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Objectives: Congenital cholesteatomas originate from epithelial tissue present within the middle ear in patients with an intact tympanic membrane, no history of otologic surgery, otorrhea, or tympanic membrane perforation. They are diagnosed by a pearl-like lesion on otoscopy and computed tomography (CT) scan showing an expansile soft-tissue mass. We describe a series of patients with no prior otologic history presenting with progressive unilateral conductive hearing loss and normal otoscopy. The CT scans showed ossicular erosion without obvious soft-tissue mass. Surgery confirmed incudostapedial erosion found to be cholesteatoma. In this study, we characterize the clinical course of patients diagnosed with isolated incudostapedial cholesteatoma (IIC) and review possible pathologic mechanisms. Methods: Retrospective review of IIC cases treated by the Department of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, 2014 to 2020. Data included patient demographics, clinical features, imaging, surgical findings, and audiologic data. Results: Five patients were diagnosed with IIC (3 [60%] female; mean age at presentation 10.7 years [range 5.5-16.0]). All patients presented with postlingual unilateral conductive hearing loss and normal otoscopy without any past otologic history; delay in diagnosis ranged from 4 months to several years. The CT scans showed ossicular chain erosion with an absent long process of the incus and/or stapes superstructure. All patients underwent middle ear exploration, revealing a thin layer of cholesteatoma in the incudostapedial region, confirmed by histopathology. Mean preoperative speech reception threshold was 55 dB and improved to a mean of 31 dB in the 4 patients who underwent ossicular chain reconstruction. Conclusion: Isolated incudostapedial cholesteatoma should be included as a possible etiology in pediatric patients with insidious onset of unilateral conductive hearing loss with normal otoscopy, unremarkable otologic history, and a CT scan showing ossicular abnormality/disruption without notable middle ear mass. These patients should be counseled preoperatively regarding the possibility of cholesteatoma and should undergo middle ear exploration with possible ossiculoplasty.

Potsic's staging system is a clinically useful procedure for evaluating the extent of congenital cholesteatoma (CC).We investigated the clinical features, presenting symptoms, and surgical results of CC according to Potsic's staging system.A total of 71 patients who had undergone surgery at our hospital were retrospectively analyzed for presenting symptoms, the location of cholesteatoma, and surgical results according to Potsic's staging system.Of the 71 patients, 21 were classified as Potsic stage I, 9 as stage II, 31 as stage III, and 10 as stage IV. More than half of the patients with early-stage CC (stages I and II) were diagnosed asymptomatically by a chance visit to a clinic or on ear screening. Others were diagnosed following a complaint of hearing loss, acute otitis media, or otitis media with effusion. The location of CC varied somewhat by stage. In stage I CC, the most frequent location was behind the anterior-superior quadrant of the tympanic membrane; however, in stage III CC, it was behind the posterior-superior quadrant. All patients were treated surgically. Recurrence was detected in 2 of the 71 patients (2.8%); both had stage II CC. Recurrent lesions were removed during revision surgery.

Objectives: Hyaluronic acid fat graft myringoplasty (HAFGM) is a new technique for tympanic membrane perforation (TMP) treatment. It is simple, inexpensive, and performed under local anesthesia at the outpatient office department. We aim to evaluate the HAFGM on different TMP sizes, to compare the success rate of HAFGM with the underlay and overlay techniques, and to assess the hearing improvement at one year postoperatively. Study Design: Prospective study. Methods: Patients were divided into three groups depending on the patient's choice of technique: HAFGM (group I), underlay technique (group II), and overlay technique (group III). Perforations were classified into four grades. Postoperatively, the status of the eardrum, the improvement of hearing, and the incidence of complications were the main criteria for measuring outcome. Results: Distribution of TMP was 131, 63, and 52 in group I, II, and III, respectively. Global successful rate and successful closure of the grade I, II, III, and IV were the same for the three groups. Postoperatively, no worsening of bone conduction threshold was noted. Air-bone gap (ABG) was statistically similar for the three groups. No complications were noted for group I. The mean duration of the operative procedures was 16, 65, and 74 minutes for group I, II, and III, respectively (P = .02). The mean postoperative follow-up was 18.7, 20.6, and 15.5 months for groups I, II, and III, respectively. Conclusions: HAFGM success rate is comparable to that of the underlay and overlay techniques. Furthermore, it requires no hospitalization and avoids the difficulty of overlay and underlay tympanoplasty.

Objectives/Hypothesis: The aim of this study was to provide a detailed cytological account on the healing tympanic membrane (TM) over 14 days and to complement existing research into TM wound healing. Study Design: The study is a prospective cohort study of 19 male Sprague-Dawley (Rattus norvegicus) rats. Methods: Rat TMs were perforated using a sterile needle and sacrificed at time points during the 14 days following perforation. Results: The healing of the TM resembles cutaneous wound healing except that the TM is unique in the lack of a supportive matrix beneath the regenerating epithelia. This prevents the influx of reparative cells and nutrients and the in growth of the usual fibroblastic reaction. Conclusions: TM wound healing contrasts with cutaneous wound healing in that keratinocytes are the first cells to close the wound and not the last. A keratin scaffold may not be important in the healing process. The malleus plays a crucial role in the healing of the TM and is the site of significant mitotic activity during the healing process. Migration across layers of the TM appears to account for the closure of the perforation. Laryngoscope, 2010

Fat-graft myringoplasty (FGM) has a reliable tympanic closure rate for small to large perforations, but yields poor hearing improvement in the latter case. A topographic evaluation of FGM showed that the procedure resulted in a reliable perforation closure rate and audiologic outcome, regardless of perforation location.This study assessed the utility of FGM in treating perforations of different sizes and locations.This retrospective study involved 45 patients (46 ears) who underwent FGM at St Mary's Hospital (Seoul, Korea) between August 2007 and February 2010.The total perforation closure rate after FGM was 87% (40 cases), with no statistical difference among perforation size groups, even though the mean closure rates of the 10-20% and30% perforation groups were lower than other groups. The difference in the closure rates of patients with anteriorly located perforations and those with perforations in other sites was not significant. The mean postoperative air-bone gap (ABG) was 14.3 (±7.5) dB. Mean postoperative ABG improved significantly after FGM; however, on a per-group basis, the30% perforation group had the poorest results and the difference was statistically significant. The difference in mean postoperative ABGs of the two groups depending on the location of the perforation (anterior and other) was not significant.

