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Introduction: Acute pediatric mastoiditis is a bacterial infection of the mastoid bone most commonly associated with acute otitis media. Complicated mastoiditis is traditionally characterized by intracranial complications or subperiosteal abscess, but definitions are inconsistent in the literature. Surgical intervention is identified as the main treatment for complicated mastoiditis, but there is some evidence to support medical management of uncomplicated mastoiditis. This study sought to clarify the diagnostic criteria and management of uncomplicated acute mastoiditis., Methods: All cases of acute pediatric mastoiditis were identified from a single institution over a 16-year period and reviewed for demographic and clinical data. Two different definitions of uncomplicated mastoiditis were compared; the traditional one that excluded patients with intracranial complications or subperiosteal abscess (SPA) and the proposed definition that also excluded patients with any evidence of bony erosion including coalescence, not just SPA. Univariate and multivariate analysis was conducted., Results: Eighty cases were identified. Using the traditional definition of uncomplicated mastoiditis, 46.3% of cases were uncomplicated, compared to 36.2% when using the proposed definition. Truly uncomplicated patients, categorized with the proposed definition, were treated more consistently: no patients underwent mastoidectomy and they were less likely to receive a long term course of antibiotics. On multivariate regression analysis, only categorization with the proposed definition of uncomplicated mastoiditis was independently associated with less long-term antibiotic therapy and non-surgical management., Conclusion: Uncomplicated acute mastoiditis should be defined using clinical criteria and exclude any cases with evidence of bony erosion, including coalescence or subperiosteal abscess. These truly uncomplicated patients often do not require mastoidectomy and can be prescribed a shorter course of antibiotics. Further research into treatment pathways is necessary to optimize the management of uncomplicated acute pediatric mastoiditis., Competing Interests: Author’s NoteThis article was presented at the American Society of Pediatric Otolaryngology Spring Meeting, Boston, MA, May 5 to 7, 2023. There are no conflicts of interest to report. Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To assess quality of life (QOL) outcomes after canal wall up (CWU) and canal wall down (CWD) tympanomastoidectomy in the pediatric population., Methods: A retrospective review tabulated pediatric patients undergoing CWU and CWD tympanomastoidectomy for cholesteatoma by 2 senior surgeons at a single tertiary academic referral center between March 2017 and March 2023. Chronic Ear Survey (CES) and cosmetic survey outcomes were collected post-operatively., Results: A total of 77 ears in 75 patients were identified, with 35 undergoing CWU and 42 undergoing CWD as the most recent (index) otologic surgery. Seventeen patients (23%) participated in the survey. Of this cohort, the mean age was 14.6 years, 12 (71%) were male, and 10 (59%) had CWD as the most recent otologic surgery. The mean time from index surgery to survey completion was 3.4 years (range, 0.1-6.7 years). Regarding QOL outcomes, there were no statistically significant differences in total CES score, CES subscores, and cosmetic survey scores between groups when categorizing by gender or index surgery. Total CES, symptom subscale, medical resource subscale, and cosmetic survey scores showed a tendency to decrease with an increasing number of surgeries ( R  = -.18, -.28, -.53, and -.56, respectively). Pediatric total CES scores appeared comparable to those reported in the published adult literature., Conclusions: It does not appear that there are worse QOL outcomes for pediatric patients who undergo CWD tympanomastoidectomy compared to those who undergo CWU tympanomastoidectomy. There appears to be no difference in QOL outcomes between pediatric and adult patients undergoing tympanomastoidectomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ADS has been a consultant for Cochlear Americas, MED-EL GmbH and Oticon Medical. ADS has been on the surgical advisory board of MED-EL GmbH.

