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PubMed1981

Phase reversal in brain stem responses: its use in the detection of asymmetry in the auditory pathways.

Electrode placement is an important consideration in the recording of a large-amplitude stable response. In this study, brain stem auditory-evoked potentials (BAEP) were obtained from subjects and patients under two electrode configurations, namely 'vertex-mastoid' and 'mastoid-mastoid'. The BAEP waveforms to ipsilateral, contralateral and binaural stimulation were examined for their phase relation with respect to stimulation. In the mastoid-mastoid recording mode, a complete polarity reversal was shown upon changing stimulation from the ipsilateral (with respect to the active input) to the contralateral ear. On simultaneous binaural stimulation, the response was shown to summate to zero. This observation has led to the objective assessment of asymmetry of hearing. Several patients exhibiting recruitment were tested under the mastoid-mastoid recording configuration with binaural stimulation. The results show that a summated 'null' response only occurs at an intensity level where loudness equality is attained at the two ears and recruitment is complete. Applied in this way the technique has promising application in the determination of the presence or absence of recruitment and hence in the differential diagnosis of cochlear and retrocochlear lesions.

Auditory Pathways↗
PubMed2003

Using high resolution computed tomography to evaluate middle ear cleft aeration of postoperative cholesteatoma ears.

BACKGROUND: Middle ear cleft mucosa and mastoid air cells are important for middle ear cleft aeration. However, the postoperative cholesteatoma ears treated in traditional open or closed techniques are often complicated by an atelectatic condition. In order to preserve the healthy mastoid air cells and also eradicate the cholesteatoma completely, we treated cholesteatoma ears by "tailored mastoidectomy with cartilage obliteration of the open cavity." METHODS: We used high resolution computed tomography (HRCT) to evaluate middle ear cleft aeration of postoperative cholesteatoma ears. Statistical analysis were used to investigate the correlation between postoperative milddle ear cleft aeration and associated clinical factors such as middle ear mucosa condition found intraoperatively (intact or defective), stage of cholesteatoma, level of mastoid pneumatization, range of cartilage obliteration, and tympanoplasty type. RESULTS: Forty-four cholesteatoma ears of forty-three patients (aged 13 to 74 years) underwent tailored mastoidectomy with cartilage obliteration of the open cavity from 1988 to 1998. Aeration of the middle ear cleft was evaluated using HRCT performed in a mean of 6.77 years after surgery. There was no aeration in 10 ears (22.7%), aeration only in the tympanic cavity in 19 ears (43.2%), and aeration in both the tympanic and mastoid cavities in 15 ears (34.1%). There were 26 ears (59.1%) with intact and healthy mucosa and 18 ears (40.9%) with defective mucosa. The correlation between the mucosal condition and recovery of middle ear cleft aeration was significant (r = 0.6855, p < 0.001). Recovery of aeration was negatively correlated with the stage of cholesteatoma (r = -0.4951, p = 0.0156) and positively correlated with the level of postoperative mastoid pneumatization (r = 0.8036, p < 0.001). CONCLUSIONS: Preserving healthy middle ear cleft mucosa and uninvolved mastoid air cells during cholesteatoma surgery enables gas-exchange through the remaining mucosa and maintains the pressure buffering effect of the mastoid, both of which are important for recovery of middle ear cleft aeration. HRCT is useful for the postoperative evaluation of middle ear cleft aeration.

Adolescent↗
PubMed1977

Mastoidectomy update.

