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Nocardia asteroides brain abscess occurred after mastoidectomy and tympanoplasty in a previously healthy 10-year-old boy. Combined surgical excision and trimethoprim/sulfamethoxazole therapy resulted in significant improvement.
Osteoma in the external auditory canal (EAC) is an uncommon benign lesion, which presents as a solitary, unilateral, and slow-growing pedunculated mass in the outer half of the bony canal. It is usually asymptomatic; but symptoms can arise if a canal obstruction occurs. External canal cholesteatoma is also a rare lesion of the external auditory canal. Cholesteatoma of the external auditory canal may arise via several mechanisms. However, an occlusion or narrowing of the external auditory canal is the basic pathogenesis. The association of an osteoma with a cholesteatoma is extremely rare, and there have been very few reports published. We encountered a rare case of a 49-year-old man with an osteoid osteoma that was complicated by a cholesteatoma in the external auditory canal. The canal wall down mastoidectomy and tympanoplasty successfully removed the osteoma and the cholesteatoma, and no recurrence or complications had occurred in the first 6 months postoperatively.
OBJECTIVES: The new endogenous substance N-chlorotaurine (NCT), which for the first time was synthesized and introduced into clinical practice by our research group, was now used for postoperative ear care following tympanoplasty. The antiseptic and drying effect of NCT was evaluated and compared to the standard postoperative procedure in our department. METHODS: Prospective randomized trial on 10 patients. Local irrigations of the external auditory canal with 1% NCT solution were performed once daily until the canal was dry. RESULTS: NCT was well tolerated. The external auditory canal showed no signs of infections and dried significantly more rapidly than the control group. In contrast to previous suppositions, epithelialization proceeded without complications and was identical in both groups. CONCLUSIONS: As NCT in our first postoperative patient study was effective in preventing infections and drying of the outer ear canal was faster without impairing epithelialization, this agent seems useful for postoperative ear care.
OBJECTIVE: This study was designed to compare clinical features, surgical findings and treatment results from children and adults affected by aural acquired cholesteatoma. METHODS: a retrospective review of 60 children (Group I: mean age 8.8 years, range 3-16 years) and 308 adults (Group II: mean age 45.4 years, range 18-81 years) with aural acquired cholesteatoma who underwent surgery from January 1992 to December 2002, was performed with a follow-up of 5 years. All patients were submitted to single-staged canal wall down tympanoplasty. Variables analysed were otoscopic features, extent of cholesteatoma, surgical findings and the rate of recidivism. RESULTS: The pathologic changes in the tympanic membrane were no different in the two groups. According to Stangerup et al. 40 cases (66.6%) of children were classified as stage III or more, with a significant higher incidence compared to adults (152 cases; 49.3%). Analysis of the ossicular chain state showed, in group I, a significant higher incidence of eroded or absent incus (76.6% versus 61.68%) and malleus (76.6% versus 56.48%), if compared to adults. Children, therefore, had a significantly higher risk of recurrence with a rate of 26.6% in Group I and 6.81% in group II. After surgery the mean gain measured in children group, was 11 dB and 13 dB in adults. CONCLUSION: In our study we found that the behaviour of cholesteatoma in children appears more aggressive than in adults. In fact, we found a greater extension of the cholesteatoma, a worse state of the ossicular chain and a higher incidence of recurrence. Therefore, we obtained acceptable hearing results both in children and in adults.
OBJECTIVE: To identify the incidence of dehiscence of the facial nerve in patients undergoing surgery for cholesteatoma and to describe its relevance with iatrogenic facial nerve injury. STUDY DESIGN AND SETTING: This was a retrospective study including 117 tympanoplasties with or without mastoidectomy performed in 49 men and 66 women. RESULTS: The presences of FND after exenteration of disease are 33.3% of total surgical procedures, 33% of the initial procedures, and 37.5% of the revision procedures. The locations of facial nerve dehiscence were 87.2% in only the tympanic segment, 7.7% in only the vertical segment, and 5.1% in both the tympanic and vertical segments. CONCLUSIONS AND SIGNIFICANCE: The incidence of facial nerve dehiscence is high (33.3%) in our study. The surgeon should keep in mind that the location of facial nerve dehiscence with cholesteatoma is comparable with the most common area of iatrogenic facial nerve injury during otologic surgery.
OBJECTIVES: Postoperative attic retraction pocket is a critical issue and may be indicative of disease recurrence after canal-up tympanoplasty for middle ear cholesteatoma. Although scutum plasty is an acceptable procedure that can be used to prevent the pocket formation, how the scutum is reconstructed has remained controversial. The aim of this study was to clarify the value of scutum plasty using bone pate. STUDY DESIGN: Retrospective study. SETTING: Bone pate scutum plasty was performed in 69 ears during first-stage operations. We attempted to reconstruct a smooth attic bony wall. At the time of the second-stage operations, the results of the scutum plasty were examined. RESULTS: The incidence of retraction pocket was statistically reduced from 20.2% to 5.8%. CONCLUSION: Although the reconstructed scutum showed atrophy to some extent, bone pate scutum plasty is effective in preventing postoperative retraction pocket if a smoothly shaped attic wall can be reconstructed.
