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Background and Purpose Cochlear vascular micro-thrombosis has been hypothesized as one of the pathogenic mechanisms for sudden sensorineural hearing loss (SSNHL) refractory to regular management. This study aimed to evaluate the feasibility and safety of intra-arterial pulsed-injection urokinase (IAPU) as a salvage therapy for SSNHL after the failure of conventional therapy. Methods We retrospectively reviewed our patient database to identify refractory SSNHL patients between November 2017 and July 2020. Study outcomes before and after the IAPU therapy were compared between IAPU and conventional therapy groups. Results Sixty-seven moderate-profound SSNHL patients (29 in IAUP group, 38 in control group) were included in this study. Compared to the control group, patients in the IAPU group showed more significant improvement in pure tone average (PTA) (34.2 ± 23.5 vs. 10.7 ± 13.1, p < 0.001) and degree of hearing recovery (total: 20.7% vs. 5.3%, partial: 24.1% vs. 10.5%, mild: 27.6% vs. 13.2% and non: 27.6% vs. 71.1%) 2 weeks after admission. In the IAPU group, a significant improvement of PTA (86.6 ± 11.5 vs. 54.6 ± 20.1 dB, p < 0.005) was observed on the first day after IAPU treatment. Conclusion In carefully selected SSNHL cases with a highly suspected vascular origin, IAPU is a safe and effective therapy when conventional treatments have failed. Despite the encouraging findings of our work, large studies are needed to better investigate the strengths and limitations of this salvage therapy.

To visualize the course of the tympanic segment of chorda tympani nerve (CTN) using ultra-high-resolution computed tomography.A hundred and fourteen ears with no evident otologic pathologies were included. The tympanic segment of CTN was divided into 4 portions as follows: periannular, posteromalleal, malleal, and anteromalleal. The length of the periannular portion running along the tympanic annulus was recorded. Four points of interest (the beginning and end of the posteromalleal and anteromalleal portions) were selected to perform distance measurements relative to the tip of the malleus manubrium. Differences in lengths and distances were compared in terms of ear sides and sexes.The length of the periannular portion was 2.49 ± 1.16 mm. The beginning of the posteromalleal portion was located more laterally on the right side than on the left side (mean: 4.09 mm vs. 3.92 mm;, P = 0.016). The end of the posteromalleal portion was located more inferiorly on the right (mean: 2.11 mm vs. 2.26 mm; P = 0.018). The beginning of the anteromalleal portion on the right was located more laterally than that on the left (mean: 2.60 mm vs. 2.45 mm; P = 0.027). The start and end of the anteromalleal portion were more posteriorly located in women than in men (both Ps 0.001).The course of the tympanic segment of normal CTN was comprehensively visualized by ultra-high-resolution computed tomography. Preoperative evaluation of the tympanic segment of CTN might be helpful in avoiding iatrogenic injury during middle ear surgery.

Recurrent otitis media and persistent otitis media with effusion in early childhood may cause an atelectatic eardrum and adhesive otitis media, which sometimes progress to pars tensa cholesteatoma. When and how children with adhesive otitis media should be operated on remain controversial. Therefore, this study aimed to analyze the clinical characteristics of children with adhesive otitis media and pars tensa cholesteatoma, and to determine the risk factors of progression to cholesteatoma.Seventeen ears of 15 children with adhesive otitis media (adhesive group) and 14 ears of 13 children with pars tensa cholesteatoma (tensa cholesteatoma group) who underwent tympanoplasty were included in this study. We analyzed the following clinical characteristics of children in both groups: medical and life history, associated diseases, sites of the adhesion, and development and aeration of mastoid air cells as shown by temporal bone computed tomography.Most of the children in both groups had a history of recurrent otitis media and/or persistent otitis media with effusion. They showed a male predominance and a frequent association of allergic rhinitis. The number of ears showing undeveloped mastoid air cells in the tensa cholesteatoma group was significantly larger than that in the adhesive otitis media group (P=0.0068). A lack of aeration of the middle ear, including the eustachian tube, was more frequently found in ears with pars tensa cholesteatoma than in ears with adhesive otitis media (P=0.0012). Using multivariate logistic regression, the presence of otorrhea (odds ratio [OR], 14.847; 95% confidence interval [CI], 0.834-264.184), total adhesion (OR, 28.550; 95% CI, 0.962-847.508), and undeveloped mastoid air cells (OR, 19.357; 95% CI, 1.022-366.589) were related to pars tensa cholesteatoma.Children with adhesive otitis media should be carefully followed up in the outpatient setting. Ears with poor mastoid development may develop pars tensa cholesteatoma. Additionally, ears with middle ear effusion, total adhesion, and the presence of otorrhea tend to be at risk of pars tensa cholesteatoma. Tympanoplasty or tympanostomy tube insertion should be considered for children with adhesive otitis media who have these risk factors to prevent progression to pars tensa cholesteatoma.