The long-term results of 375 primary mastoidectomy operations for chronic otitis media and chronic mastoiditis are described and discussed. Two-thirds of these cases were open cavity mastoidectomies and 1/3 closed cavity mastoidectomies. Primary pathology was cholesteatoma in 1/3 and granulation tissue in 2/3 of the cases. The method of reducing the size of the mastoid cavity by sculpturing mastoid cavity by sculpturing mastoid cortical bone is most important in avoiding large postoperative cavity problems. Principles and methods are described. Healing (dry ear) is a more important management objective than hearing and, indeed, enhances the prospects of obtaining a long-term hearing result. Three important phases of controlling mastoid disease (preoperative, operative, and postoperative) are equally stressed. Intact wall tympanomastoidectomy is not recommended in sclerotic mastoids (the majority of our cases) as being unsafe and unnecessary. Revisions, mostly minor, were done in 31% of the cases for a total of 521 procedures. We recomment a one-stage tympanomastoidectomy. Multiple planned procedures are, in the main, unnecessary and should be avoided to reduce unnecessary hospitalization and expense.

Adolescent↗
PubMed2005

Cholesteatoma surgery in pneumatized and non-pneumatized temporal bones.

BACKGROUND: This report compares the different surgical methods for large and pneumatized mastoid cavity (large cavity) and small and poorly pneumatized mastoid cavity (small cavity) cholesteatomas and their results for the facial nerve and mastoid cavity. METHODS: In the period from January 1996 to December 2000, 101 ears with cholesteatomas underwent tympanoplasty with mastoidectomy. In the large cavity group, the posterior canal wall was removed and the vertical portion of the facial nerve was skeletonized to lower the facial ridge. Partial obliteration with conchal cartilage and perichondrium at the epitympanum and mastoid tip was used to make the external auditory canal and the mastoid a smooth common cavity without reconstruction of the posterior canal wall. In the small cavity group, the facial ridge was not intentionally lowered as long as the cholesteatoma was completely removed. The whole mastoid cavity was obliterated and the posterior canal wall was reconstructed. The newly reconstructed posterior canal wall was composed of preserved facial ridge in the lower part and obliterated conchal cartilage in the upper part. RESULTS: There were 27 ears with large cavity cholesteatomas and 74 with small cavity cholesteatomas. The incidences of postoperative complications (large cavity versus small cavity) were: facial paralysis, 3 versus 0; minor wound infection, 2 versus 8; flap partial necrosis, 1 versus 4; cartilage partial necrosis, 0 versus 2; external auditory canal stenosis, 0 versus 2; residual drum perforation, 3 versus 3; otitis media with effusion, 3 versus 4; recurrent cholesteatoma, 0 versus 2; and residual cholesteatoma, 1 versus 2. CONCLUSION: Significantly more postoperative facial nerve paralysis in the large cavity group was correlated to skeletonization of the facial nerve and treatment of the facial ridge.

Cholesteatoma↗
PubMedDate not supplied

Cholesteatoma surgery: residual and recurrent disease. A review of 1,024 cases.

This is an analysis of 1,024 primary cases of mastoid surgery for cholesteatoma operated upon during a ten-year period at the Otologic Medical Group, Inc. Our philosophy of management of the mastoid in these cases has been as follows: 1) avoid an open mastoid cavity when possible; 2) perform the operation in two stages if necessary; 3) reexplore the mastoid and middle ear for residual cholesteatoma when indicated. One-third of 380 revised cases had residual cholesteatoma, disease left by the surgeon. In 260 cases in which the surgeon felt it unlikely that there was residual disease he found it in 23%. In 4% this residual cholesteatoma was found in the mastoid. The incidence of residual cholesteatoma was higher in children and in planned, as opposed to unplanned, revisions. Residual cholesteatoma was detected in the middle ear more frequently than in the epitympanum, and in the epitympanum more frequently than the mastoid. Indications for, and timing of, the reexploration are discussed. Recurrent cholesteatoma refers to a retraction pocket and must be differentiated from residual cholesteatoma; the causes, prevention and treatment are different. Recurrent cholesteatoma was detected in 5%. The most common complication of the disease was a labyrinthine fistula (10%). Operative facial nerve damage occurred in one case. The most common postoperative complication was graft failure (3%). Intact canal wall tympanoplasty with mastoidectomy should be performed as a two-stage procedure in most cases when used in the treatment of aural cholesteatoma.

Adolescent↗
PubMed1984

A study of auditory middle latency responses in relation to electrode combinations and stimulus conditions.

