the margin of the perforation rim, so that no epithelial migration was observed on the inner side of the tympanic membrane. In 27 specimens (24%) we found an epithelial migration on the inner side of the tympanic membrane, but this did not extend to the margins of the excised tissue. In 17 tissue specimens (16%) epithelial migration extended to the margins of the resected tissue. Clinically, these patients were found to have non-functioning Eustachian tubes. The size of the tympanic membrane perforation was not found to impact on epithelial migration. However, there was a correlation between the extent of the epithelial migration seen in the specimens and the occurrence of a permanent tympanic membrane perforation after tympanoplasty. Of 17 patients with these findings, 4 (23%) had consistent reperforations. The tympanic membrane rims of these patients were completely covered with squamous epithelium. Patients with no or only little epithelial migration to the inner side of the tympanic membrane were found to have a significantly lower postoperative rate of recurrent infection and drum reperforation.

Adolescent↗

PubMed2005

Management of an "Ear Camp" for children in Namibia.

OBJECTIVE: In this publication, we present our experiences with managing an "Ear Camp" in northern Namibia, where the population is predominantly black. Medical coverage for ear problems is poor in this part of the country. METHODS: Within 10 days, 38 children (median age 12 years) were operated mainly for (sub) total defects of the tympanic membrane. In two cases, an open cavity had to be created because of a cholesteatoma. We performed a tympanoplasty type I in 18 cases and a tympanoplasty type III in 20 cases. Additionally, in 8 cases an antrotomy and in another 8 cases a mastoidectomy was performed. The ossicular chain was reconstructed with a titanium-PORP (14 cases), a titanium-TORP, interposition of the head of the malleus or a cartilage columella (one case each) or by placing the reconstructed tympanic membrane directly onto the head of the stapes (three cases). The tympanic membrane was reconstructed by the use of tragal cartilage with overlapping perichondrium in underlay-technique. RESULTS: Thirty-one children could be followed up. A defect of the tympanic membrane was found in five cases because of continuous purulent discharge. The average improvement of air conduction thresholds in the frequencies between 250 and 4000 Hz was 15 dB. CONCLUSIONS: Surgical techniques, antibiotic treatment and perioperative management have to be adapted to limited possibilities of pre-treatment and aftercare. As development aid should support people to look after themselves, we started to instruct local doctors with regard to pre- and postoperative care in ear surgery. Training of the local doctors will be continued in our next "Ear Camp" in 2004.

Adenoidectomy↗

PubMed2001

[Long-term functional results in ossicular reconstruction with cartilage].

Optimal hearing is one goal of otologic surgery. This study examines the long-term functional success rate of cartilage as graft material for ossicular chain reconstruction in type III tympanoplasty. A retrospective review of seventy-nine patients having undergone type III tympanoplasty (53 with closed techniques and 26 with open techniques) was made. Lateral graft ("onlay") techniques were used in almost all cases. All operations were performed by one of the authors, a well-established otologic surgeon. Seventy-four percent of the reconstructions were performed in an one-stage procedure. The mean period of follow-up was 54 months (range 1-17 years). The results of air-bone gap closure and complications of the surgery are presented. Our results show that a significant percentage of patients gain a long-term substantial improvement in their hearing with minimal risk. However, this hearing improvement tends to decline eventually in a progressive manner. A post-operative air-bone closure equal or < 30 dB was achieved in 92.2% of the all cases (n = 79) with a mean gain of 9.72 dB. Functional outcomes in closed techniques were slightly better than in open techniques. There were few complications. Perforation and retraction of the tympanic graft were the most common observed complications. In conclusion, cartilage is an available, costless, reliable and technically easy to use graft material for functional reconstructions of the ossicular chain. It is a well-tolerated element in middle ear space as well as by the tympanic membrane, it has a very low risk of extrusion and a good long-term functional viability. Therefore, update cartilage is an interesting option in functional restoration of the ossicular chain as graft placed on the stapes capitulum.

Adolescent↗

PubMed1992

Importance of atticotomy in chronic otitis media with fixation of ossicles.

Seventy-seven patients with chronic otitis media were reviewed. Of the 77 patients, 42 underwent tympanoplasty with a columella, and 35 underwent myringoplasty and atticotomy. Twenty-five of the latter 35 patients showed less than 10 dB of hearing improvement with a patch test before operation. The ossicular chain was not disconnected in any of the 25 patients, but the mobility was severely restricted. It was interesting that fixation of the malleus was found at surgery in 80% (20/25) of the patients, whereas the stapes was immobilized in only 16% (4/25). Myringoplasty and atticotomy instead of tympanoplasty with a columella was sufficient to achieve hearing improvement in most of such cases. However, conventional atticotomy was not able to achieve improvement in the mobility of the ossicles because the mobility is usually severely restricted at the malleus. Removal of the anterior tympanic spine is the key to recovery of the mobility of the malleus, resulting in hearing improvement. Rate of success was obtained in 24 of 25 ears (96%).

Auditory Threshold↗

PubMed1989

Hearing after surgery for cholesteatoma using various techniques.

The late results in 740 patients with cholesteatoma subjected to one-stage canal wall down mastoidectomy (262 patients), modified canal wall up mastoidectomy (324 patients), and tympanoplasty without mastoidectomy (154 patients) were analyzed with regard to hearing and the condition of the drum. Mean observation time was 9.3 years, range 3-21 years. Postoperative hearing (air bone gap and pure tone average) and as hearing at the last evaluation was significantly better in the canal wall up group, than in the canal wall down group, but also the preoperative hearing was better in the canal wall up group. The postoperative hearing was best in the group with tympanoplasty only without mastoidectomy. It is concluded that no single method is optimal in all cases of cholesteatoma and that cholesteatoma surgery should be individualized.

Acoustic Impedance Tests↗