Objective: To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma., Methods: A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY., Results: Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations., Conclusion: Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized., Level of Evidence: V., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To report a recalcitrant spontaneous cerebrospinal fluid (CSF) fistula arising from multiple, anatomically-linked lateral skull base defects, and to review the available literature to determine optimal techniques for operative repair of congenital CSF fistulae., Methods: A patient with recurrent episodes of otologic meningitis was found to have a patent tympanomeningeal fissure, also known as a Hyrtl's fissure, and internal auditory canal (IAC) diverticulum that communicated with the jugular bulb. A systematic review of the literature characterized all reports of spontaneous congenital perilabyrinthine CSF leaks, and all cases of Hyrtl's fissures., Results: An 11-year-old female was referred for recurrent meningitis. Imaging demonstrated a fistulous connection between the middle ear and IAC diverticulum via the jugular foramen. Specifically, a Hyrtl's fissure was identified, as well as demineralized bone around the jugular bulb. Obliteration of the fissure was initially performed, and a fistula reformed 4 months later. Multifocal CSF egress in the hypotympanum was identified on re-exploration, and middle ear obliteration with external auditory canal (EAC) overclosure was performed. A systematic review of the literature demonstrated 19 cases of spontaneous congenital perilabyrinthine CSF leaks. In total, 6 cases had multiple sources of CSF leak and 2 had history suggestive of intracranial hypertension. All of these noted cases demonstrated leak recurrence. Middle ear obliteration with EAC overclosure was successful in 4 recalcitrant cases., Conclusions: Repair of spontaneous congenital perilabyrinthine CSF leaks in cases demonstrating multiple sources of egress or signs of intracranial hypertension should be approached with caution. Middle ear obliteration with EAC overclosure may provide the most definitive management option for these patients, particularly if initial attempt at primary repair is unsuccessful.

Objectives: Mastoid cortex defects resulting from mastoidectomy surgery can rarely lead to negative sequelae, including unsightly post-auricular depression and discomfort. This study sought to evaluate the use of hydroxyapatite cement (HAC) to reconstruct mastoidectomy cortex defects., Methods: Retrospective chart review was undertaken for all patients that underwent reconstruction of the mastoid cortex using HAC at a single tertiary medical center between 2013 and 2019. Collected data included demographics, indications for mastoidectomy, complications, and associated symptom status., Results: Twenty-nine patients that underwent mastoid cortex repair using HAC were included, and ten of these underwent mastoid revision in a secondary procedure to reconstruct the mastoid cortex with a specific goal to eliminate negative signs and symptoms. There were no associated postoperative complications and no instances of post-auricular depression following repair. All cases of secondary reconstruction resolved the primary signs and symptoms that prompted mastoid revision., Conclusions: HAC mastoid cortex reconstruction may be a safe and effective method to resolve negative sequelae resulting from previous mastoidectomy defects. Also, upfront HAC mastoid cortex reconstruction appears viable in select instances as an option to prevent potential future complications.

Background: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess., Methods and Results: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms., Discussion: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

Objective: Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision., Methods: A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level., Results: Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established., Conclusion: We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.

Objectives: The aim of this study was to investigate the audiometric outcomes of tympanomastoidectomy in children with cholesteatoma and to evaluate factors that may affect outcomes., Methods: A retrospective cohort study was conducted. All pediatric patients diagnosed with cholesteatoma who underwent primary canal wall-up tympanomastoidectomy with or without ossicular reconstruction from 2009 to 2016 at a tertiary university-affiliated pediatric medical center were included. Pure tone average (PTA) and air-bone gap (ABG) at 0.5, 1, 2, and 4 kHz were compared before and after surgery., Results: The cohort included 100 children (104 tympanomastoidectomies) of mean age 10.35 ± 3.6 years. The mean duration of follow-up was 35.4 ± 24.1 months. At surgery, 22 patients (21.2%) had intact ossicular chains, and 82 (78.8%) had ossicular discontinuity. Fifty-three patients (51%) underwent ossicular reconstruction, either partial (34 patients [64.1%]) or total (19 patients [35.8%]). In comparison with preoperative audiometry, there was a statistically significant improvement in PTA-ABG at the first postoperative examination (27.5 ± 12.7 vs 21.1 ± 11.1 dB, P = .001) and at the end of follow-up (20.2 ± 12.7 dB, P = .003) . Overall, values of less than 20 dB were measured in 34% of patients preoperatively and 73% postoperatively. On subgroup analysis, in patients who underwent any ossicular reconstruction, PTA-ABG was significantly improved relative to the preoperative value (28.1 ± 14.7 dB) at both the first (19.1 ± 11.9 dB, P = .006) and last (22.4 ± 15.1 dB, P = .011) audiometry examinations., Conclusions: Hearing outcomes after pediatric cholesteatoma surgery are diverse and related to several factors. The authors found that ossicular reconstruction improves audiometric outcomes, and the changes remain stable over time., Level of Evidence: IIB.