Objective:To obtain information on the success rate of tympanoplasty with concomitant myringosclerosis.Methods:The medical records of 40 children with myringosclerosis (23 girls, 17 boys; age range six to 16 years, mean age 9.85 years) who had undergone primary tympanoplasty were retrospectively studied. Surgical success was defined as the perforation remaining closed 12 months post-operatively.Results:Sclerotic plaques occupied whole remnant eardrums in 17 patients, and were located in various parts of the eardrum in 23. Tympanosclerosis associated with myringosclerosis was present in six patients. The success rate of primary tympanoplasty was 92.5 per cent. All three surgical failures were observed in girls with marginal perforations. These children underwent successful revision procedures for their residual perforations, variously at four, eight and 10 months after the initial surgery.Conclusion:Appropriate freshening of the perforation edges, with removal of sclerotic plaques, can result in a high rate of successful closure of perforated tympanic membrane with coexisting myringosclerosis.

Objectives/Hypothesis: To compare cartilage palisades with fascia grafting in reconstruction of the eardrum after surgery for sinus or tensa retraction cholesteatoma in children, with respect to long-term postoperative eardrum retraction and perforation, cholesteatoma recurrence, and hearing acuity. Methods: A total of 64 children underwent surgery for either sinus or tensa retraction cholesteatoma during the period 1995 to 2000 (mean age 9 years, range 5–15). The eardrum was reconstructed using cartilage palisades in 32 children (32 ears) and fascia or perichondrium in 32 children (33 ears). The patients were followed for at least one year postoperatively and re-evaluated 4 years after surgery, and again recently at a mean of 10 years. The main outcome measures were postoperative drum retraction and perforation, cholesteatoma recurrence, and hearing acuity (pure tone average, speech reception threshold, and pure tone air-bone gap). Results: All but two patients in both groups attended the 10-year follow-up examination (94% attendance). The mean overall follow-up period was 119 months (115 months in the palisade and 125 months in the fascia group). Total number of retractions during follow-up and at the 10-year examination was six (19%) for the palisade group and 14 (42%) for the fascia group (P = .03; chi-square test). The accumulated numbers for a perforation were four (13%) for the palisade group and seven (21%) for the fascia group (difference not significant). Two residual cholesteatomas, which are not related to the graft material, occurred in the palisade group (6%), whereas both recurrencies, which may be related to the graft material, occurred in the fascia group (6%). The hearing acuity for children operated on for a sinus cholesteatoma and for children with type III tympanoplasties was significantly better when cartilage palisade grafting had been employed. Conclusions: The cartilage palisade grafting technique appears superior with respect to prevention of long-term eardrum retraction. The occurrence of cholesteatoma recurrency and eardrum perforation seem to be independent of grafting material, although these results may be due to type 2 error (low number of ears). In sinus cholesteatoma surgery and in type III tympanoplasty, the long-term hearing results appear better when grafting cartilage palisades. Laryngoscope, 2009

Objectives:To investigate the impact of perforation size and other variables on the success of myringoplasty, and also to determine audiological gain following successful closure of tympanic membrane perforations of various sizes.Study design:Retrospective analysis of 130 case notes.Main outcome measures:(1) Successful closure of tympanic membrane following myringoplasty, in relation to recorded variables (i.e. perforation size, grade of surgeon, surgical technique, graft material, previous myringoplasty and smoking history). (2) Mean, four-frequency, air conduction audiometric gain following successful myringoplasty for various, pre-operatively categorised tympanic membrane perforation sizes.Results and Conclusion:The collective myringoplasty success rate was 80.8 per cent (105/130); for successful patients, the mean air conduction audiometric gain was −6.8 dB (t = 5.29, p

Annales Francaises d'Oto-Rhino-Laryngologie et de pathologie cervico-faciale - Vol. 125 - N° 5 - p. 261-272

Objective:This study aimed to compare outcomes for mastoidotympanoplasty and for tympanoplasty alone in cases of quiescent, tubotympanic, chronic, suppurative otitis media.Study design:Single-blinded, randomised, controlled study within a tertiary referral hospital.Methods:Sixty-eight cases were randomly allocated into two groups. In group one, 35 ears underwent type one tympanoplasty along with cortical mastoidectomy. In group two, 33 ears underwent type one tympanoplasty alone. Outcome measures were as follows: perforation closure and graft uptake, hearing improvement, disease eradication, and post-operative complications.Results:There were no statistically significant differences in hearing improvement, tympanic perforation closure, graft uptake or disease eradication, comparing the two groups at three and six months post-operatively.Conclusion:Mastoidotympanoplasty was not found to be superior to tympanoplasty alone over a short term follow-up period. Hence, it may not be necessary to undertake routine mastoid exploration at this stage of disease.

Objective: To evaluate the impact of patient and graft variables on the successful closure of tympanic membrane perforations treated with myringoplasty at the Children's Hospital of Pittsburgh from 2000 to 2005. Study Design: Retrospective chart review at an academic tertiary-care children's hospital. Methods: Charts were reviewed for 604 children, ages 1 to 18 years old, with complete records who underwent myringoplasty by the pediatric otolaryngology practice at Children's Hospital of Pittsburgh of UPMC from 2000 to 2005, totaling 777 procedures. Results: Significant variables include patient age, number of prior tubes, perforation etiology (P < .000), presence of a retained tube (P < .000) as well as tube type (P = .016), graft material (P = .001), and history of Down syndrome (P = .035). Nonsignificant variables include season of procedure (P = .599), status of adenoid tissue (P = .910), prior otorrhea (P = .175), as well as perforation location (P = .318) and duration (P = .150). Conclusions: Proper patient and graft material selection can affect the outcome of myringoplasty procedures. Practical implications from these data suggest that Gelfoam myringoplasty is more successful than either paper patch or fat graft closures, with a 90.8% success rate (P = .001). Myringoplasty should not be deferred during the winter months as the season of procedure does appear to not affect the success of closure (P = .60). Similarly, the presence or absence of adenoid tissue did not affect the success of closure (P = .91).

We evaluated auditory performance following cartilage tympanoplasty for the management of tympanic membrane retraction pockets. We performed a 230-patient retrospective study over a 10-year period (1990-2000) and compared pre-operative and postoperative audiograms. Postoperative audiograms were better in 49% of cases, identical in 16% and worse in 11%. Cartilage tympanoplasty for the management of tympanic membrane retraction pockets has a good postoperative functional outcome. Cartilage graft is useful for reconstruction of the eardrum and tympanic bone defects.