The Eustachian tube disfunction and abnormalities in gas exchange through the middle ear mucosa may produce negative pressure and retraction pockets, adhesions, atelectasis and cholesteatomas. If this problem is present postoperatively, it may again lead to retraction, reperforation, and/or extrusion of the reconstructed ossicular chain. This applies especially if conventional autologous material, such as fascia and perichondrium, are used to reconstruct the tympanic membrane. This paper reviews the indications, surgical technique, and functional results of 23 tympanoplasties using cartilage and titanium prostheses, with range follow-up of 20-55 months and a mean of 30 months. Seven out of sixteen canal wall down (43.7%) and three out seven canal wall up (42.9%) had a postoperative air-bone gap between 0 and 10 dB.
In order to secure both long-lasting carefree ears and hearing-preservation/restoration, the best method to apply is the closed-method tympanoplasty, especially for cholesteatomatous otitis media in children. We agree with this method, in spite of the high percentages of postoperative residual cholesteatoma in children. Until a better way of irradicating cholesteatoma becomes available, either staged operations or periodical check-ups for many years are mandatory. While postoperative attic retraction/cholesteatoma formation seems to be preventable in most cases, the rate of residual cholesteatoma is very high in our data and in other reports. Looking for a reason, the differences between the cholesteatoma in children and those in adults are to be investigated in macro-, micro- and ultramicroscopic observations. In addition, basic rather than clinical studies on cholesteatoma in children are requested.
This study describes 20 years' experience with autogenous temporalis fascia that is formed and shaped by formaldehyde cross-linking with special Fasciaform (Hear America, Palo Alto, Calif.) molds in the repair of large tympanic membrane perforations. One hundred twenty operations in 113 patients were performed between 1973 and 1993 to close large perforations in patients with intact ossicular chains. All perforations were successfully closed by this technique. Audiometric studies indicated that the postoperative air-borne gap was closed to within 0 to 10 dB in 63% and to within 0 to 20 dB in 97%. One patient had a 15-dB sensorineural hearing impairment. Graft lateralization requiring revision occurred in three patients, two of whom had previous unsuccessful tympanoplasties. Comparisons of adult vs. pediatric groups and primary vs. revision groups were made. The technique ensures the removal of any ectopic epithelium on the medial surface of the tympanic membrane remnant and provides for easy graft placement and stability during healing without the use of middle ear Gelfoam (Upjohn Co., Kalamazoo, Mich.). The formaldehyde-formed fascia graft or Fasciaform graft technique provides an effective method of closing large perforations with excellent functional results and minimal complications.
From 1965 to 1978, 122 children with cholesteatoma had one-stage surgery. Follow-up examinations were carried out several times, with the last two taking place in 1980/81 and 1985/86. Ninety-eight percent of the children were seen at follow-up; the median observation time was 11 years, with a range of three to 21 years. The increase in recurrence rate with increasing observation time was analyzed. In 1980/81 there was a total recurrence rate of 12 percent of patients, including residual cholesteatoma in the tympanic cavity in 8%, in the attic in 2%, and recurrent cholesteatoma in 2%. In 1985/86 the recurrence rate had increased to 17%, distributed among residual cholesteatoma in the tympanic cavity in 10.6%, in the attic in 1.6%, and recurrent cholesteatoma in 4.8%. The recurrence rate was the same regardless of whether modified canal-wall-up mastoidectomy or canal-wall-down mastoidectomy had been employed. We conclude that cholesteatoma surgery should be individualized according to pathologic findings in the tympanic cavity, tubal function, and size of the mastoid air cell system. Small cholesteatomas confined to the tympanic cavity may be removed by tympanoplasty alone, without mastoidectomy. In ears with adhesive otitis, canal-wall-down mastoidectomy is preferred; and in ears with a reasonably good tubal function and a large air cell system, canal-wall-up mastoidectomy is recommended. The long-term results reported here seem to indicate that, in children, canal-wall-up mastoidectomy is preferable to canal-wall-down mastoidectomy.
In this report, we presented 3 cases of congenital middle ear cholesteatoma which occurred in a 12-year-old girl, a 4-year-old boy, and a 6-year-old boy. In all 3 cases, there was a whitish mass behind a normal tympanic membrane. Congenital middle ear cholesteatoma is not a rare disease. In the early stage, it is asymptomatic. But when it progresses, this disorder can destroy conductive systems of the middle ear and cause many symptoms. One patient (Case 1) had a complaint of hearing impairment. She underwent mastoidectomy and tympanoplasty; however, the cholesteatoma recurred. The other 2 patients had no symptoms. The abnormal appearance of their tympanic membrane was found by chance at their local otologists. We performed tympanotomies and removed cholesteatomas without aftereffects. When otologists note an abnormal appearance behind a normal tympanic membrane, with or without symptoms, tympanotomy should be done due to the possibility of congenital middle ear cholesteatoma.