Auditory middle latency responses were recorded from healthy right-handed subjects. Acoustic clicks at a rate of 10/s were presented to the subjects via headphones. Using the electrode combination unilateral mastoid-nose tip, responses characterized by two early negative waves (about 11.5 and 18 ms peak latencies), followed by a late positive one (about 30 ms peak latency), were elicited by binaural stimulation (50-dB SL clicks). The waveform of responses from the unilateral mastoid-nose tip combination was similar to that recorded from a combination of the same side mastoid and a balanced noncephalic reference electrode, although the phase was opposite to that recorded from the Cz-unilateral mastoid combination. Auditory middle latency responses were recorded simultaneously from right mastoid and left mastoid and referenced to the nose tip; interaural differences in amplitude were found in most subjects. The amplitudes of the early components for binaural stimulation were larger than those for monaural stimulation.

Acoustic Stimulation↗
PubMed1995

Otitis media in developing countries.

OBJECTIVE: This article reviews the available information concerning the disease burden, epidemiology, and etiology of otitis media in developing countries and the likelihood that case management with appropriate antibiotic therapy can reduce the burden of this disease. METHODOLOGY: The available literature was reviewed to determine the extent to which otitis media impacts mortality and morbidity in developing countries. EPIDEMIOLOGY: In community studies, perforation was present in 0.4% to 33.3% of children and youth; otorrhea occurred in 0.4% to 6.1%; and mastoiditis occurred in 0.19% to 0.74%. In school surveys, perforation was identified in 1.3% to 6.24% of students, and otorrhea was found in 0.6% to 4.4%. Mastoiditis was diagnosed in 18% of children and youth who presented to a hospital ear, nose, and throat (ENT) clinic in Uganda. The proportion of patients presenting to ENT clinics with mastoiditis regardless of their initial symptoms varied from 1.7% to 5%. Patients presenting to these ENT clinics with mastoiditis often experience severe complications, including subperiosteal abscess, labyrinthitis, facial palsy, meningitis, and brain abscess. Hearing impairment was a major public health problem compromising the quality of life in approximately one third of the population of developing countries. ETIOLOGY: The pathogens isolated from ear aspirates in children with acute otitis media and chronic suppurative otitis (CSOM) carried out in developing countries are similar to those isolated in studies carried out in developed countries. CASE MANAGEMENT: Historical data supports the effectiveness of antibiotic therapy in reducing the frequencies of mastoiditis and CSOM complicating acute otitis media. In addition, the introduction of primary care services targeted at otitis media for high-risk populations living in developed countries may have reduced the prevalence of mastoiditis and CSOM. However, it is not clear whether there is a causal relationship between these programs and the reduction because of the use of historical controls. CONCLUSIONS: International research organizations should support controlled intervention studies to document the impact of case management of otitis in developing countries. In addition, the efficacy of a conjugated pneumococcal vaccine to prevent otitis and its complications should be evaluated in a developing country site. Pending the results of studies, developing countries should develop primary care case management programs to diagnose and treat otitis and its associated complications.

Acute Disease↗
PubMedDate not supplied

Sinonasal computed tomography in patients with Wegener's granulomatosis.