Objectives: To analyze hearing outcomes following Type 3 tympanoplasty with stapes columella grafting after canal wall down mastoidectomy and determine disease recurrence rates in patients undergoing this procedure., Methods: This retrospective cohort analysis examines patients undergoing Type 3 tympanoplasty with stapes columella grafting following canal wall down mastoidectomy for cholesteatoma at a tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if they were found to have undergone the aforementioned procedure. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 6 months and 1 year postoperatively., Results: Nineteen patients met criteria for this study. Erosion of the otic capsule, posterior fossa plate, or tegmen was noted in 37% of cases, highlighting disease severity. Eighteen (95%) had undergone prior otologic surgery. Mean time to short-term follow-up was 6 ± 3 months. The average short-term ABG was 26 ± 11 dB HL; 26% achieved an ABG <20 dB, and 58% achieved an ABG <30 dB. Fifteen had follow-up at least 1 year postoperatively (mean = 33 ± 16 months). At longer-term follow-up, mean ABG was 25 ± 10 dB HL; 33% achieved an ABG <20 dB, while 66% achieved an ABG <30 dB. Hearing remained stable over time ( P = .52). At date of last clinical follow-up, only 1 (5%) patient had undergone revision for recurrent disease., Conclusion: In some patients undergoing canal wall down mastoidectomy for advanced or recurrent cholesteatoma, Type 3 tympanoplasty with stapes columella grafting yields marginal hearing benefit. This type of reconstruction is a viable option in this challenging patient cohort, particularly as it is associated with low rates of revision surgery.

Objective: To evaluate the effectiveness of a modified Palva flap used for external auditory canal reconstruction and mastoid obliteration in canal wall down mastoidectomy., Methods: We retrospectively analyzed patients who underwent canal wall down mastoidectomy with tympanoplasty using modified Palva flap. All patients underwent pure tone audiometry and temporal bone computed tomography (CT) before surgery, and the same tests were performed in the first year after surgery. The external auditory canal volumes were calculated by summing the areas of each section selected in temporal bone CT. For each patient, the ratio of external auditory canal volume was calculated from CT taken before and after surgery., Results: The mean of external auditory canal volume after canal wall down with a modified Palva flap was about 1.4 times larger than before surgery. The modified Palva flap is effective for the reconstruction of the external auditory canal. Both pure tone audiometry level and air-bone gap showed statistically significant improvement after surgery ( Ps = .001 and .002, respectively)., Conclusions: The external auditory canal volume slightly increased, but the status of mastoid obliteration was well maintained 1 year after surgery. The modified Palva flap used in this study is an easy and effective method in external auditory canal reconstruction and mastoid obliteration.

Objectives: To describe a unique case of bilateral dehiscence of the malleus and incus heads into the middle fossa making contact with the temporal lobes, along with its clinical implications., Methods: An analysis of a patient case and review of pertinent literature were performed., Results: A patient with a history of right-sided mastoidectomy for cholesteatoma was evaluated for persistent conductive hearing loss. On computed tomography (CT) and magnetic resonance imaging (MRI), the patient had a complete dehiscence of the tegmen tympani on the right, with ossicular heads being located above the floor of the middle cranial fossa. A similar finding to a milder degree was noted on the left. The patient underwent revision tympanoplasty with mastoidectomy with removal of the incus and ossicular chain reconstruction and middle fossa craniotomy for repair of the right epitympanic dehiscence., Conclusions: We present some of the unique imaging and operative findings involved in an unusual presentation of encephalocele in which the bilateral malleus and incus heads rise above the level of the middle fossa floor.