In the eight years from 1973 to 1980, we performed tympanoplasty on approximately 350 cases, in 50 of which malleostapediopexy was undertaken. Postoperative hearing improvement occurred in 86%. Hearing further improved as compared with that at the third postoperative week occurred in 17 of 31 long-term follow-up cases (55%). Malleostapediopexy proved satisfactory in that it could be applied if the malleus and stapes were intact, it was technically simple, requiring no higher skill, and produced good improvement of hearing.
Since 1981, we have used the stapes allograft, singly or in combination with homograft incus, in 20 cases of tympanoplasty and in 7 cases of fixed stapes. All of the allograft stapes discussed were procured, processed and stored in 1980 by the Hyogo Ear Bank, the first to be established in Japan. The stapes allograft was used in three situations: an intact posterior canal wall, an open mastoidectomy cavity, or a fixed stapes (postinflammatory, congenital or otosclerotic). Two modalities of positioning of the donor stapes were attempted: (1) the allograft stapes was placed in the normal position and a shaped incus or cortical bone or tragal cartilage was placed on the top of the stapedial head and connected and (2) the allograft stapes was placed in the upside-down position and the columella was placed on the stapes footplate. Better results were obtained with the allograft stapes placed in the normal position. A two-stage operation, first to place an allograft stapes in the normal position with myringoplasty and then ossiculoplasty, was preferable to one-stage middle ear surgery.
Our method of improving hearing in patients with old radical cavity is presented. Tympanoplasty is generally indicated for cases of persistent aural discharge with no severe tubal dysfunction. A preserved homologous septal cartilage plate was used to reconstruct the aerated tympanic cavity and to hold the columella material. For cases with insufficient opening of the eustachian tube, planned staged operations were performed following reopening of the tube and insertion of the protuberance part of a silicone plate. Functional results were satisfactory in 12 cases followed up for longer than 2 years (success rate in 80% of the modified type III and in 57% of modified type IV procedure).
This study was carried out to evaluate the anatomical and hearing results of the reparation of attic defects in closed tympanoplasty. Reparation was carried out in 194 patients by using a costal cartilage allograft, and in 159 patients with a bone pate autograft. The follow-up was from 1 to 5 years. The study was not truly randomized owing to an occasional lack of allogenic costal cartilage. In the group 'costal cartilage' a partial resorption was observed in 5.7% and a complete resorption in 4.7% of the cases. In the group 'bone pate', partial resorption was observed in 5.5% and total resorption in 2.7% of the patients. Satisfactory hearing results were obtained in 86% of the patients of the group 'costal cartilage' and in 82% of the patients of the group 'bone paté'. Both graft materials may be recommended for repairing erosions caused by the cholesteatoma in the wall of the external auditory canal.
OBJECTIVE: Bilateral same day surgery has been performed rarely because of the risk of postoperative sensorineural hearing loss following conventional myringoplasty or tympanoplasty (CMT). Simple underlay myringoplasty (SUM) through the ear canal has been developed by Yuasa R, Saijo S, Tomioka Y, et al. Office closure of eardrum perforation with fibrin glue (in Japanese), Otolaryngol Head Neck Surg (Tokyo) 1989;61:1117-1122, which has little risk of sensorineural hearing loss. We tried bilateral same day surgery using this technique and evaluated its outcome. METHODS: Of 86 cases with bilateral perforated chronic otitis media that we treated between 1995-1997, 25 cases underwent bilateral same day surgery. Bilateral SUMs was performed on seven patients, SUM and CMT on 16 patients, and bilateral CMTs on two patients. RESULTS: Closure of perforation was successful in 18 patients (72%) on both sides and in seven patients (28%) on one side. Postoperative air-bone gap of less than 20 dB was achieved in 15 cases (60%) on both sides and in 23 cases (92%) on one side. CONCLUSION: Bilateral same day surgery for bilateral perforated chronic otitis media is possible if the operative indications are considered.
The complication of retraction and lateralization of the graft after a tympanoplasty operation is described, and the underlying mechanism discussed. This complication occurs mainly when using the overlay procedure and causes a severe conductive hearing loss. A surgical technique for correcting this problem is described. It consists of removing all of the former graft, positioning the new graft medial to the eardrum remnants and covering the denuded ear canal bone with split-thickness skin graft. The results of 7 cases successfully treated by the technique described are presented.
Hearing results and causes of failure with three types of ossicular reconstruction techniques over an intact stapes, during second-stage intact canal wall tympanoplasty, are reported herein. The three types of reconstruction are: fitted autologous incus (38 cases); Plastipore PORP with cartilage (41 cases); Plastipore PORP without cartilage (32 cases). A residual air-bone gap within 15 dB. was found in 63.2 per cent of fitted includes, in 41.5 per cent of PORPs with cartilage, and in only 37 per cent of PORPs without cartilage. Eighty-four per cent fitted incudes, 63 per cent PORPs with cartilage and 44 per cent PORPs without cartilage yielded a residual air-bone gap within 25 dB. Extrusion has been the main cause of failure among Plastipore prostheses.