The goal of this study was to describe pathologies of sinonasal CT in patients with Wegener's granulomatosis. Between 1993 and 2004, sinonasal CT was performed in 28 patients (15 male, 13 female) with Wegener's granulomatosis. The following imaging findings were assessed on the CT scans: mucosal thickening, subtotal opacification, air-fluid level, bony destruction, sclerosing osteitis, bony thickening, orbital mass, and saddle nose deformity. Of the 28 patients, 61% showed mucosal thickening in the nasal cavity and 75% in the paranasal sinuses. A subtotal opacification of the paranasal sinuses was detected in 25%, and of the mastoid cells in 7% of patients. Fifty-seven percent of patients had bony destruction of the nasal cavity, and 54% of the paranasal sinuses. CT revealed sclerosing osteitis of the paranasal sinuses in 21%, and of the mastoid cells in 18% of patients. Bony thickening of the paranasal sinuses was detected in 18%, and of the mastoid cells in 14% of patients. With respect to all imaging findings, the maxillary sinuses were the most frequently affected paranasal sinuses. The authors conclude that the following sinonasal CT findings are observed in patients with Wegener's granulomatosis: (1) bony destruction, mainly of the nasal cavity, maxillary sinuses, and mastoid cells; (2) sclerosing osteitis, mainly of the maxillary sinuses and mastoid cells; (3) bony thickening, mainly of the maxillary sinuses and mastoid cells; and (4) mucosal thickening, mainly of the maxillary sinuses. These findings are, however, nonspecific and should be combined with other clinicopathologic and laboratory studies to confirm the diagnosis of Wegener's granulomatosis.

Adult↗
PubMed2003

Otomastoiditis-related facial nerve palsy.

A 9-year-old girl with persistent otitis media, despite antibiotic therapy developed a facial nerve palsy. Computed tomography (CT) scan revealed ipsilateral mastoiditis, prompting admission for intravenous antibiotic and steroid therapies. Acute mastoiditis, uncommon in the post-antibiotic era, is usually diagnosed on physical examination findings, but two variants, masked mastoiditis or silent mastoiditis, may be difficult to appreciate clinically. Patients who present with facial nerve palsy in the setting of persistent otitis media should undergo CT scan for evaluation of intracerebral or extracerebral pathology, including mastoiditis. Failure to identify associated concomitant pathology may result in treatment failure or persistent neurological deficit.

Anti-Bacterial Agents↗
PubMed1993

Treatment of cholesteatoma and retraction pockets.

Treatment of retraction pockets (RP) and cholesteatomas depends on their nature and evolvement and the size of mastoid pneumatization. RP are secondary to vacillating middle ear negative pressure. Treatment when necessary consists of placing a ventilating tube, excision of the RP or both. In most children and adults, cholesteatoma is derived from RP (or "atelectasis") of the tympanic membrane, where it can be termed "retraction pocket" cholesteatoma or "secondary" cholesteatoma. This type of cholesteatoma is associated with a non-pneumatized mastoid coupled by negative pressure. Approximately one-third of children's cholesteatomas present clinically behind an intact drum despite a pneumatized mastoid. Pathogenetically this type may be "congenital" or "metaplastic" and should be best termed "primary" cholesteatoma. Central perforations associated with cholesteatoma are probably derived from continuous tympanic membrane destruction by infection in cases of RP cholesteatomas or due to a primary cholesteatoma bursting out from the tympanic cavity. Canal-up surgery of cholesteatoma fails in 60% of cases at Tel Aviv University because of the inherent tendency of the tympanic membrane to retract once again. Residual disease was found in our cases to be a lesser cause for failure. Treatment depends on the type of cholesteatoma, emphasizing small "radicals" in sclerotic mastoids. When a pneumatized mastoid is encountered, a posterior tympanotomy should be considered.

Adult↗
PubMed1988

Transmastoid encephaloceles. A case report.

Encephaloceles are uncommon abnormalities occurring in the pediatric age group. For the otolaryngologist they are usually encountered in the nasopharynx or nose, but may also be found in other sites adjacent to the brain. Encephaloceles usually develop as a result of prior mastoid surgery, trauma, or infections; but it is extremely rare for large encephaloceles to occur congenitally in the mastoid. It is even more uncommon for there to be a second mastoid defect which would allow the brain to present as a subcutaneous postauricular mass. The case history of a child with congenital subcutaneous transmastoid encephalocele is presented and the management discussed. In this child, the right temporal lobe of the brain herniated through a congenital defect in the tegmen and then through the mastoid cavity to exit through a lateral wall defect in the mastoid cortex. It then presented as a postauricular subcutaneous mass. The initial diagnosis was a subperiosteal abscess. The correct diagnosis was not made until surgery despite a normal preoperative CT evaluation. The world literature is reviewed and similar diagnostic and therapeutic problems are discussed.