This study aimed to determine the effectiveness of using endoscopes in reducing recidivism secondary to residual cholesteatoma after canal wall-up tympanomastoidectomy.Randomized clinical trial.Tertiary referral center.Patients with cholesteatoma, aged 7 to 70 years.Subjects were randomly allocated into two groups: endoscopic-assisted canal wall-up (EACWU; group 1) and conventional canal wall-up (CWU; group 2) techniques. Pars flaccida and pars tensa subgroups were analyzed according to the anatomic location of cholesteatoma origin.Presence or absence of residual cholesteatoma, based on second look surgery, diffusion-weighted magnetic resonance imaging, or video-otoscopy at 12 and 18 months after surgery.In total, 57 ears were analyzed: 29 in group 1 and 28 in group 2. Group 1 revealed residual disease in 17.2% of ears, whereas group 2 had residual disease in 35.7% (p0.05) of the ears. In the pars tensa cholesteatoma subgroup, the incidence of residual disease was 13.3% for EACWU and 47.1% for the CWU technique (p0.05). A tendency of reduced incidence was observed for cholesteatoma due to residual disease using EACWU. In addition, a statistically significant reduction in the residual disease was observed in the subgroup of pars tensa cholesteatomas. In this subgroup, the relative risk was 0.28, and the number needed to treat was 4.6.The use of the endoscope reduces the incidence of recidivism secondary to residual disease in pars tensa cholesteatomas. Endoscopic-assisted surgery may be useful in cases with an indication for canal wall-up tympanomastoidectomy.1b.

Welding injuries to the tympanic membrane (TM) or middle ear are rare but can cause significant damage. These injuries occur when a hot spark or molten slag drops directly into the external auditory canal and through the action of gravity (because the ear is upright during such an injury), then risks burning through the TM. This can lead to a multitude of adverse consequences including chronic TM perforation, secondary purulent otorrhoea, facial palsy, taste disturbance, vertigo and hearing loss. We present the case of a welding injury to the right TM, resulting in a chronic perforation and hearing loss. The patient required surgical intervention for removal of the metallic foreign body and repair of the TM. The patient obtained a good surgical result with no sensorineural hearing loss. This is a preventable occupational injury, which can be avoided by use of ear protection and increased awareness of this potential risk.

BACKGROUND: The function of the tensor tympani muscle and its effects, as well as a universal testing procedure, is not yet known. The purpose of this study is to investigate the effect of tactile stimulation on the tensor tympani muscle activity in an attempt to evaluate the functional status of the muscle. METHODS: In this study, 20 healthy adults aged between 18 and 30 years were included. All participants had their history taken, as well as the evaluation of otoscopy, audiometry, and tympanometry. A modified reflex decay paradigm was used to evaluate the tensor tympani muscle activity, in both humans and a fresh-frozen cadaver. The tactile stimulation was applied by thumb tappings on different forehead areas. RESULTS: Reflex decay responses were in the form of the absence of a response or either a positive or negative waveform. Tactile stimulation had no impact on reflex decay recordings obtained from the cadaver. There was no significant difference between the waveforms obtained from both ears, at different stimulation frequencies, tactile stimulation areas, or the 3 successive stimuli for 1 individual in 1 ear (P > .05). Changes observed in the reflex decay test upon tactile stimulation seem to be due to tensor tympani muscle activity as supported by the previous findings in the literature. CONCLUSION: The application of a tactile stimulus on the forehead is a non-invasive test method to assess tensor tympani muscle contraction. Understanding the function of the tensor tympani muscle using a non-invasive method will be helpful during the decision-making process in the practice of otology.

Most traditional tympanoplasties require elevating the tympanic membrane (TM). These techniques are rather complicated and success rates are not perfect. Therefore, the authors developed a novel technique, transtympanic soft tissue (TST) tympanoplasty, which does not require raising eardrums, and evaluated its surgical efficiency compared to perichondrium underlay (PU) tympanoplasty.A retrospective study was conducted in a single center.152 cases who underwent TST tympanoplasty (n = 70) or PU tympanoplasty (n = 82) between 2011 and 2020 were included in the study. Perforation location, pure tone audiometry, complications, and closure rates were analyzed according to the size of the TM perforations: moderate perforation (25-40%, n = 100) and large perforation (≥ 40%, n = 52).For the moderate perforations, the closure rates of the TST (n = 45) and PU (n = 55) groups were 93.3% and 89.1%, respectively (p = 0.461), and even for the large perforations, the success rates were 88.0% in the TST group (n = 25) and 81.5% in the PU group (n = 27) (p = 0.515). The mean postoperative air-bone gap (ABG) values of the TST group for moderate and large perforations were 5.3 ± 5.8 dB and 6.6 ± 5.7 dB, respectively. There was no significant difference in postoperative ABG between the two surgical procedures (p 0.05). The total operation time for TST tympanoplasty was significantly shorter than that for PU tympanoplasty (p = 0.002).TST tympanoplasty is considered a novel, simple technique to replace traditional tympanoplasty techniques involving raising eardrums, even for large-sized perforations.

ObjectiveIn the wake of the 2019 coronavirus disease pandemic, elective cases and opportunities for clinical application have decreased, and the need for useful simulation models has become more apparent for developing surgical skills. A novel myringotomy with ventilatory tube insertion simulation model was created.MethodsResidents across all levels at our institution participated in the simulation. Participants were evaluated in terms of: time of procedure, microscope positioning, cerumen removal, identification of middle ear effusion type, canal wall trauma, tympanic membrane damage and tube placement.ResultsEleven residents participated. Scores ranged from 14 to 34, out of a maximum of 40. The average score among junior and senior residents was 24 and 31, respectively. The simulation was felt to be representative of the operating theatre experience.ConclusionThis study demonstrates a low-cost simulation model that captures several important, nuanced aspects of myringotomy with tube insertion, often overlooked in previously reported simulations.

