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PubMed1993

Pathology of the eustachian tube in otitis media: an electron microscopic study.

The ultrastructure of the mucosa of the eustachian tube was studied in four temporal bones showing tympanosclerosis, cholesteatoma, otitic meningitis and a grafted tympanic membrane (tympanoplasty). The mucosa of tube was abnormal in the four cases confirming the relationship between the state of the eustachian tube and the inflammatory process in the middle ear. The observed abnormalities included: ciliary loss, abnormal ciliary morphology and motility, oedema of the microvilli, hyperplasia of the goblet cells and the seromucinous acini, desquamation of the non-ciliated cells and appearance of mast cells in the lamina propria of the tube. Ciliary changes were the most frequent abnormalities and the morphological changes, in general, were fewest in the case of healed tympanoplasty. The pathophysiology of the morphological changes was discussed and correlated with the disease in the middle ear.

Adolescent↗

PubMed1997

Myringotomy and ventilation tube insertion: a ten-year follow-up.

Eighty children who had myringotomy performed for otitis media with effusion in 1984 were reviewed in 1994. This had involved surgery on 158 ears. Three aspects of ear condition were studied: hearing loss, tympanic membrane perforation, and tympanosclerosis. Hearing losses were present in 13 ears (8.2 per cent), involving 10 children (12.5 per cent), although losses were under 20 dB in seven of these ears (five patients). Of the six ears with losses more than 20 dB (3.8 per cent), in five patients bilateral losses of 30 dB were due to a recurrence of effusions, a large dry posterior perforation was the cause of a 30 dB loss, an infected anterior perforation had caused a 30 dB loss, an ear which had a cholesteatoma, and had a mastoidectomy and ossiculoplasty in 1987, had a 30-40 dB loss, and one ear which had a Type 1 tympanoplasty in 1994 had a 50 dB loss. Therefore in only three ears (1.9 per cent) could hearing loss be associated directly with myringotomy and ventilation tube insertion. Perforations had persisted unilaterally in seven patients, three having had tympanoplasties. Of the remaining perforated tympanic membranes, two were free of symptoms, one had only a slight hearing loss, and one had a more significant loss with recurrent infection. Tympanosclerosis was only found in those ears which had ventilation tubes inserted (and not those which had myringotomy only), occurring in 48 ears (31 per cent, of 39 per cent of those which had a ventilation tube inserted). There was no link between tympanosclerosis and hearing loss. The site of tympanosclerosis was not restricted to the site of myringotomy, and in many cases was present only in other areas of the tympanic membrane. There was a tendency for more extensive tympanosclerosis to occur in those ears which had more ventilation tube insertions. The risk of perforation in particular lends support to a policy of 'watchful waiting'.

Child↗

PubMed2006

Differentiation between cholesteatoma and inflammatory process of the middle ear, based on contrast-enhanced computed tomography imaging.

OBJECTIVE: To assess the usefulness of delayed post-contrast computed tomography (CT) examination for the detection of residual or recurrent cholesteatoma after canal wall up tympanoplasty. STUDY DESIGN AND SETTING: This prospective, non-randomized study, set within an academic medical centre, included 17 consecutive patients who had undergone canal wall up tympanoplasty for cholesteatoma, with possible recurrence. Pre-contrast CT scans and delayed post-contrast images were compared with second look surgical findings. RESULTS: A residual or recurrent cholesteatoma was found in eight of the 17 patients at revision surgery and was correctly diagnosed on post-contrast CT images in six patients (75 per cent). In the two misdiagnosed cases, cholesteatoma pearls smaller than 2.5 mm were not seen on post-contrast CT. The sensitivity of the imaging test was 75 per cent, the specificity was 60.1 per cent, the positive predictive value was 88.1 per cent and the negative predictive value was 81.8 per cent. CONCLUSION: Computed tomography with delayed post-contrast images is a sensitive imaging modality for the detection of residual cholesteatoma. If proven reliable, this method of non-invasive imaging could spare the patient unnecessary revision surgery.

Adult↗

PubMed2000

Pars tensa retraction pockets in children: treatment by excision and ventilation tube insertion.