Child, Preschool↗
PubMed1998

Postauricular myocutaneous flap in otologic surgery.

Management of a large mastoid defect resulting from skull base operations or extensive surgical procedures because of chronic ear disease continues to challenge the otologic surgeon. Various local muscle or periosteal rotation flaps have been used to help reduce the size of the postoperative mastoid cavity. With these techniques there are problems with flap retraction and epithelization that may result in delayed healing or chronic drainage. Closure of the ear canal and tissue obliteration of the mastoid results in a maximal conductive hearing loss. A postauricular myocutaneous flap based on the occipital artery and sternocleidomastoid muscle has been used effectively to reconstruct mastoid defects after both surgical procedures for chronic ear disease and skull base operations. The skin muscle flap reduces the mastoid cavity and promotes rapid healing of the surgical defect. Although postauricular myocutaneous flaps have been found to be reliable, their viability may be compromised by arterial embolization used in larger glomus tumors. Indications for and creation of a postauricular myocutaneous flap, with results in 18 cases, are presented.

Adolescent↗
PubMed1999

A case of bilateral eosinophilic granuloma in the temporal bone.

We present a case of bilateral eosinophilic granuloma in the temporal bone in a 47-year-old woman, who visited our hospital with a headache and a feeling of occlusion in her left ear. Her left tympanic membrane was slightly turbid and pure tone audiometry revealed mild left sensorineural deafness. CT disclosed a shadow of soft tissue in the left mastoid antrum and mastoid cells, which was indicative of marked destruction of the bone. Because MRI findings led us to suspect otitis media cholesteatoma, a mastoidectomy was performed. The mastoid antrum and mastoid cells were filled with easily bleeding granulation, and there was a wide range of bone deficit in the posterior cranial fossa. Histopathologically, the granulation tissue was an eosinophilic granuloma. Her postoperative clinical progress was good and she was discharged. However 2 months after discharge, she had a feeling of occlusion in the right ear and CT revealed a shadow in the right mastoid antrum and cells. Therefore, right tympanoplasty was performed and the same findings as in the left ear were obtained. A histopathological diagnosis of eosinophilic granuloma was made again. To date, there has been no recurrence.

Audiometry, Pure-Tone↗
PubMed1981

Mastoidectomy for chronic serous otitis media.

The purpose of this paper is to show that satisfactory results following mastoidectomy can be obtained for the problem of chronic serous otitis. The success of the simple mastoid operation or mastoidectomy with facial recess approach and the subsequent increased aeration of the mastoid-antral-attic-middle-ear complex is to be suggested when the repeated use of myringotomy tubes alone is not the answer to chronic serous otitis. It is chronic negative pressure due to eustachian tube dysfunction that leads to irreversible mastoid disease. Seven cases of mastoidectomy for chronic serous otitis media are presented. All cases had adequate conservative medical and surgical treatment over a period of years for chronic serous otitis before mastoidectomy wa considered. The clinical history, as well as lateral mastoid X-ray, was used in diagnosing irreversible mastoid disease.

Adolescent↗
PubMed2005

[Management of occult malformations at the lateral skull base].