Middle ear implants (MEI) are for the medical rehabilitation of the hearing function in case of sound conduction hearing losses as well as cochlear hearing losses and their combinations.An objective tool to reach the best fitting of the external worn sound processors is essential for patients who do not want or cannot participate in the fitting process.In addition to Laser-Doppler-Vibrometry (LDV) measurement, the sound pressure was measured distant to the eardrum to attain additional information for comparison. Three groups of patients with different middle ear characteristics were examined.Because of the large spreading of measuring results even within a patient group with similar eardrum and middle ear conditions it is difficult to develop characteristic diagrams which represent the mean values of eardrum displacements with different sound processor adjustments being the base for normative data courses.The LDV measurements can be used as a tool for fitting sound processors by finding individual maximum eardrum velocities in the frequency range 125 Hz to 8 kHz. In comparison to acoustical measurements the optical measurements have advantages concerning lower variations of measurement values, higher spectral resolution, and robustness against disturbing acoustic noise, especially at low frequencies.

Background The conventional microscopic overlayer myringoplasty is preferred because it allows a both hands technique, not reducing middle ear space, increasing the blood supply in the repaired area, and providing graft support; however, this technique may be troublesome for the novice surgeon during tympanomeatal flap elevation. Recently, the endoscopic push-through myringoplasty technique has developed. It provides better visualization of the hidden areas and does not require raising tympanomeatal flap. Therefore, the comparison of clinical outcomes between endoscopic push-through myringoplasty and conventional microscopic overlay myringoplasty technique was investigated. Methods A retrospective case–control hospital-based study was conducted using archival data from the patients who underwent myringoplasty between January 2015 and May 2021 at Srinagarind Hospital and Khon Kaen Hospital, Thailand. The medical records of patients who underwent endoscopic push-through technique or microscopic overlayer technique were chosen by simple randomization and matched 1:1 based on the air conduction threshold, air-bone gap, size of perforation, and experience of the surgeon. The two techniques were compared for clinical outcome success, including tympanic membrane closure, improved air conduction threshold, air-bone gap closure, and operation time duration. Results Medical records of 70 patients were retrieved and classified into 35 patients who underwent endoscopic push-through and 35 patients who underwent microscopic overlayer myringoplasty. The size of tympanic membrane perforation and preoperative audiometry were not significantly different between both groups (p > 0.05). The postoperative outcome in endoscopic technique revealed that the air-bone gap and the success rate of tympanic membrane closure were comparable with microscopic techniques (p = 0.420 and p = 0.156, respectively). The operation time was significantly shorter in the endoscopic technique (p Conclusions Endoscopic push-through myringoplasty is an alternative minimally invasive technique that may allow the potential outcomes comparable with the microscopic overlayer myringoplasty and with a significantly shorter operation time.

Introduction Traumatic large tympanic membrane perforations usually fail to heal and require longer healing times. Few studies have compared the healing and hearing outcomes between gelatin sponge patching and ofloxacin otic solution. Objectives To compare the healing outcomes of large traumatic tympanic membrane perforations treated with gelatin sponge, ofloxacin otic solution, and spontaneous healing. Methods Traumatic tympanic membrane perforations >50% of the entire eardrum were randomly divided into three groups: ofloxacin otic solution, gelatin sponge patch and spontaneous healing groups. The healing outcome and hearing gain were compared between the three groups at 6 months. Results A total of 136 patients with large traumatic tympanic membrane perforations were included in analyses. The closure rates were 97.6% (40/41), 87.2% (41/47), and 79.2% (38/48) in the ofloxacin otic solution, gelatin sponge patch, and spontaneous healing groups, respectively (p = 0.041). The mean times to closure were 13.12 ± 4.61, 16.47 ± 6.24, and 49.51 ± 18.22 days in these groups, respectively (p < 0.001). Conclusions Gelatin sponge patch and ofloxacin otic solution may serve as effective and inexpensive treatment strategies for traumatic large tympanic membrane perforations. However, ofloxacin otic solution must be self-applied daily to keep the perforation edge moist, while gelatin sponge patching requires periodic removal and re-patching. Resumo Introdução As grandes perfurações traumáticas da membrana timpânica geralmente apresentam falha de cicatrização e requerem tempos de cicatrização mais longos; poucos estudos compararam os resultados de cicatrização e a audição dessas perfurações obtidos com curativo de Gelfoam® e solução otológica de ofloxacina. Objetivo Comparar os resultados de cicatrização de grandes perfurações traumáticas da membrana timpânica tratadas com Gelfoam®, solução otológica de ofloxacina e cicatrização espontânea. Método Perfurações traumáticas de > 50% de todo o tímpano foram divididas aleatoriamente em três grupos: tratamento com solução otológica de ofloxacina, com curativo de Gelfoam® e grupo de cicatrização espontânea. O resultado da cicatrização e o ganho auditivo foram comparados entre os três grupos após 6 meses. Resultados Foram incluídos nas análises 136 pacientes com grandes perfurações traumáticas de membrana timpânica. As taxas de cicatrização foram de 97,6% (40/41), 87,2% (41/47) e 79,2% (38/48) com a solução otológica de ofloxacina, curativo de Gelfoam® e grupos de cicatrização espontânea, respectivamente (p = 0,041). O tempo médio de cicatrização foi de 13,12 ± 4,61, 16,47 ± 6,24 e 49,51 ± 18,22 dias nesses grupos, respectivamente (p < 0,001). Conclusões O curativo de Gelfoam® e a solução otológica de ofloxacina podem servir como estratégias de tratamento eficazes e de baixo custo para grandes perfurações traumáticas de membrana timpânica. Entretanto, a solução otológica de ofloxacina deve ser autoaplicada diariamente para manter a borda da perfuração úmida, enquanto o curativo de Gelfoam® requer sua remoção e reaplicação periódicas.