Objective: To evaluate the therapeutic efficacy of intratympanic dexamethasone (ITD) injections added to systemic steroids in patients with idiopathic sudden sensorineural hearing loss (HL). Materials and Methods: A total of 120 patients diagnosed with sudden HL were treated with ITD injections (0.3 mL on days 1, 3, and 5) plus 48 mg methylprednisolone (ITD group) or methylprednisolone alone (control group). Results: The total recovery rate after the treatment was 73.3% in the ITD group and 70.0% in the control group. Although improvements in pure-tone average were the same in the two groups, the ITD group showed significantly better hearing improvement at 250 Hz than the control group. Conclusion: The addition of ITD to systemic steroids did not result in significant improvements in the treatment of idiopathic sudden HL.

Conclusions. Important information about the basic reparative process of tympanic membrane (TM) healing is shown, which can be incorporated for further clinical understanding. This provides a basis for the exploration of stem cell treatment for TM perforations and holds promise for future improvements. Objectives. This study aimed to analyse the healing of TM perforation by using stem cells and the stiffness of the membrane was tested in an acute and long-term study. Materials and methods. Sprague-Dawley rats were used in a model of TM perforation. The perforation was performed with a laser system. Stem cells were applied and the healing time and morphological analysis were performed with light and transmission electron microscope. Stiffness was examined by moire interferometry. Results. The stiffness of the perforated and healed TM was restored after just 2 weeks. In the chronic perforation model, mesenchymal stem cells enhanced the healing.

The objective of the present study was to evaluate the efficacy of fat graft myringoplasty in repairing residual or recurrent tympanic membrane perforation. A retrospective analysis was performed on 31 patients, aged 25-57 years (mean 43.3), submitted to myringoplasty revision using fat graft. Fourteen were males and 17 females. Perforation size ranged from 1 to 5 mm. Follow-up time ranged from 4 to 62 months (mean 26 months). Fat graft myringoplasty was performed under local anesthesia, using ear lobe fat in 26 patients and abdominal fat in five patients closure of tympanic membrane perforation was achieved in 87.1% of ears. No modification of the hearing level was evidenced at the statistical analysis. Fat graft myringoplasty is a safe, effective and minimally invasive procedure, suitable to repair small residual/recurrent perforations of the tympanic membrane. The angiogenic properties of the fat are ideal to overcome the poor vascular supply in the vicinity of the tympanic membrane perforation.

Objectives:Wound healing, epithelial regrowth and collagen synthesis are very important factors in the repair of the traumatised tympanic membrane. The aim of the present study was to determine the role of plasma fibronectine in the aetiopathogenesis of tympanosclerosis.Methods:This prospective study included 58 patients with and 49 without tympanosclerosis. No inflammation or trauma was noted in either patient group. All patients underwent otoscopic and otomicroscopic examination, and the degree of tympanosclerosis was graded from mild (stage I) to severe (stage III). Following otological examination, blood samples were taken for plasma fibronectine measurement.Results:Following otoscopic and otomicroscopic examinations, patients' tympanosclerosis was graded as follows: 18 patients were stage I; 29 were stage II; and 11 were stage III. Statistical analyses revealed that the plasma fibronectine concentrations were significantly lower in the study group compared with the control group (p = 0.031). In addition, fibronectine levels were lowest in the patients with severest tympanosclerosis (p = 0.0001 in each comparison).Conclusion:The results of the present study show that serum fibronectine is important in the development and severity of tympanosclerosis.

Intratympanic membrane cholesteatoma, occurring in the absence of trauma or surgery to the ear, is rare with less than 20 cases reported in the literature. We report a rare incidental finding of intratympanic membrane cholesteatoma in a 12-month-old girl and review the literature.

Purpose The objective of this study was to examine the success of a pilot treatment algorithm for tympanic membrane perforations in children after tympanostomy tube placement. Materials and Methods A retrospective chart review of children with diagnosed tympanic membrane perforations after tympanostomy tube placement from 1998 to 2003 at a tertiary care children's hospital was performed. The patients had been treated according to an algorithm used by 2 pediatric otolaryngologists for management of tympanic membrane perforations: observation vs myringoplasty. Success rates were examined. Results Ninety-five children were identified, 27% of whom had nonhealing perforations after tube extrusion; 73% of the perforations were caused by a retained tube. The median duration of tube retention was 48 months, ranging from 13 to 120 months. After the treatment protocol, 76% of the patients underwent gelatin film or paper patch myringoplasty, 23% had adipose myringoplasty, and 1% were observed. Overall, 91% had healed perforations after the first intervention. Among those requiring a second intervention, the sizes of initial perforations were between 15% and 40%, with postrepair perforation sizes between 5% and 40%. In addition, 75% of those requiring a second intervention underwent tympanoplasty repair and 25% had fat patch myringoplasty. None required a third intervention. Conclusions Our treatment algorithm for children with tympanic membrane perforations after tympanostomy tube placement appears to be successful and is an excellent model for other clinicians.

Objective: This case-control study aimed to analyze the effect of intratympanic dexamethasone injection (ITDI) as a treatment option for patients with sudden sensorineural hearing loss (SSNHL) who were refractory to classic oral steroid treatment. Methods: Sixty-six patients with SSNHL, who were refractory to a course of oral steroid therapy, were included in this study. We prospectively treated consecutive 33 patients (34 ears) with ITDI from August 2002 to January 2004. We then retrospectively collected data from age- and sex-matched previous patients who did not take any more treatments after the initial regimen between March 2000 and July 2002. ITDI was performed in the supine position on four separate occasions over the course of 2 weeks. Hearing was assessed immediately before every injection and at 1 week after therapy. Hearing improvement was defined as more than 10 dB in pure-tone average (PTA). Results: Hearing improvement was observed in 13 (39.4%) of 33 patients who underwent ITDI and in two (6.1%) of 33 patients in the control group. Five of 13 represented hearing improvement over than 20 dB in PTA, and 11 of 20 patients, who showed no improvement in PTA by ITDI, showed improvement over 10 dB in some frequencies. There were no definite prognostic factors between the patients who responded to ITDI and those who did not. Conclusion: ITDI may be a simple and effective therapy for patients with refractory SSNHL.

The objective of this animal study was to compare topical mitomycin C (MMC) before and after nonlaser myringotomy. Bilateral myringotomies were performed in 12 rats. On the left side, MMC was applied to the intact tympanic membrane for 10 min before myringotomy (preapplication group). On the right side, MMC was applied to the tympanic membrane following myringotomy. Tympanic membranes were observed for a total of 8 weeks. By day 35, all myringotomies with application of MMC after perforation of the tympanic membrane were closed, whereas 42% of the myringotomies with application of MMC prior to perforation remained patent. One tympanic membrane in the preapplication group showed an enlargement of the perforation with partial destruction of the malleus. The present study showed that the application of MMC to the intact tympanic membrane prolongs the patency of nonlaser myringotomies in rats. Specific side effects of the MMC application must be kept in mind.