Tympanic membrane retraction pockets involving the pars tensa are not uncommon in clinical practice. Recurrent infections, ossicular erosion and cholesteatoma are the recognized sequelae. The management options include surveillance, medical treatment and surgery. The surgical procedures range from grommet insertion to extensive tympanoplasty procedures. We report our experience with simple excision and grommet insertion, performed in 31 ears in 26 patients as day cases. The follow-up ranged from 8 to 34 months with a mean of 16 months. The procedure was successful in 23 ears (success rate of 74%). Recurrence of retraction occurred in seven ears and in one ear there was a persistent perforation. Age, previous grommet insertion and severity of retraction did not have a statistically significant influence on the final outcome. We conclude that excision and grommet insertion is a simple, safe and efficient procedure for the management of tympanic membrane retraction pockets and can be considered in preference to extensive tympanoplasty.

Adolescent↗

PubMed1998

[Functional long-term results after open cholesteatoma surgery and ossiculoplasty with allogenic ossicles in adulthood].

BACKGROUND: Characteristic features of cholesteatoma of the middle ear are destruction of the bone and a high tendency for recurrent disease. The choice of surgical procedure is determined by audiological results and the rate of recurrent cholesteatoma. PATIENTS: One hundred fifty patients who underwent primary cholesteatoma surgery were investigated 3-5 years postoperatively. Preoperative and postoperative audiological results and rate of revision surgery were compared for the respective surgical procedures. All cholesteatomas were treated with an open surgical technique. The lateral attic walls and cholesteatomas were removed. RESULTS: Cholesteotoma recurred in 15 patients (10%). Primary reconstruction of the ossicular chain with a tympanoplasty (type III) was performed in 98 patients in the first operation. Approximately 80% of patients treated with a type III tympanoplasty had a maximum postoperative air-bone gap of 20 dB in the main speech range, depending on the frequency. In about 50% of patients, this value was 10 dB or less. Comparison of preoperative and postoperative conductive hearing loss between 250 Hz and 8000 Hz revealed an improvement (p < 0.05) of 10 dB (500 Hz, 3000 Hz, 4000 Hz) and 15 dB (250 Hz, 1500 Hz, 2000 Hz, 8000 Hz). CONCLUSIONS: In our opinion, a second look operation should be performed in cases where a large cholesteatoma cannot be removed with sufficient reliability. This applies especially to a cholesteatoma in the oval window. Here, we suggest second-look surgery after one year.

Adolescent↗

PubMed2001

Tympanic membrane grafting with alloderm.

OBJECTIVE/HYPOTHESIS: The purpose of this work is to evaluate the performance of an acellular dermal allograft (AlloDerm; LifeCell Corp., The Woodlands, TX) in tympanic membrane (TM) grafting. STUDY DESIGN: A retrospective review of 20 consecutive tympanoplasty surgeries using temporalis fascia and 20 consecutive procedures using AlloDerm. METHODS: The charts of 20 consecutive adults who underwent tympanoplasty surgery were reviewed to evaluate graft take and hearing results. Similarly, 20 consecutive patients who had TM grafting with AlloDerm were reviewed. Pre- and postoperative air-bone gaps (ABG) at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were compared. RESULTS: There were no graft failures in either the temporalis fascia group or the AlloDerm group. No statistically significant difference was noted in hearing results when comparing the residual conductive loss in both postoperative groups. CONCLUSIONS: AlloDerm is a suitable material for TM grafting. This product is especially valuable in revision surgery in which the availability of appropriate autologous grafting material is limited.

Audiometry↗

PubMed2003

Preliminary results with the use of AlloDerm in chronic otitis media.

OBJECTIVES/HYPOTHESIS: AlloDerm, an acellular dermal graft, has been used successfully as a material for soft tissue implantation. The authors report their experience with the use of AlloDerm in the reconstruction of the tympanic membrane. STUDY DESIGN: Case review study. METHODS: Charts were reviewed for all patients who underwent tympanoplasty with and without mastoidectomy between June 1999 and June 2002 in whom AlloDerm was used as a grafting material. There were 24 patients, 17 with simple perforations (8 revisions) and 7 with chronic otitis media with cholesteatoma (6 revisions). Success was defined as closure of the tympanic membrane perforation. RESULTS: Closure of the perforation using AlloDerm was achieved in 87.5% of the patients (ie, in all but three patients). Another patient developed serous otitis media and required a myringotomy tube in the postoperative period. CONCLUSIONS: The success rate for AlloDerm in tympanoplasty was similar to that of temporalis fascia in the authors' experience. AlloDerm can provide a suitable grafting material when fascia is not available or when the size of the defect precludes the use of fascia.

Biocompatible Materials↗

PubMed2004

Dimensional stability of the free fascia grafts: a human study.