Most commonly, autologous grafts are used in tympanic membrane (TM) reconstruction. However, apart from the limited availability and the increased surgical risk, they cannot replicate the full functionality of the human TM properly. Hence, biomimetic synthetic TM implants have been developed in our project to overcome these drawbacks. These innovative TM implants are made from synthetic biopolymer polycaprolactone (PCL) and silk fibroin (SF) by electrospinning technology. Static and dynamic experiments have shown that the mechanical and oscillatory behavior of the TM implants can be tuned by adjusting the solution concentration, the SF and PCL mixing ratio and the electrospinning parameters. In addition, candidates for TM implants could have comparable acousto-mechanical properties to human TMs. Finally, these candidates were further validated in

ObjectiveFor centuries, the tympanum has remained the only visible structure of the organ of hearing. This study aimed to trace the understanding of the tympanic membrane from antiquity to the early twentieth century.MethodsA review was conducted of primary and secondary historical and scientific literature describing the tympanic membrane anatomy.ResultsAlthough ancient polymaths sensed that sounds were vibrations that could spread in the air and be perceived by the hearing organ, there were numerous misconceptions about the tympanum until human dissections performed during the Renaissance. The tympanum was correctly described only centuries later when technological advances enabled otologists to understand it as a fundamental part of the hearing organ.ConclusionThe tympanic membrane history reflects key stages in medical knowledge; limited for centuries, a great technological leap was possible in the nineteenth century, contributing to the emergence of otologists and laying the foundations of modern otology.

Objectives: As telemedicine has become increasingly utilized during the COVID-19 pandemic, portable otoendoscopy offers a method to perform an ear examination at home. The objective of this pilot study was to assess the quality of otoendoscopic images obtained by non-medical individuals and to determine the effect of a simple training protocol on image quality. Methods: Non-medical participants were recruited and asked to capture images of the tympanic membrane before and after completion of a training module, as well as complete a survey about their experience using the otoendoscope. Images were de-identified, randomized, and evaluated by 6 otolaryngologists who were blinded as to whether training had been performed prior to the image capture. Images were rated using a 5-point Likert scale. Results: Completion of a training module resulted in a significantly higher percentage of tympanic membrane visible on otoendoscopic images, as well as increased physician confidence in identifying middle ear effusion/infection, cholesteatoma, and deferring an in-person otoscopy ( P Conclusions: At-home otoendoscopes can offer a sufficient view of the tympanic membrane in select cases. The use of a simple training tool can significantly improve image quality, though often not enough to replace an in-person otoscopic exam.

The non-invasive tympanic electrocochleography (TM-ECochG) is useful for clinical diagnoses. Nevertheless, the influence of the electrode location on tympanic membrane (TM) on ECochG results needs to be studied.The aim of the present study was to compare the TM-ECochG results obtained when the electrode was placed on the superior region versus the inferior region of TM.Forty healthy adults (aged 29 to 50 years) participated in this comparative study. The TM-ECochG testing was conducted with the electrode placed on the superior and inferior regions of TM.SP and AP amplitudes were statistically higher for the inferior region of TM (In TM-ECochG recording, when the electrode was placed on the inferior region of TM, SP and AP amplitudes were greater than when the electrode was placed on the superior region of TM. On the other hand, SP/AP amplitude ratio was not affected by the location of electrode on TM. The findings from the present study could be useful to guide clinicians in optimizing TM-ECochG recording when testing their respective patients.

This study aimed to investigate the effect of chronic otitis media (COM) and COM surgery on infrared tympanic thermometer measurements. We retrospectively reviewed the medical records of 192 patients (192 surgery cases) who underwent surgery for COM and whose bilateral tympanic membrane temperature was measured with an infrared tympanic thermometer the day before surgery and at 2, 3, 4, and 6 months after surgery. Patients underwent surgery for COM in 1 ear, the other eardrum was intact. Patients who underwent tympanoplasty, simple mastoidectomy, and canal wall up mastoidectomy, surgeries performed to preserve the ear canal, were included in group A, and patients who underwent canal wall down mastoidectomy, a surgery to remove the ear canal, were included in group B. There were 115 and 77 patients in groups A and B, respectively. The mean temperature on the side with COM measured the day before surgery was 37.09°C ± 0.325°C and the mean temperature on the opposite normal side was 37.03°C ± 0.330°C (P = .000). In group A, the eardrum temperature on the surgical and contralateral side was not statistically different after surgery (P = .439). The temperature difference between both sides of the eardrums (dTemp) changed from 0.056°C before surgery to 0.014°C after surgery (P = .008). However, in group B, which canal wall down mastoidectomy was performed, the eardrum temperature of the surgical side was higher than that on the other side (P = .001). The dTemp increased up to 0.15°C after surgery (P = .000). The temperature of the eardrum was slightly increased by COM. The COM surgeries, which preserve the ear canal, brought the temperature of the eardrum close to that of the normal eardrum, and the surgery to remove the ear canal raised the temperature of the eardrum.