The object of this study was to investigate the efficacy of topical mitomycin C (MMC) in combination with subsequent topical dexamethasone to prolong the patency of myringotomies. Bilateral instrumental myringotomies were performed in 12 rats. On both sides, a solution of MMC (2 mg/ml) was applied to the intact tympanic membrane for ten minutes before myringotomy. Dexamethasone (4 mg/ml) was applied to one tympanic membrane of each animal at days 3, 6, 9 and 14. Tympanic membranes were observed weekly for a total of 9 weeks. The mean healing period was found to be 17.5 days (range 4.5–45.5 days) in the group with MMC alone, and 32 days (range 17.5–59.5 days) in the group MMC + dexamethasone. The difference was significant. A combination of topical MMC and subsequent dexamethasone did delay the healing rate of myringotomies in rat tympanic membranes longer than MMC alone.

Our results support the proposition that hyaluronic acid (HA) provides a moist wound-healing environment to aid in the healing process of tympanic membrane perforation. A single MeroGel administration can be effective as well as daily topical HA application in the treatment of tympanic membrane perforations. A single application of esterified HA may be more suitable for patients and also for otolaryngologists.The purpose of the present study was to evaluate the effectiveness of a single MeroGel application on traumatic tympanic membrane perforations in rats.The posterior quadrant of the tympanic membranes in both ears of 24 male pathogen-free Sprague-Dawley rats was perforated with a 20-gauge needle. Subjects were divided into two groups: MeroGel and daily topical HA-treated groups. All subjects were sacrificed and histopathological examinations of the tympanic bullas were carried out.Perforations of controls, and MeroGel- and daily HA-treated groups closed in 17/24 (70.8%), 11/12 (91.7%), and 12/12 (100%) ears, respectively. There was a significant difference between control and MeroGel-treated groups, and also between control and daily topical HA-treated groups for the presence of vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), lymphocytes and collagen fibrils (p0.05), whereas there was no significant difference between MeroGel- and daily topical HA-treated groups (p0.05).

Autogenous cartilage-perichondrium-composite-grafts have become essential and well established transplant materials in reconstructive middle ear surgery. They have proven to be particularly appropriate for surgical situations which benefit from the bradytrophy and stiffness of the cartilage (adhesive otitis, retraction pockets, subtotal tympanic membrane defects, revision tympanoplasty). Of the numerous techniques available, the perichondrium-island technique and the palisade-cartilage technique are described in detail in this review, also regarding modifications and comments in the literature. Both methods show good functional and morphological results and should be chosen according to individual surgical requirements. The data of experimental investigations are involved in the decision which technique should be favored.

Over-under tympanoplasty is a technique aimed at eliminating the disadvantages of the two classical techniques of overlay and underlay myringoplasty, which are employed in repairing the tympanic membrane. In this retrospective study, a total of 104 patients underwent myringoplasty, which was performed by means of the underlay technique in 46 patients and over-under technique in 58 patients. The mean follow-up period was 11 months. In the first group of patients, the underlay technique was performed; the grafted membrane was placed medial to the remaining drum and the manubrium of the malleus. In the second group, the over-under technique was performed; the grafted membrane was placed under the remaining drum and over the malleus. The rate of success in the first group of 46 patients was 91.5%, and that of atelectasis was 19.5%. The rate of success in the second group of 58 patients was 94.9% and 12%, respectively. Lateralization of the graft was not observed in either of the groups. In the patients operated on by means of the underlay technique, the air-bone gap decreased by 16.55 dB this rate was 16.96 dB in those operated on by the over-under technique. The authors consider over-under tympanoplasty to be superior to the other two classical methods not only because of its effectiveness, but also because of the results achieved by this technique.

Mastoidectomy has long been identified as an effective method of treatment for chronic ear infection. The effect of mastoidectomy on patients without evidence of active infectious disease remains highly debated and unproven. The objective in the study was to examine the impact of mastoidectomy on the repair of uncomplicated tympanic membrane perforations.Retrospective study of patients at tertiary referral center.Four hundred eighty-four patients who underwent surgical repair of simple tympanic membrane perforations were identified and reviewed in a retrospective manner. Simple tympanic membrane perforations were defined as tympanic membrane perforations of any size and location without any of the following confounding variables: 1). active infection (active otorrhea, abnormal middle ear mucosa, or granulations tissue); 2). ossicular abnormalities (ossicular fixation, ossicular discontinuity, ossicular malformation, or ossicular absence); 3). cholesteatoma; or 4). prior attempt at tympanic membrane repair (prior tympanoplasty or mastoidectomy). Surgical outcome and clinical course were assessed to compare results of tympanic membrane perforation repair with and without canal wall up mastoidectomy.Tympanic membrane repair was equally effective in both groups at 91%. Hearing results were comparable. Development of persistent ipsilateral otological disease requiring a subsequent ipsilateral procedure was approximately twice as common in the tympanoplasty group. In the tympanoplasty group, 14.1% of patients underwent subsequent ipsilateral otological procedures, and 6.1% of patients in the tympanoplasty with mastoidectomy intact canal wall group underwent subsequent ipsilateral procedures (P.05). The most common subsequent ipsilateral procedures were tympanoplasty, tympanostomy tube placement, tympanoplasty with mastoidectomy canal wall up, and tympanoplasty with mastoidectomy canal wall down, in that order. After including untreated tympanic membrane perforations as subsequent procedures, the adjusted rate of subsequent procedures was 15.5% in the tympanoplasty group and 12.2% in the tympanoplasty with mastoidectomy group (P.05).Mastoidectomy was not necessary for successful repair of simple tympanic membrane perforations. However, mastoidectomy impacted the clinical course in patients by reducing the number of patients requiring future procedures and by decreasing disease progression. This suggests that even in the absence of active evidence of infection, mastoidectomy improved the underlying disease process. Combining mastoidectomy with tympanoplasty during repair of simple perforations in patients with no active evidence of infection remains an appropriate option and may be valuable in reducing the need for future surgery.