OBJECTIVES/HYPOTHESIS: In animals it has been shown that autologous free fascia grafts (fascia lata and temporal fascia) change dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations, particularly in large perforations. Dimensional stability of these fascias has been studied in humans. STUDY DESIGN: Prospectively, 11 patients were studied. METHODS: Patients who were subjected to open mastoid cavity surgery were included in the study. The mastoid cavity was exteriorized, and the fascia graft was used to seal the perforation and cover a part of the bare mastoid bone in the routine way. At this stage, equally cut pieces of temporal fascia and fascia lata were laid on the remaining part of the bare mastoid bone. The mastoid cavity was then packed with Gelfoam and wound sutured. The pieces of graft material under study were removed after 5 days, leaving the graft used to seal the tympanic membrane perforation undisturbed. The harvested grafts were measured for their dimensional variations, if any. RESULTS: It was observed that free autologous temporal fascia grafts exhibited poor dimensional stability as compared with free autologous fascia lata grafts. CONCLUSION: Poor dimensional stability of free temporal fascia grafts as seen in animals was confirmed in the present human study. This poor dimensional stability of temporal fascia grafts might be contributing to failure of closure of tympanic membrane perforations in tympanoplasty.

Cholesteatoma↗

PubMed2006

Titanium mesh for functional reconstruction of the mastoid cortex after mastoidectomy.

OBJECTIVE: To describe a rapid and effective means of reconstructing the mastoid cortex after mastoidectomy for chronic otitis media with and without cholesteatoma. STUDY DESIGN: Retrospective. SETTING: Tertiary referral otology clinic. PATIENTS: Those undergoing tympanoplasty and mastoidectomy for chronic otitis media. INTERVENTION: After tympanoplasty and mastoidectomy, the mastoidectomy defect was reconstructed using titanium mesh with subsequent closure as routine. MAIN OUTCOME MEASURES: Evaluation of soft-tissue ingrowth into the mastoid 12 to 24 months after surgery and clinical evaluation of the postauricular surgical site for accentuation of the postauricular sulcus. RESULTS: In 99 patients, the mastoidectomy defect was reconstructed using titanium mesh. None was found to have pitting of the postauricular sulcus. One patient had partial extrusion of the mesh through the ear canal. No instance of wound infection was observed. Soft-tissue growth into the mastoid cavity was found to be minimized. CONCLUSION: Titanium mesh is a rapid and effective means of minimizing soft-tissue ingrowth into the mastoid and preventing accentuation of the postauricular sulcus after mastoid surgery.

Adolescent↗

PubMed1984

Congenital aural atresia. A new subclassification and surgical management.

The four surgical methods currently in use to improve hearing in patients with congenital aural atresia are (i) fenestration of the lateral semicircular canal, (ii) type III tympanoplasty, (iii) canal plasty and (iv) canal plasty with homograft tympanoplasty. Because the surgery is difficult and the functional results are not always good, the criteria for surgery are also influenced as to whether the anomaly is unilateral or bilateral and what the cosmetic goal is. When aural rehabilitation and cosmetic surgery are contemplated, co-ordinated planning by the otological and plastic surgeon is necessary to attain the best end result. Of the 36 ears with a type II anomaly operated on at the University of Nijmegen between 1972 and 1983 by the technique of canal plasty, the average hearing gain was 20 db, with 18 patients having a 35 dB or better air conduction threshold. The functional results seem to be related to the degree of malformation involved. Classification of the malformations has proved to be useful in discussing the surgical results.

Deafness↗

PubMed2005

Navigation-assisted construction of an external ear canal using an autogenous foreskin graft.

Classic microtia is combined with external ear canal atresia and middle ear malformation. In order to evaluate whether an operation to improve hearing ability and the use of computer-assisted surgery are indicated, preoperative high-resolution navigation CT is mandatory. We combined atresia surgery and tympanoplasty with auricular reconstruction in the case of an 8-year-old boy with bilateral microtia, aural atresia and malformation of the middle ear. After creating an auricle framework with rib cartilage and transplanting it under the skin of the mastoid plane, we shifted it forward in the second step, and the new auditory canal was drilled under computer-assisted navigation and facial nerve monitoring. In the same operation, tympanoplasty was accomplished, and a silastic cylinder, wrapped into pieces of rib cartilage, was inserted into the constructed canal and removed 2 months later. For lining the new auditory canal, we used the patient's prepuce, harvested by elective circumcision.

Child↗

PubMed2004

Anatomic and functional long-term results of canal wall-down mastoidectomy.