In most anuran amphibians, acoustic communication is of prime importance for mate localization and selection. The tympanic middle ear increases auditory sensitivity and directionality and is therefore expected to be favoured by natural selection. However, especially within the family of true toads (Bufonidae) there is a tendency for species to lose parts of the middle ear apparatus and consequently have a reduced sensitivity to high-frequency sounds (above 1 kHz). Part of the explanation for this may be that development of the middle ear is especially slow in bufonids, and thus the middle ear would be more likely to be lost or non-functional in paedomorphic species. However, a timeline of development of the middle ear has not been established previously. The goal of the present study was to investigate middle ear development in a toad species that has a well-known natural history and acoustic communication behaviour. We made a detailed study of anatomy and biophysics of the middle ear with measurements of auditory sensitivity across age in post-metamorphic natterjack toads (Epidalea calamita). The tadpoles and toadlets were raised in the laboratory, so their exact age was known, their auditory sensitivity was measured using auditory brainstem responses, and middle ear development and function were assessed by anatomical studies and laser vibrometry. We found that the developmental stage of the middle ear depends on the size of the toad rather than its age. The middle ear was functional at the earliest at a snout–vent length of 40 mm, which for these toads was around 500 days post-metamorphosis, close to the time of first reproduction. The functional, adult-like middle ear was shown to have 30 dB increased sensitivity to the dominant frequency of the mating call compared with sensitivities measured in newly metamorphosed individuals.

Chronic otitis media enables the appearance of a benign middle ear tumor, known as a cholesteatoma, that may compromise hearing. To evaluate the influence of a cholesteatoma growth on the hearing function, a computational middle ear model based on the finite element method was used and three different size of cholesteatoma were modeled. The cholesteatoma solidification and the consequent degradation of the ossicles were also simulated as two condition that commonly occurs during cholesteatoma evolution. A sound pressure level of 80 dB SPL was applied in the tympanic membrane and a steady state analysis was performed for frequencies from 100 Hz to 10 kHz. The displacements of both the tympanic membrane and the stapes footplate were measured. The results were compared with a healthy case and it was shown that the cholesteatoma development leads to a decrease in the umbo and stapes displacements. The ossicles degradation simulation showed the higher difference comparing with the cholesteatoma in an initial stage, with lower displacements in the stapes footplate mainly for high frequencies. The observed displacement differences are directly connected to hearing loss, being possible to conclude that cholesteatoma evolution in the middle ear will lead to hearing problems, mainly in an advanced stage.

BACKGROUND The elevation of the tympanomeatal flap in endoscopic myringoplasty will cause considerable tissue damage. OBJECTIVE To analyze anatomic and audiological results of tympanic membrane perforation underwent endoscopic transtympanic cartilage push-through myringoplasty without tympanomeatal flap elevation (EPM) and their relationship with the size of perforation. METHODS A clinical retrospective study was performed on 75 cases of tympanic membrane perforation that underwent EPM from January 2019 to March 2021. Graft success and hearing outcomes were evaluated 3 months after surgery. RESULTS The overall graft success rate for EPM was 94.7% (71/75). The total rate of hearing success, postoperative ABG ≤ 20 dB was achieved in 96.0% (72/75). The overall mean AC threshold of 35.1 ± 5.6 dB was lowered to 25.0 ± 4.8 dB postoperatively (p

ObjectiveThis case series, conducted during the coronavirus disease 2019 pandemic, investigates the impact of leaving aural foreign bodies in situ for a prolonged period of time, including the risk of complications and success rates of subsequent removal attempts.MethodA retrospective study of aural foreign body referrals over a six-month period was carried out.ResultsThirty-four patients with 35 foreign bodies were identified (6 organic and 29 inorganic). The duration of foreign bodies left in situ ranged from 1 to 78 days. Four patients suffered from traumatic removal upon initial attempts. First attempts made by non-ENT specialists (68.8 per cent) all failed and were associated with a high risk of trauma (36.4 per cent).ConclusionBecause of the coronavirus disease 2019 pandemic, this is the first case series to specifically investigate the relationship between the duration of aural foreign bodies left in situ and the risk of complications. Our data suggest that prolonged duration does not increase the incidence of complications.

Background and Hypothesis: Isolated malleus shaft fractures are rare cases. A commonly reported cause is a finger pulled out from a wet outer ear canal after a shower or bath. The objective was to investigate experimentally the mechanism and forces needed to establish an isolated malleus shaft fracture. Methods: Ten fresh-frozen human temporal bones were adapted to allow visual inspection of the structures involved while negative pressure trauma was applied. Thirty malleus bones were broken and the required forces were measured. Measurements from 60 adult test subjects were used to create mathematical and physical models to calculate and measure the forces necessary for generating trauma. To calculate the maximum muscle force developed by the tensor tympani muscle, the muscle area and fiber type composition were determined. Results: The temporal bone experiments showed that applied negative pressure in a wet ear canal could not fracture the malleus shaft with only passive counterforce from supporting structures, although the forces exceeded what was required for a malleus shaft fracture. When adding calculated counteracting forces from the tensor tympani muscles, which consisted of 87% type II fibers, we estimate that a sufficient force is generated to cause a malleus fracture. Conclusion: The combination of a negative pressure created by a finger pulling outward in a wet ear canal and a simultaneous counteracting reflexive force by the tensor tympani muscle were found to be sufficient to cause an isolated malleus fracture with an intact tympanic membrane.

Zygomatic root abscess is a rare extracranial extratemporal complication of otitis media. To the best of our knowledge, there are only a few scattered cases of zygomatic root abscesses reported in the literature. We present an unusual case of a zygomatic root abscess in a 24 years old adult. He presented with one month duration of right zygomatic swelling. Otoscopic examination revealed superior and posterior external auditory canal wall sagging with an intact tympanic membrane. High Resolution Computed Tomography (HRCT) temporal bone revealed a rim enhancing lesion lateral to the zygomatic process with fluid filled mastoid air cells. He was managed with antibiotics and staged surgical interventions. He recovered well. Our case serves to shed light on the pathways of infection, clinical manifestations and timely staged surgical intervention in this rare pathology.