Background: A new method for the stimulation of the organ of equilibrium by means of a broad-scale and monochromatic near infrared emission was developed. This method should be examined within the framework of a pilot study, evaluated and its clinical possible applications examined. Patients and Methods: Healthy probands (n = 15), patients with a radical cave of the ear (n = 5), patients with a defect of the tympanic membrane (n = 5) and spontaneous nystagmus (n = 5) were examined. In healthy probands an irritation with broad-scale as well as monochromatic near infrared (NIR) was performed and compared with a water irrigation (44 degrees, 50 ml in 30 seconds). The subjective, local feelings during the application and the appearance of giddiness according to irritation were corded and the nystagmus was registered by means of videonystagmography. In patients with radical cave of the ear and tympanic membrane defects, a broad-scale NIR-irritation before a comparative irritation with warm air (44 degrees) was performed exclusively. Results: In all healthy probands, a nystagmus reaction could be seen with broad-scale and monochromatic NIR. Compared to the hot water irritation slow phase velocity (SPV) was decreased however registrable by means of Frenzel glasses and elektronystagmography during the culmination stage. In patients with radical cave (n = 4) and tympanic membrane defects (n = 3) showing paradoxical nystagmus reaction during hot air irritation, a nystagmus to the site of stimulation resulted by means of light calorisation. In patients with a spontaneous nystagmus an attenuation (n = 1) or inversion (n = 2) could be achieved by NIR-radiation. Conclusions: The method of the NIR-radiation is suitable in clinical practice for the caloric test proofing warm reaction. Vaporization cold does not occur. The application of heat charm is better proportionable and steerable than during air irritation. The procedure is sterile, noiseless and non-contact. Difficulties in interpretation of results of vestibular tests because of evaporation coldness do not occur.

BACKGROUND: Among other materials it is also possible to use autologous fat tissue for closing tympanic membrane perforations. In this study we have evaluated 44 consecutive myringoplasties with adipose tissue performed between 1999 and 2001. MATERIAL AND METHOD: The indications were residual microperforations following tympanoplasty with temporalis fascia or tympanic membrane perforations due to trauma or chronic otitis media simplex. Myringoplasty with fat tissue was performed as an outpatient procedure and took about 15 minutes. The adipose tissue was harvested from the posterior side of the ear lobe in local anaesthesia. After refreshing the borders of the tympanic membrane perforation with a micro hook, the adipose tissue was positioned into the perforation by using a handheld or fixed ear speculum. The graft was covered with a silk strip soaked with Garamycine ointment. In bigger perforations a bed of gelfoam was put into the tympanic cavity in order to avoid adhesions between the graft and the promontorium. RESULTS: A permanent healing of the tympanic membrane was achieved in 40 (91 %) out of the 44 patients. In 21 patients hearing improved between 5 -10 dB. Surgical complications did not occur. CONCLUSIONS: Our results indicate that transcanal myringoplasty with adipose tissue is a simple and minimally invasive method for closing small to medium sized tympanic membrane perforations.

Objective: To describe the pathophysiology and treatment of the lateralized tympanic membrane that occurs after canal wall down tympanoplasty. Study Design: Retrospective case review. Setting: Tertiary referral hospital. Patients: Four patients in whom lateralization of the tympanic membrane developed as a complication of canal wall down tympanoplasty. Results: The patients had undergone middle ear surgery 20 to 34 years before their first visit to the authors. A Bondy operation with soft-wall reconstruction of the ear canal had been performed in three patients and a modified radical mastoidectomy in one patient. They all had severe conductive hearing loss. Common findings were anterior canal sulcus blunting, good tubal function, normal middle ear mucosa, and mobile stapes. At revision surgery, the lateralized tympanic membrane was removed, and the temporalis fascia was grafted medial to the malleus manubrium. The exposed bony surface in the ear canal was covered with a split-thickness skin graft, and the ear canal and the mastoid cavity were tightly packed to secure the graft. All the patients regained good hearing after the revision. Although deterioration of the anterior tympanic ring was presumed to be the primary cause of the graft lateralization, the lack of a posterior bony ear canal might have facilitated this condition. Conclusion: Lateralization of the tympanic membrane can occur even in an ear with a radicalized mastoid cavity, especially when the anterior tympanic ring is torn and the posterior ear canal is reconstructed with soft tissue.

Objective: To review the outcome in consecutive patients who have undergone complete epitympanic and mastoid obliteration and concurrent tympanic membrane reconstruction over a 53-month period. Study Design: Retrospective review. Setting: Tertiary referral center. Patients: Sixty-two ears in 56 sequential patients undergoing mastoid obliteration with major indications including recurrent infection, debris trapping in the canal wall-down cavity, intolerance of water exposure, calorically induced vertigo in an existing cavity, a semicircular canal fistula, and inability to wear a hearing device. Thirty-six ears in 33 patients who underwent second-stage surgery for ossicular reconstruction during the same time period are also reviewed. Intervention: Transplanted autogenous cranial bone is used to induce osteoneogenesis resulting in complete obliteration of the epitympanic and mastoid spaces while maintaining a mesotympanic space. Main Outcome Measures: Success of obliteration, incidence of symptoms prompting intervention, hearing outcome, incidence of recurrent cholesteatoma, and incidence of eustachian tube dysfunction necessitating treatment and need for revision surgical procedures. Results: Complete take of the bony obliteration occurs in over 95% of cases; 90% of treated patients enjoy complete absence of original symptoms, whereas symptoms improved in the remainder. For over 95% of patients. existing eustachian tube function has been adequate after obliteration. To date, no patient has required revision surgical intervention. Conclusion: Mastoid obliteration with autogenous cranial bone is a safe and extremely effective option for treatment of problematic canal wall-down mastoid cavities. Surgical techniques that include sterile harvest of the cranial bone graft mixed with antibiotic, revision of the cavity to expose viable native bone, inclusion of the epitympanic spaces in the obliteration, and complete coverage of the pAte with autogenous fascia have proven critical to successful outcome.