The objective of this study was to evaluate, over the long-term, the anatomic and functional outcome of canal wall-down mastoidectomy performed for chronic otitis media with cholesteatoma and chronic otomastoiditis resistant to all conservative treatment. The study was made through a retrospective review of 338 cases of consecutive primary canal wall-down mastoidectomies performed between 1974 and 1998. Included were 259 cases with sufficient data. In all cases, functional reconstruction was performed at the same time as the mastoidectomy. Demographic and clinical data were collected from each file. From the clinical data, the surgical techniques, complications, the number of follow-up visits necessary to ensure cavity cleanliness, details of care provided over the period 1 to 24 years (mean, 7 years) after the operation, and audiometric data from admission and from the latest postoperative follow-up were retained. Canal wall-down mastoidectomies were followed up an average of 10 times during the first 6 months after operation, twice a year over the 6-year period following surgery, and less than twice a year beyond the 6-year period. Care was dispensed for meatal stenosis, scars, infections, polyps, and beads of cholesteatoma. Surgical revisions were performed because of residual or recurrent cholesteatoma in 6.1% of the cases, because of perforation of the tympanic membrane in 7.3% of the cases, and to improve hearing in 12.2% of the cases. At the last consultation, 1 to 24 years after surgery, cavities were found to be dry and self-cleaning in 95% of the cases, and still humid, with otorrhea, in 5% of the cases. Over the long-term, the hearing threshold remained unchanged in 41.3% of the cases. It was improved after surgery by 10 to 19 dB in 15.4% of the cases, by 20 to 29 dB in 11.5% of the cases, and by more than 29 dB in 3.8% of the cases. The hearing threshold was thus improved or at least remained unchanged in 72.0% of cases. Hearing losses occurred in 28% of the cases: by 10 to 19 dB in 11.9%, by 20 to 29 dB in 6.5%, and by more than 29 dB in 9.2% of the cases. A sensorineural hearing loss of more than 60 dB at all frequencies occurred immediately after the operation in 2 cases (0.7%). There was 1 case of facial paralysis (0.3%). Four patients (1.5%) complained of persistent vertigo. Canal wall-down mastoidectomy is an adequate treatment for chronic otitis with cholesteatoma or chronic otomastoiditis. The anatomic and functional results are satisfactory, and the rate of complications is acceptably low. A tympanoplasty can be performed simultaneously. Thus, for the large majority of patients, only a single intervention is required; however, a small minority can benefit from a revision tympanoplasty. In order to obtain these results, both the patient and the surgeon should engage in a long-term follow-up.

Adolescent↗

PubMed1994

Tympanic membrane perforations and tympanostomy tubes.

Tympanoplasty and tympanostomy tubes were developed at the same time and have dramatically changed the treatment of chronic middle ear disease. One hundred forty-nine children who had tubes inserted between ages 6 months and 8 years for chronic otitis media with effusion have been prospectively followed up for an average of 4 years. Fourteen percent developed tympanic membrane perforations. No preoperative factor completely predicted the development of perforation. A majority of the perforations closed spontaneously. Three ears had noncontiguous observations of perforations during follow-up. The implications of these findings are discussed with respect to tympanoplasty.

Child, Preschool↗

PubMedDate not supplied

Antigenicity of tympano-ossicular homografts of the middle ear: analyses of immune response to viable and preserved grafts in animal models.

Primary and secondary response transplantation experiments in allograft tympanoplasty reveal that after various preservation procedures at least part of the original histoincompatibility between donor and recipient still exists. Clinical pathologic data are in accordance with this phenomenon. The abolished immune reactivity in successful allograft-tympanoplasty is placed in the light of acquired immunotolerance. The consequences of prior tissue-typing are discussed.

Animals↗

PubMed1988

Histologic study of homograft cartilages implanted in the middle ear.

We examined conditions of the micro-sliced homograft cartilages implanted in the middle ear, implanted cartilages removed at revision surgery or implanted cartilages removed at the second stage of staged tympanoplasty, both macroscopically and histologically. Macroscopically, the appearance and shape of the cartilages remained unchanged, with no evidence of erosion. There was no evidence of any foreign body reaction or rejection phenomenon. In general, no marked histologic changes of the matrix tissues were found, although chondrocytes showed degenerative changes. There was partial absorption of cartilage and replacement by fibrous connective tissue when inflammatory changes occurred in the middle ear. It is concluded that implanted homograft cartilage maintains its stiffness for more than 6 months in a healthy, aerated middle ear and appears to be clinically useful for tympanoplasty.

Cartilage↗

PubMedDate not supplied

[Otologic surgical procedures in an Ear, Nose and Throat Department in Subotica from 1987 to 2001].