BACKGROUND: Occult malformations of the lateral skull base are rare anomalies, but can cause severe complications such as recurrent meningitis. Therefore, they need to be precisely delineated and sufficient surgical closure is mandatory. PATIENTS AND METHODS: Between 1986 and 2004 twenty patients (10 children and 10 adults) with occult malformations at the lateral skull base were treated surgically at the ENT-Department of the Hospital Fulda gAG. Of these 3 Mondini-malformations, 11 defects of the tegmen tympani or the mastoidal roof, 2 dural lesions to the posterior fossa and 4 malformations within the pyramidal apex have been found. Four patients have had multiple anomalies. Routing symptom was in all cases at least one previous meningitis. Radiological diagnostics included high-resolution computed tomography (CT) and magnetic resonance imaging (MRI) as well as CT- or MR-cisternography. Depending on type and localisation of the defect the following surgical algorithm was carried out: The trans-mastoidal approach was used in all cases of Mondini-malformation (including obliteration of the ear), in case of lesions to the posterior fossa as well as partly in anomalies at the tegmen tympani and mastoidal roof, respectively. Defects of the pyramidal apex should be explored via the trans-mastoidal way if the lesion is located caudally to the inner auditory canal (IAC), whereas the trans-temporal approach should be used if the lesion is situated ventral to the IAC and dorso-medially to the internal carotid artery (ICA). The trans-temporal approach was also performed in large defects of the tegmen tympani and mastoidal roof as well as in recurrences. CONCLUSIONS: In all cases of recurrent meningitis caused by agents of the upper airway tract the basic principle should be to search for occult skull base malformations radiologically as well as by sodium fluorescein endoscopy as long as the anomaly is detected.

Adolescent↗
PubMed2003

Middle ear gas exchange in the air phase.

OBJECTIVE: The rate of gas exchange between the tympanum and mastoid is important for middle ear pressure regulation. The best-studied model of middle ear pressure regulation is the cynomolgus monkey. The aim of this study was to determine the time required for the equilibration of tympanum and mastoid partial pressures for two inert gases, argon and helium, in cadaveric cynomolgus monkey middle ears. MATERIAL AND METHODS: In separate experiments on 5 air-dried temporal bones from monkeys, helium or argon was introduced into the tympanum to bring the total pressure to 300 mmH2O above ambient and the partial pressures of all relevant gases in the tympanum and mastoid were measured using mass spectrometry at 0, 1, 3, 5, 10 or 15 min. RESULTS: The average ratios of tympanum:mastoid partial pressure at 0 min were 4.7 +/- 1.9 and 3.9 +/- 2.0 for helium and argon, respectively. By 5 min those ratios had decreased to 1.2 +/- 0.2 and 1.1 +/- 0.1, respectively, suggesting approximate equilibrium. CONCLUSIONS: Air-phase gas exchange between the tympanum and mastoid is rapid. Partial-pressure gradients across the middle ear will be dissipated quickly and are not an important contributor to middle ear pressure regulation in the studied model.

Animals↗
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

Serous otitis media revealing temporal en plaque meningioma.

OBJECTIVES: To present a series of temporal en plaque meningiomas involving the middle ear or mastoid, whose main symptoms suggested a serous otitis media. STUDY DESIGN AND SETTINGS: Multicentric retrospective study reviewing clinical records originating from eight tertiary referral centers. MATERIALS AND METHODS: The clinical records of 10 patients presenting with signs and symptoms suggesting serous otitis media and whose neuroimaging studies revealed a temporal en plaque meningioma involving the middle ear or mastoid are reported. RESULTS: All the patients were women, ranging from 49 to 71 years old. The delay between the onset of symptoms and the diagnosis of meningioma varied from 1 to 10 years. All the patients underwent various procedures usually applied for the treatment of serous otitis media, which failed in all the cases, particularly ventilating tube placement, which was followed by severe episodes of discharge. In all cases, the computed tomographic scans showed three imaging signs: soft tissue mass filling the middle ear or mastoid, hyperostosis of the petrous bone, and hairy aspect of the intracranial margins of the affected bone. This imaging triad must alert the otologist of the possibility of intracranial meningioma. Magnetic resonance imaging was the method of choice to assess the diagnosis of intracranial meningioma involving the middle ear or mastoid. When analyzing management options, it appeared that conventional middle ear procedures were inefficient. CONCLUSION: Temporal en plaque meningioma involving the middle ear or mastoid can mimic a serous otitis media. A computed tomographic scan is recommended for cases of atypical or prolonged unilateral serous otitis media to investigate indirect signs of a meningioma, which has to be confirmed with magnetic resonance imaging.

Aged↗