Purpose: To study the effectiveness of AlloDerm (LifeCell Corporation, Branchburg, NJ) as a graft material in underlay tympanoplasty by comparison to autologous fascia in a chronic tympanic membrane perforation animal model. Materials and Methods: Seventeen chinchillas underwent creation of bilateral chronic tympanic membrane perforations over a 6-week period. Twenty-two stable perforations were divided equally between the experimental AlloDerm and control fascia graft groups. The grafts were surgically placed through a postauricular tympanomeatal flap. The tympanic membranes were examined at 4 and 10 weeks and then harvested for histopathological analysis. Tympanoplasty operative times, perforation closure rates, and gross and histological analyses were compared between the AlloDerm and fascia grafts. Results: A statistically significant difference in mean surgical time was recorded between the AlloDerm (47 minutes) and fascia (68 minutes) grafting procedures ( t test, P =.001). Perforation closure was achieved in 90% of the AlloDerm and 100% of the fascia treated tympanic membranes. Gross and histopathologic inspections revealed no significant differences. Microscopically, AlloDerm and fascia grafts had similar inflammatory responses, but AlloDerm showed increased fibroblast infiltration and neovascularization. Conclusion: The avoidance of donor site morbidity, reduction of surgical time, and excellent gross and histologic outcomes in this animal model reveal that AlloDerm could be a safe, cost-effective alternative to autologous fascia. Further study would be necessary in human clinical trials. (Am J Otolaryngol 2003;24:6-13. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Purpose: To determine whether Alloderm (Life Cell Corporation, The Woodlands, TX) can be used to cover canal wall down mastoid defects, as well as repair dural defects from translabyrinthine and transpetrosal approaches to the skull base. Methods: A retrospective analysis was performed at an academic tertiary care medical center. Eighteen patients were operated on with canal wall down mastoidectomies, and Alloderm was used to reconstruct the tympanic membrane and line the mastoid cavity. Eleven patients had dural defects reconstructed after skull base approach surgery. We wanted to determine whether the Alloderm graft healed in canal wall down mastoidectomy procedures with good epithelialization. For the skull base approaches, we determined whether a cerebrospinal fluid leak had occurred. Results: The 18 patients who were reconstructed with an Alloderm graft after a canal wall down mastoidectomy all had good epithelialization. As with fascia reconstruction, some granulation tissue occurred, but this was easily controlled in the office setting. Of the 11 patients who underwent reconstruction for skull base surgery approaches, none developed a cerebrospinal fluid leak. Conclusion: Alloderm may provide a suitable grafting material when fascia is either not readily available, or the size of the defect precludes the use of fascia. (Am J Otolaryngol 2002;23:148-152. Copyright 2002, Elsevier Science (USA). All rights reserved.)

This cross-sectional study enrolled 95 elderly Emergency Department patients aged 60 years or more to determine if rectal temperatures identify fevers more often than oral or tympanic temperatures when the chief complaint suggests an infection. A fever was defined as a temperature greater than 38 degrees C (100.4 degrees F). Discordance was defined as any patient with an oral or tympanic temperature of 38 degrees C or less but manifesting a rectal temperature greater than 38 degrees C and 0.5 degrees C (1 degrees F) greater than the oral or tympanic temperature. Rectal thermometry identified a fever in 14 of 95 (14.7%) patients who were afebrile orally and in 11 of 90 (12.2%) patients who were afebrile tympanically. Five of 90 (5.6%) patients were febrile rectally but were afebrile by both oral and tympanic thermometry. Thus, rectal thermometry identified fevers missed orally and tympanically in elderly patients whose presentation suggested infection. To identify these febrile patients with possible infection, clinicians must be attentive to elderly patients' vague clinical presentation.

Objective: To determine the feasibility of inserting tympanostomy tubes in children using office-based laser-assisted tympanic membrane fenestration. Methods and materials: Study consisted of a retrospective review of the charts of all children who underwent office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion from July 1, 1998 to August 31, 2000. Tetracaine eardrops were used for topical anesthesia. Fenestration was achieved with the OtoLAM flashscanner laser (ESC Sharplan, Yokneam, Israel). Results: Of the 127 patients (185 ears) who underwent laser-assisted tympanic membrane fenestration, 61 ears underwent tympanostomy tube insertion. Ten ears were treated for otitis media with effusion, 43 for recurrent acute otitis media, and eight for acute otitis media not responding to antibiotics. Fifteen ears had purulent effusion, five had a serous effusion, and 23 had mucoid middle ear fluid. Eighteen ears had no middle ear fluid. At the first follow-up visit, all tested ears had hearing of 20 dB or better. Two children had tubes that were blocked. Blockage occurred in ears that required more than one laser firing to penetrate the tympanic membrane. Otorrhea was present in 13 ears (21%). Otorrhea occurred exclusively in ears with purulent or mucoid middle ear fluid. Conclusions: Office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion is a safe and effective alternative to tube placement in the operating room. The outcome compares favorably with previously published data.

Objective Human eustachian tubes with known pathologic conditions of the ear were inspected endoscopically, and video recordings were made for slow-motion analysis of the pathophysiologic changes. Setting Ambulatory office in a tertiary referral center. Subjects Forty-four adults with 64 ears having pathologic conditions. Interventions Transnasal endoscopic examination of the nasopharyngeal opening of the eustachian tube during rest, swallowing, and yawning to study the dilatory movements of the eustachian tube. Main Outcome Measures Slow-motion video analysis of the dilatory movements of the eustachian tube. Results Sixty-four ears and eustachian tubes with pathologic changes were studied. Tubal function was graded on (1) the extent of lateral excursion and progression of dilatory wave as estimates of tensor veli palatini and dilator tubae muscle function, reduced function being observed in 43 tubes; (2) the degree of mucosal disease, which was significant in 48 tubes; (3) obstructive mucosal changes, which were present in 15 tubes; (4) ease and frequency of tubal dilation with maneuvers—26 tubes opened moderately, 21 opened minimally, and 11 were unable to open; and (5) patulous tubes—all 6 clinically patulous tubes showed concavities in the superior third of the tube, which is convex in normal subjects. All tubes with active pathologic conditions of the ear (otitis media with effusion, tympanic membrane retraction, draining ear, cholesteatoma) had significant abnormalities. A correlation could not be made between the severity of middle ear disease and the severity of observed eustachian tube dysfunction. Conclusions Slow-motion endoscopic video analysis is a potentially useful technique in classifying types of pathologic changes in the eustachian tube. Additional studies of dysfunctional tubes are needed to predict outcomes in operative ear cases and to design intratubal therapy for chronically dysfunctional tubes.

Different policies on the treatment of tympanic membrane perforation in the pediatric age group continue to exist. Thirty patients were included in this study over a period of 2 years, where cartilage perichondrium composite graft (CPCG) was used to close the tympanic membrane perforation. Successful drum closure was achieved in 86.6% of cases, regardless of the site of perforation or the status of the operated ear. The graft was taken from the tragus and was placed in an underlay fashion with cartilage towards the promontory and the perichondrium immediately to the tympanic membrane remnants. The postoperative hearing gain although delayed up to 6 months was excellent either subjective or objective. So, CPCG has proved advantageous as a graft material to close perforation in the tympanic membrane in pediatric age group.