INTRODUCTION: This paper deals with otologic surgical procedures performed in a an Ear, Nose and Throat Department during a 15-year period. The authors compared the number of otologic surgical procedures with the number of laryngomicroscopies and procedures performed in Waldeyer's ring. RESULTS: From January 1, 1987 to December 31, 2001, 1184 patients underwent the following surgical procedures in total endotracheal anesthesia: 285 paracenteses, 473 ventilation tubes insertions, 175 antrotomies or mastoidectomies, 194 tympanoplasties, 34 radical mastoidectomies, 4 facial nerve decompressions, 5 exostoses or osteoma of the external auditory canal operations and 14 stapedectomies. DISCUSSION: Otologic surgical procedures are presented in table 1. In Yugoslav literature Topolac reports approximately 700 tympanoplasties in a 10-year period (1968-1978). Radonjić and associates report 2272 ear operations in the period 1975-1985. Distribution of operations is presented in table 2, whereas in table 3 we can see that the number of operated ears is much greater than the number of operated patients. CONCLUSION: We think that the number of operations is not bigger, because we operate only in critical cases. Our human and technical resources should provide advanced ear microsurgery, but only with financial and organizational support.

Hospital Departments↗

PubMed2003

[Congenital auditory ossicle malformation without external ear abnormality].

In 29 ears of 24 patients with auditory ossicle malformation, but without external ear abnormalities, who were operated on at our clinic in the 10 years between June 1993 and June 2002, we studied the condition of ossicles, preoperative examination, surgical procedures, and postoperative hearing improvement. Our study did not include patients with cholesteatoma or those with only fixed stapes but without ossicular deformity. Samples were 12 ears of 11 men and 17 ears of 13 women. We clinically distinguished 3 major categories: (i) discontinuity between the incus and stapes with mobile stapes, (ii) congenital fixation of the stapes with ossicular deformity, and (iii) congenital fixation of the malleus and deformity of the incus with mobile stapes. We classified each category into minor abnormalities based on the condition of the long process of the incus, the superstructure of the stapes, and the stapes footplate. We conducted auditory ossicle reconstruction by mobilization of the malleus and incus in 2 ears, by type III tympanoplasty in 5 ears, by type IV tympanoplasty in 13 ears, and by stapes surgery in 8 ears. Improvement in hearing after the operation was observed in 25 of the 29 ears treated. In the classification of the auditory ossicle malformation without external ear abnormalities, we should evaluate discontinuity or fixation of the ossicles and their deformity. This requires that varied ossicular reconstruction be prepared for surgery, but the possibility of hearing improvement is high, so intensive treatment is needed in many cases of auditory ossicle malformation.

Adolescent↗

PubMed2003

[Sclerotic changes in ossicular ligaments in human temporal bone pathology].

When tympanoplasty is performed for conductive hearing loss due to otitis media, hearing recovery may not be as good as anticipated preoperatively. Sclerotic changes may therefore exist in the conduction system of the middle ear. To clarify the relationship between middle ear inflammation and sclerotic changes of middle ear sound conduction, particularly of the ossicular ligaments, specimens of human temporal bones were studied. Histology of the anterior malleal ligament, posterior incudal ligament, and stapediovestibular ligament was examined in 636 ears from 367 individuals (postmortem) ranging from infancy to 90 years old and without blood disease, neoplasm, anomaly, or cholesteatoma. Only small numbers of acute and subacute inflammatory were identified, but sclerotic changes in ligaments were compared between normal and chronically inflamed ears. In anterior malleal and posterior incudal ligaments, the severity of sclerotic hyalinization and calcification increased with age in normal ears, but sclerotic changes in chronically inflamed ears were more severe than in normal ears and displayed a reduced association with age. Conversely, sclerosis of the stapediovestibular ligament was less severe than that of the anterior malleal and posterior incudal ligaments in both normal and chronically inflamed ears, and displayed a reduced relationship with age. The sclerotic changes apparent in the anterior malleal and posterior incudal ligaments therefore seem to be more readily influenced by inflammation than by age. Sclerotic changes of the stapediovestibular ligament are not as severe as those of anterior malleal and posterior incudal ligaments. For cases in which tympanoplasty of inflamed ears is planned, mobility of the anterior malleal and posterior incudal ligaments should be tested independent of testing of the stapediovestibular ligament. When mobility of anterior malleal and posterior incudal ligaments is not as good as mobility of the stapediovestibular ligament, surgical modification of the anterior malleal and posterior incudal ligaments may be advisable.

Adolescent↗