Objectives We aimed to clarify the usefulness of high-resolution computed tomography (HRCT) and establish HRCT criteria for presurgical assessment of the mastoid extension in pars flaccida cholesteatomas of the middle ear. Methods Retrospective observational study. Patients who underwent primary surgery for pars flaccida cholesteatoma and those who underwent temporal bone HRCT for pretreatment evaluation were reviewed. The distance in the anterior-most portion of the mastoid sinus on HRCT was measured, and the presence of surgically verified mastoid extension of cholesteatoma was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative). Results A total of 107 patients with pars flaccida cholesteatoma were included. The distance in the M+ cases was significantly longer than that in the M- cases, and the cutoff value was 3.6 mm. The difference between the ipsilateral/diseased-side distance and the contralateral/evaluable side (difference value) in M+ cases was larger than that in M- cases, with a cutoff value of 0.6 mm. The inter-rater reliability of this distance measurement was excellent, regardless of imaging experience. Conclusions The cutoff values of the distance and the difference value can be used for pretreatment HRCT evaluation of mastoid extension in middle ear cholesteatoma with relatively high accuracy, regardless of the experience and skill levels of the evaluator.

ObjectiveAdvice to patients following grommet insertion and waterproofing can vary from clinician to clinician. A laboratory based experiment was performed to determine at what depth water contamination would occur through various grommet tubes.MethodsA novel experimental ear model was developed using an artificial tympanic membrane and ventilation tubes. Water contamination was identified using an effervescent solid that reacts when in contact with water. Measures of dispersion were used to describe the results.ResultsThe average depth of water contamination was: 19.64 mm (range = 11–33 mm, standard deviation = 5.55 mm) using a Shepard grommet; 20.84 mm (range = 18–26 mm, standard deviation = 1.97 mm) with a titanium grommet; and 21.36 mm (range = 18–33 mm, standard deviation = 3.03 mm) using a T-tube. Water contamination was possible at depths of 11–33 mm. The average pressure at water effervescent activation was 0.20 kPa.ConclusionSubmersion underwater at any depth with grommets is likely to lead to middle-ear contamination. These findings are concordant with clinical studies.

Myringoplasty is a surgical procedure to reconstruct tympanic perforation. However, repair of anterior perforations is still challenging. To analyze the anatomical and hearing outcomes of myringoplasty with a new technique of chondroperichondrial graft via endoscopy, 23 adult patients were retrospectively analyzed. All patients had anterior perforations of tympanic membranes that were repaired with a composite strip-type cartilage-perichondrium graft through a total endoscopic transcanal approach. The anatomical graft success rate at postoperative 1 month was 86.96% (20/23) and reached 100% at the 6- and 12-month follow-up. Compared to the preoperative air conduction threshold (44.7 ± 13.56 dB) and air-bone gap (ABG) (22.35 ± 6.54 dB), the postoperative air conduction threshold and ABG decreased to 33.52 ± 10.88 dB and 12.52 ± 3.94 dB, respectively (P.0001). Twenty-two (95.65%) patients had an ABG below 20 dB postoperatively. The mean ABG improvement in our cohort was 9.83 ± 5.00 dB. The functional graft success rate was 95.65% (22/23). The convenience, reliability, time, and labor savings accrued from the approach described here make it a good choice for repair of anterior perforation of tympanic membrane.

The objective of this study was to compare the efficacy of ofloxacin ear drops, vaseline gauze (VG) and dry gelfoam alone on the large traumatic perforations of tympanic membrane (TM).A randomized prospective analysis was performed for the treatment of traumatic perforation larger than 25 % of the entire TM. The closure rate, closure time, and hearing gain between ofloxacin ear drops, VG and gelfoam alone groups were compared at 3 months.Final analysis was performed on 70 patients. The closure rates of perforation in the ofloxacin ear drops, VG, and dry gelfoam patch groups were 100.0 %, 92.0 %, and 87.5 %, respectively (P = 0.41).The mean closure times were 8.67 ± 3.1, 10.65 ± 4.2, and 14.33 ± 7.5 days for the ofloxacin ear drops, VG, and gelfoam patch alone groups, respectively. The closure times among the 3 groups were significantly different (P = 0.003). In addition, there was a significant difference between the ofloxacin ear drops and gelfoam patch alone groups with regard to closure time (P = 0.003), while there was no significant difference between the ofloxacin ear drops and VG groups (P = 0.080) or VG and gelfoam patch groups (P = 0.056).The mean hearing gain was 11.4 ± 2.3 dB for the ofloxacin ear drops group, 11.7 ± 4.1 dB for the VG group, and 12.2 ± 1.6 dB for the gelfoam patch group (P = 0.69).The repairing of traumatic perforations didn't require an exogenous biological scaffold. Ofloxacin ear drops and VG were a deal material for repairing traumatic perforation in otology clinic, which not only was readily available and inexpensive but also showed faster closure compared with dry gelfoam alone.