Objective: To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME). Setting: Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent. Methods: An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF. Outcome Measures: Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing. Results: At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years (P

Objectives To assess the use of an acellular dermal allograft in the repair of chronic tympanic membrane perforations. Chronic tympanic membrane perforations are a common problem in otolaryngology, and although surgical tympanoplasty using either temporalis fascia or rice paper has proven to be highly successful, these materials are not without their own limitations. The search has continued for a simpler, yet equally effective, means of repairing persistent tympanic membrane perforations in an office setting. In this study we experimentally evaluated the use of an acellular dermis (AlloDerm, (LifeCell Corporation, The Woodlands, TX) as an alternative to traditional tympanoplasty materials. Study Design Prospective study using 28 adult chinchillas. Methods Subtotal tympanic membrane perforations were created bilaterally in 28 adult chinchillas. Animals with noninfected, stable perforations that showed no signs of epithelial regeneration after 5 to 8 weeks were used to compare the use of rice paper patch with AlloDerm in patch tympanoplasties. Results Eighteen of 23 tympanoplasties (78%) that were performed using AlloDerm showed no signs of perforation after 5 to 6 weeks. In those performed using rice paper control, 14 of 21 (66%) showed no signs of perforation after 5 to 6 weeks. In addition, histological evaluation of the healed tympanic membranes demonstrated that the acellular dermis had been incorporated within the middle fibrous layer of the tympanic membrane. Conclusions The results and histological studies suggest that acellular dermis may be a suitable alternative to traditional materials currently used for patch tympanoplasty. Future studies to evaluate the efficacy of acellular dermis in humans are warranted.

To describe and analyze a middle ear condition in which the steady state of the middle ear pressure is elevated above the atmospheric pressure. SETTING AND STUDY DESIGN: This is a long-term survey of 59 patients from a private clinic who were observed on routine examination to have a ballooned out (hyperinflated) tympanic membrane.All patients underwent hearing tests, tympanometry, and Shullers (lateral) mastoid radiography.A hyperinflated tympanic membrane indicates a middle ear pressure that is higher than atmospheric pressure. The ballooned tympanic membrane returns to its physiological level after being punctured. This pressure situation is the reverse or opposite of atelectasis and is therefore termed hyperectasis. Hyperectasis, like atelectasis, is associated with a poorly pneumatized mastoid.Fifty-nine hyperectatic ears persisted in their hyperinflated state for weeks, months, or even years. The hyperectasis was preceded by atelectasis, and both conditions occasionally changed one into the other. The ballooned part of the tympanic membrane is usually thin and "scarred." Hyperectasis is not a rare situation and, once recognized, can be readily encountered in an otologic clinic.Like most biologic systems (e.g., blood pressure, temperature), the middle ear's central feature, i.e., pressure, also has a dynamic character vacillating up and down. It is conceivable that middle ear pressure is also actively regulated and controlled with the aid of a feedback mechanism. Passage of gas through the eustachian tube or absorption by diffusion-perfusion is also at least partly an active process. The up and down middle ear pressure vacillations are usually clinically benign and do not lead to any pathologic features as long as they are buffered by an accompanying normal mastoid pneumatization. It is the ear with a nonpneumatized mastoid that has limited ability to buffer pressure changes and that will present as an atelectasis, a retraction pocket, or (eventually a cholesteatoma) or their reverse, a hyperectatic tympanic membrane.

This study was carried out to establish which type of cholesteatoma is controllable by conservative treatment from the viewpoint of mastoid ventilation. We examined the area of the air cell system and airspace (aeration) in the mastoid cavity by computed tomography and eustachian tube (ET) function by inflation-deflation test in 20 ears (20 patients) with severe attic retraction for over 12 months (retraction pocket group), 16 ears (16 patients) with cholesteatoma which could be controlled only by conservative treatment for over 12 months (nonsurgical group) and 43 ears (43 patients) which required surgery within a year in spite of similar conservative treatment (surgical group). The size of the mastoid air cell system in the retraction pocket group, nonsurgical group and surgical group was 2.9 ± 1.3, 1.9 ± 0.7 and 1.5 ± 0.9 cm2 on average, respectively, with no significant difference between both cholesteatoma groups (nonsurgical and surgical group). While aeration was observed in the mastoid in 17 of 20 ears (85.%) in the retraction pocket group and in 12 of 16 ears (75.0%) in the nonsurgical group, aeration was present only in 9 of 43 ears (26.5%) in the surgical group, being significantly less in the surgical group than in the nonsurgical group and the retraction pocket group. In all ears in the retraction pocket and nonsurgical groups, and 19 of 30 ears in the surgical group, ET function was poor, there being no significant difference among the three groups. The present clinical observations suggest that progressiveness of cholesteatoma could be related to the ventilatory conditions in the mastoid rather than ET function, and that conservative treatment may be effective when ears with cholesteatoma have aeration in the mastoid.

Objective: the purpose of this study was to document the aeration and drainage pathways of Prussak's space. Methods: 55 temporal bones with an age range from neonate to 11 years of age were serially sectioned to 20 microns, every 10th section was saved and stained by Hematoxylin eosin. Each consecutive section was studied as to the connections of Prussak's space to adjacent compartments and measurements of the dimensions were made for both Prussak's space and its aeration pathways. Results: the classic aeration pathway via the posterior pouch, as described by Prussak in 1867, was found in 34 ears (62%). In 19 (36%), aeration occurred superior to the posterior pouch in the region of the lower lateral attic and the upper mesotympanum. In these ears the posterior pouch had formed, but its superior limit ended blindly in the tympanic membrane. In two temporal bones the aeration pathway was from the anterior pouch and in these cases also a blind posterior pouch had developed. In one temporal bone an auxiliary pathway in addition to the route via the posterior pouch was through the roof (the lateral malleal ligamental fold) of Prussak's space to the overlying lateral malleal space. The height of the posterior pouch varied with a range from 0.5 to 2.4 mm, and the greatest width, which was towards the posterior tympanic spine, varied from 1.6 to 3.2 mm. The superiorly blind posterior pouch was shorter, ranging from 0.4 to 1.2 mm in height. The most frequent route of the chorda tympani nerve was running from 0.5 to 1 mm medial to the posterior malleal ligament in the anterior half of the pouch, joining it posteriorly, or it was connected to it by a short fold, 37 ears (67%). In 18 cases (33%) the chorda was surrounded by its own fold, thus entirely separate from the posterior malleal ligamental fold during its entire course across the tympanum. Conclusions: we have made a detailed documentation of the aeration and drainage pathways of Prussak's space and the findings concur, with important modifications, with Prussak's original description. There is no evidence for contemporary claims that Prussak's space would be aerated superiorly between the lateral incudal and malleal folds. Prussak's space and its aeration pathway is an unit of its own, entirely separate of the major epitympanic compartments which are aerated via the tympanic isthmus. Due to frequent disease processes in the lower lateral attic and posterior mesotympanum, Prussak's space and its aeration pathway are likely to become blocked. This may lead to obliteration of Prussak's space and to the development of retraction pocket or papillary ingrowth cholesteatoma.