There are several factors that seem to affect the surgical success rate of tympanoplasty, one of them being the pneumatization of the contralateral mastoid. In the current literature, several studies have been published with classification proposals for temporal bone pneumatization pattern. This study aims to evaluate the role of mastoid air cell extension in relation to the sigmoid sinus in predicting the surgical success of tympanoplasty.This case-control study was performed on patients diagnosed with chronic otitis media (COM) who underwent type I tympanoplasty. The study group did not close the tympanic membrane, or there was a retraction or lateralization of the graft. The control group consisted of patients with surgical success.No statistically significant difference was found between groups regrading age, gender, perforation side/type, previous nasal surgery, and the presence of chronic otitis media in contralateral ear. A statistically significant difference was found when groups were compared in relation to the degree of pneumatization of the contralateral ear (p = 0.046), and this relationship does not seem to be influenced by age.To predict surgical success in terms of tympanic membrane closure in tympanoplasty, classification of contralateral ear pneumatization degree using the sigmoid sinus as a reference seems to be a valid and easy to apply method, and makes it possible to restrict the evaluation of pneumatization to the mastoid, a cell complex that does not seem to change with age.

It was the aim of this study to report a rare case of electrode positioner extrusion in cochlear-implanted patients as a late complication and introduce safe management. A retrospective case report in a tertiary referral center. Extrusion of Silastic electrode positioner through tympanic membrane occurred 17 years after cochlear implantation surgery. Although electrode positioner cochlear implants are not being used anymore, otologists and surgeons should be aware of their possible related complications and provide a proper management.

Meniere's Disease (MD) is a complex and multifactorial inner ear problem characterized by episodic vertigo, unilateral sensori-neural hearing loss and tinnitus or fullness in the ear due to Endolymphatic hydrops. There are multiple treatment options available for this disease; from which cortisone therapy can be given in different routes and in different doses.is to identify the successfulness of treatment of MD by multi-session intra-tympanic dexamethasone injection compared to the single-session method.Interventional prospective study of study 70 cases of definite MD treated by 4 sessions of intra-tympanic injection weekly and compared to a control group of 66 cases of age matched patients with definite MD treated by the traditional single intra-tympanic injection. Patients In the study and the control group were observed for 6 months after the treatment for the development of any vertiginous attacks.only 3 patients in the study group and 30 patients in the control group failed to respond to treatment and developed vertigo in the period of 6 months after treatment. The difference between the success rate in the two groups was statistically highly significant.multi-session Intra-tympanic dexamethasone injection is superior to the single injection in control of vertigo in patients with definite MD.

Objective: The differential of an external auditory canal mass is broad. One rare potential cause is a pneumatocele of the tympanic membrane, which has only been described 1 other time in the literature. This report serves to describe the second case of this pathology, including its unique presentation, and benign clinical course. Methods: Case report. Results: A case is discussed in which a pneumatocele of the tympanic membrane was incidentally identified during evaluation of contralateral otologic pathology. The etiology was suspected to be habitual auto-insufflation. After cessation of this practice, the pneumatocele was noted to resolve without further intervention. Conclusion: A tympanic membrane pneumatocele represents a rare cause of an external auditory canal mass. The diagnosis can be made clinically via history, palpation, and otoscopy during auto-insufflation, potentially avoiding further diagnostic testing. Depending on the etiology, resolution can occur after lifestyle modification; however, further interventions may definitively treat the condition if so required.

Objective: To evaluate early results on hygiene, safety and functional outcome in a population undergoing a canal wall up technique with bony obliteration of the mastoid and epitympanic space (CWU-BOT) for extensive cholesteatoma, performed by a single surgeon. This study compares different techniques of tympanic membrane reconstruction, viz. allografts and autografts. Patients: A consecutive series of 61 ears with acquired cholesteatoma treated with primary or revision CWU-BOT surgery from 2009 to 2014. Intervention: Obliteration was performed by the use of cortical bone-chips and bone pâté. Patients were followed up with micro-otoscopy and MRI with diffusion-weighted imaging. Ossicular reconstruction was performed using a remodelled autologous or allogenic incus or malleus. Main outcome measures: Residual and recurrence rate and short- and mid-term hearing outcome prior to any revision tympanoplasty were analysed, the effect of type of tympanic membrane reconstruction was considered. Results: 44 Ears were primary cholesteatoma cases, 17 cases were referred for revision surgery. Mean postoperative follow up was 45 months (SD 18.08) and mean follow-up until the last non-EP DW MRI 42 months (SD 17.72). Recurrent disease was present in 3%, no residual disease was present. An AC gain was seen in 75% of all ears undergoing ossicular reconstruction. Conclusion: Reproducible safety, hygiene and hearing results with limited recurrence and residual disease can be obtained by younger otologic surgeons performing the BOT-CWU for extensive cholesteatoma while using a variety of grafts for tympano-ossicular reconstruction. The tympano-ossicular allograft nevertheless shows superior hearing results when a mobile intact stapes is present. Level of evidence: Level 4

Background Various extratympanic recording electrodes have been used to make electrocochleography (ECochG) and auditory brainstem response (ABR) measurements in clinics, translational research, and basic science laboratories. However, differences may exist in ECochG and ABR measurements depending on the different types of extratympanic electrodes that are used. Purpose The purpose of this research is to compare simultaneously recorded ECochG and ABR responses using three different extratympanic electrodes. This research helps clinicians and researchers to understand how electrode types and recording sites influence EcochG and ABR results. In addition, our findings could provide more normative data to the ECochG and ABR literature as well as give perspective on a preferred electrode approach when performing simultaneous ECochG and ABR testing. Research Design Ours was a repeated-measures study with measurements being made from individual participants on two separate sessions. Study Sample Twenty young adult females with normal hearing. Procedure A three-channel recording system was used to simultaneously record ECochG and ABR measurements in response to alternating polarity click stimuli. In each session, measurements were simultaneously recorded with a TipTrode electrode and one of the tympanic membrane (TM) electrodes. Data Collection and Analysis Suprathreshold summating potential (SP) and action potential (AP) of the ECochG and waves I, III, and V of the ABR, and threshold responses (AP and wave V) were identified. Results Compared with the ear canal TipTrode electrode, TM electrodes yielded suprathreshold amplitudes that were larger than those from the ear canal electrode, smaller SP–AP ratios, lower AP thresholds, and less variability. These findings can help guide choices made by clinicians, translational investigators, and basic science researchers on which type of extra-tympanic electrode to use for their intended purpose.

Objectives This study was performed to evaluate the efficacy of microwave ablation (MWA) eustachian tuboplasty for the treatment of patients with retracted tympanic membrane (TM) due to eustachian tube dysfunction (ETD). Methods This was a prospective study of 20 patients with ETD (middle ear atelectasis) who underwent MWA eustachian tuboplasty. Outcomes included the ability to perform a Valsalva maneuver, audiometry results, tympanometry results, ETD Questionnaire (ETDQ-7) score, and TM status. Results Eighteen patients (18 ears) were included in this study. There were statistically and clinically significant improvements in the mean ETDQ-7 score at 6 months postoperatively (change in mean score of 16.7 ± 3.6, P P Type A tympanogram was obtained in 27.8% of patients (5/18) at 6 months postoperatively, and in 77.7% at 30 months postoperatively. A Valsalva maneuver was possible in 72.2% of patients at 6 months postoperatively and in 88.9% of patients at 30 months postoperatively. In addition, the ears of 13 patients (72.2%) showed both normal tympanograms and TM at 30 months postoperatively. Interestingly, 38.5% of patients (5/13) exhibited complete sclerosis of the pars tensa. None of the patients experienced severe MWA-related complications during follow-up. Conclusions MWA eustachian tuboplasty is a feasible alternative to conventional tuboplasty, and can improve subjective and objective outcomes in patients with ETD for up to 30 months following treatment. In addition, this study showed that the extent of sclerotic plaque increased over time, whereas the extents of atrophy and tensa retraction decreased following tuboplasty in most patients. Graphical abstract

Objectives (1) To test the effect of local administration of insulin-like growth factor-1 (IGF-1) in patients with sensorineural hearing loss (SNHL). (2) To test the effect of local administration of IGF-1 in patients with ototoxicity. Methods Forty patients with SNHL were included in the study. Their hearing thresholds at different frequencies (0.5, 1, 2, and 4 kHz) along with the average hearing threshold were noted. The patients were then randomly allocated to 2 groups and were treated with IGF-1 via one of the following routes: (1) intratympanic injection and (2) Gelfoam. Patients were followed-up at weekly intervals for 6 weeks but follow-up PTA was done at 3 weeks, 6 weeks, and 6 months only. Results Forty patients (25 male, 15 female) participated in the study. Their age ranged from 13 to 63 years, with a mean of 31.3 years. Nineteen (47.5%) patients exhibited some degree of recovery after 6 months of follow-up, while 21 (52.5%) did not exhibit any recovery. Fourteen (35%) patients showed slight recovery (SR), 1 (4%) patient showed marked recovery, and complete recovery was observed in 4 (10%) patients. Twelve of the 20 patients who underwent treatment using Gelfoam showed improvement in hearing (measured as a reduction in hearing threshold), while only 7 of the 20 patients who underwent intratympanic injection showed such improvement. Among adverse reactions, the most common was pain (88%) which typically did not last beyond 3 days. Other adverse reactions observed were dizziness (24%) and headache (20%). One patient suffered from acute suppurative otitis media (ASOM) and had a perforation in the tympanic membrane. However, this was treated successfully with medications. Conclusion Intratympanic IGF-1 is a novel drug that has shown early promise in controlling and reversing SNHL.

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.

Objective To evaluate local and systemic safety of bilateral iontophoretic administration of lidocaine with epinephrine or lidocaine alone to the tympanic membrane (TM). Study design A randomized, double-blind, two-arm study was conducted at a single center. Healthy adults were randomized to bilateral iontophoretic treatment with 2% lidocaine, 1:100,000 epinephrine, or 2% lidocaine (control). Otoscopy, cranial nerve examination, tympanometry, and audiometry safety evaluations were conducted before and 3-days post-procedure. Systemic safety was evaluated via analysis of vital signs taken before and up to 120 minutes post-iontophoresis, and blood samples collected before and up to 230 minutes post-iontophoresis. Results Twenty-five subjects were treated with bilateral iontophoresis of either lidocaine and epinephrine (n = 15 subjects) or lidocaine alone (n = 10). Mean plasma epinephrine concentrations for both groups remained within the normal range for endogenous epinephrine. Mean plasma concentrations of lidocaine were not statistically different between groups, ranging from 0.245 to 2.28 ng/ml after administration of lidocaine with epinephrine (immediate post-iontophoresis to 230 min post-iontophoresis), compared with 1.35 to 2.14 ng/ml after administration of lidocaine alone. The presence of epinephrine slowed the systemic absorption of lidocaine. Lidocaine levels (Cmax 2.24 ng/ml) were approximately 2000-fold lower than the threshold for minor lidocaine toxicity. No device-, procedure- or drug-related adverse events were reported. Conclusion The local and systemic safety of bilateral iontophoretic delivery of 2% lidocaine, 1:100,000 epinephrine to the TM was demonstrated by low plasma levels of drug and absence of both serious and non-serious device-, procedure-, or drug-related adverse events.