The aim of this study was to examine the clinical presentation and natural history of chronic myringitis (CM).Retrospective case review.Tertiary referral center.Chronic myringitis is defined as a loss of tympanic membrane epithelium for1 month without disease within the tympanic cavity. Seven hundred fifty patient records were reviewed to determine the prevalence of CM in an academic otology practice. The records of 40 patients (45 ears) with CM seen between 1995 and 1999 inclusive were reviewed.The series was reviewed with attention to previous medical and otologic history, the nature and duration of symptoms, the physical findings, and management.The prevalence of CM was found to be -1% (approximately one fourth as common as cholesteatoma). Symptoms were often present for many years before the diagnosis of CM, with CM often mistaken for chronic otitis media. Sixty percent of patients had undergone previous otologic procedures. There did not appear to be an association between CM and systemic disease. Physical findings were varied, with granulation tissue and tympanic membrane perforations often occurring transiently. The clinical course of CM is typified by recurrent episodes of symptoms, often interspersed with long asymptomatic periods. A subset of CM can result in an acquired atresia. The most effective treatment appeared to be prolonged topical medications, surgery being reserved for only the most refractory cases.Chronic myringitis is often mistaken for chronic otitis media. Such confusion prolongs the initiation of appropriate management and sometimes leads to needless tympanomastoid surgery. The otologist should be aware of this clinical entity and its varied presentation.

To try to solve the pathogenesis of severe attic retraction viewed from mastoid condition, we examined the residual soft tissue density (RSTD) in the mastoid by computed tomography (CT) in 85 patients (107 ears) with otitis media with effusion (OME) 3 months after tympanostomy tube insertion or later. The incidence of RSTD in the mastoid was significantly higher in OME of adults (52.6%) than in children (24.1%). Ears with severe attic retraction had RSTD significantly more frequently (80%) than those with no or mild attic retraction, and many of the mastoids with severe attic retraction were occupied totally by RSTD. The area of the mastoid (mastoid pneumatization) was significantly smaller, and CT density of the mastoid (sclerotic tendency) was significantly higher in ears with RSTD than in those without. RSTD after tympanostomy tube insertion in the mastoid indicating organic change of effusion was considered one of the important factors relating to the pathogenesis of severe attic retraction.

This prospective study compared the surgical outcomes of 35 patients who underwent myringoplasty—16 who were treated as outpatients and 19 who were admitted as inpatients. The outpatient technique involved a free skin graft, with the temporalis fascia placed as an underlay graft. The inpatients underwent the standard myringoplasty procedure. Postoperatively, 14 of the 16 outpatients (87.5%) and 17 of the 19 inpatients (89.5%) were completely healed within 2 weeks. The results of this study indicate that outpatient myringoplasty with a free skin graft is as safe and effective as standard myringoplasty for most patients.

We evaluated the possible relationship between tympanic membrane perforations resulting from blast trauma or slap and pneumatization of the mastoid cells. A total of 25 male patients with tympanic membrane perforations resulting from blast injury (n = 7), slap (n = 17), and football hit (n = 1) and 20 healthy male volunteers without any ear problem had temporal bone computed tomographic scans in the axial plane, parallel to the infraorbitomeatal line, with 2 mm slice thickness and 2-mm intervals using bone algorithm with a ProSpeed Spiral tomography machine. The area of air cells in each slice was measured using trace and area measurement functions of the tomography machine, and by multiplying the resulting area by slice thickness, the volume of each slice was calculated. For each ear, the total of volumes of air cells was calculated by adding the volumes of each slice containing air cells. The calculated volumes of mastoid cells were evaluated by comparing microscopic findings. Both patient and control groups consisted of males, and their ages ranged from 17 to 32 (mean 24.5) years. Microscopic examinations revealed that perforations were frequently located in the lower quadrants and that most of them were less than 3 mm. There were no pars flaccida and marginal perforations. Ossicular chain destruction was noted neither in temporal bone tomographic nor during intraoperative examinations. The mean (± SD) volumes of right and left ear mastoid air cells in patient and control groups were 6.92 ± 2.45 vs. 7.00 ± 2.59 cm3 and 9.04 ± 4.55 vs. 8.95 ± 4.53 cm3, respectively, and the differences were not statistically significant. It was found that the level of mastoid pneumatization has no statistically significant effect on tympanic membrane pathologies due to blast or other injuries.

The preoperative findings and operative outcome were evaluated in 49 patients who underwent tympanic neurectomy to treat chronic parotitis. Forty-two patients had chronic non-suppurative parotitis and 7 patients had chronic suppurative parotitis. The main symptoms prior to operation were recurrent swelling and pain of the parotid gland. After operation, 40 patients (82%) had relief of their symptoms (28 patients were totally free of symptoms and 12 patients were markedly improved). In 9 patients (18%) the symptoms remained the same. Three patients (6%) had a tympanic membrane perforation due to the operation.

Insertion of a sufficient number of electrodes is important for a successful use of cochlear implants. We investigated the results of scala vestibuli insertion for cochlear implantation in cases of obstructed scala tympani. In a series of 200 cochlear implantations, scala vestibuli insertion was successfully performed in 4 cases with obstruction of the scala tympani. Etiologies included a temporal bone fracture, severe otosclerosis and malformations of the cochlea. The maximum insertion depth obtained via the scala vestibuli was 30 mm. Postoperative results were comparable to patients in whom conventional scala tympani insertion was performed. No adverse effects related to the site of insertion were observed. Scala vestibuli insertion offers a valuable alternative in cases of obstructed scala tympani that can be employed for a variety of etiologies.

A primary tumor of the tympanic membrane is very rare. Herein, we describe a patient with a thick tympanic membrane that caused progressive hearing loss. The patient was treated with total resection of the tympanic membrane and was diagnosed with fibroma after histopathologic examination. There was no evidence of recurrence 2 years after the operation, and the patient's hearing was normal. Fibroma may arise in the tympanic membrane and should be regarded as a possible cause of the mass of the tympanic membrane.