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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.

Item does not contain fulltext OBJECTIVE: To study the effect of various middle ear effusions on the structure of the lamina propria of the tympanic membrane. METHODS: Sterile and infective middle ear effusions were induced by obstruction of the eustachian tube in specific pathogen-free (SPF) rats and in rats with upper airway infections (URI), respectively. The condition of the tympanic membrane was monitored at regular intervals. After varying survival times, the animals were killed and the tympanic membranes processed for light and electron microscopy. RESULTS: Sterile effusions always resulted in tympanosclerotic lesions. These lesions did not develop in the presence of primary-infected effusions. These effusions had a severe destructive effect on the lamina propria, followed by fibrosis. Generally, secondary infection did not markedly affect preexisting tympanosclerotic lesions. Moreover, calcification disappeared when re-aeration of the middle ear occurred, but the abnormal collagen depositions persisted. CONCLUSIONS: Both sterile and infective effusions result in comprehensive irreversible changes in the lamina propria of the pars tensa. The development of tympanosclerosis is confined to sterile effusions. Mechanical injury and compromised vascularization of the lamina propria are likely to be important etiological factors in the development of tympanosclerosis.

Objective To perform quantitative analysis of pathological changes in the tympanic membrane using video-otoscopic images. Study Design Prospective case-control study. Methods Forty-two ears of children with chronic otitis media with effusion (OME) and 15 ears of normal children were included in this study. Tympanic membrane images were captured and digitized using a Welch-Allyn (Skaneatales Falls, NY) VDX-300 Illumination and Imaging system with S-VHS input to a MIRO DC 30 (Pinnacle Systems, Mountain View, CA) visual board in a Power PC–based computer. These images were visualized and recorded during static and pneumatic pressure changes. Quantitative analysis of tympanic membrane disease was performed using Image Pro Plus Imaging software (Media Cybernetics, Del Mar, CA). The measurements included area of the tympanic membrane and its quadrants, area of tympanic membrane involved by disease, angle formed at the umbo, and length of the malleus versus vertical length of the tympanic membrane. Results Tympanosclerosis was present in 57% of ears and occurred most frequently in the anteroinferior quadrant, but the ma-imum area of involvement was in the posteroinferior quadrant. The ratio of the angles formed at the umbo was significantly greater (P = .01) for the OME group compared with the control group. The ratio of the length of the umbo and the vertical length of the tympanic membrane was almost identical for the OME and the control groups (P = .4). Conclusions Video-otoscopic images can be used for quantitative analysis of tympanic membrane disease. The ratio of the posterior angle to the anterior angle formed at the umbo seems to be a more reliable indicator of post otitis media than is a reduced length of the long process of malleus.

The detection of distortion-product otoacoustic emissions (DPOAEs) depends on the viability of the ear's conduction apparatus. However, tympanic membrane perforations and other conductive disorders have not been fully investigated with regard to the examination of DPOAEs. Using the guinea pig model, we made perforations of different sizes and loci on the tympanic membrane and collected DPOAE data for frequencies between 2,193 and 5,508 Hz for each condition. We found that small perforations, up to 25% of the area of the tympanic membrane, still allow us to detect emissions at the specified frequencies. However, perforations of 50% and larger, as well as those accompanied by traumatic perilymph fistulas and ossicular disarticulations, severely interfered with the detection of DPOAEs. We discuss the clinical relevance of these findings with respect to the potential uses of DPOAEs.

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.

Core temperature measurement using a pulmonary artery (PA) catheter is considered the gold standard for measuring temperatures in critically ill patients. The objective of this study was to compare oral and tympanic temperature measurements (in both the oral and core equivalence modes) against PA core temperature measurements to determine which method was the most accurate and reliable in the absence of a PA catheter.Prospective, descriptive comparative analysis.Convenience sample of 102 critically ill orally intubated patients with a PA catheter in place.A 24-bed medical/surgical/trauma intensive care unit in a university-affiliated medical center.Four experienced intensive care unit nurses were trained in the use of temperature measurement with the oral, tympanic (both core and oral equivalence modes were used), and PA core methods. Simultaneous temperature measurements were then taken once in each subject using each method. The potential covariates that were analyzed were mean blood pressure, patient acuity using the Simplified Acute Physiology Score II, age, sex, ambient room temperature, and ventilator circuit temperature.The training period indicated that it took more time to train experienced nurses in the use of tympanic thermometry than oral thermometry. Descriptive statistics were the following: core, x = 37.33 (SD = 0.89); oral, x = 37.18 (SD = 0.92); tympanic oral, x = 36.80 (SD = 0.93); and tympanic core, x = 37.12 (SD = 1.0). Bias averages were calculated and were significantly different from 0 for all three methods (oral-PA core, -0.15 [SD = 0.36]; tympanic core-PA core, -0.11 [SD = 0.57], tympanic oral-PA core, -0.52 [SD = 0.53]), indicating that there is some degree of decreased accuracy associated with each method when compared with PA core. However, scatter plots using the Bland and Altman methodology (Altman DG, Bland JM: Practical Statistics for Medical Research. London, Chapman and Hall, 1991) illustrate that the greatest variability is associated with the tympanic method.Temperature measurement is an important piece of clinical data in a critically ill patient population. We found oral thermometry to be the most accurate and reproducible method when a PA core measurement was not available.

Retraction pockets of the pars tensa formed due to poor mesotympanic ventilation can result in chronic infection, ossicular damage and even acquired cholesteatoma. A diversity in opinion exists as to the best surgical treatment of an established retraction pocket. This paper presents a consecutive prospective series of 39 ears managed over the last 4 years by means of simple excision and insertion of a middle ear ventilation tube. The retraction pockets were graded according to Sade’s 1979 classification. There were 23 grade II and sixteen grade III retractions. All 39 pockets were successfully excised. Thirty-four of the perforations healed, with the remaining five failing to heal at the time of analysis. In 13 cases the pockets recurred, but in five of these cases the recurrence is minimal and has required no further surgical intervention. Of the eight remaining significant recurrences, four have undergone a repeat procedure with no further recurrence in three cases. Following initial surgery, 67% of the ears operated upon had either minimal or no recurrence. Following further surgery this figure increased to 75%. The air conduction threshold improved by an average of thirteen decibels in those ears that healed with no recurrence.

OBJECTIVE: The purpose of this study was to investigate the immediate effects of tympanic over- and under-pressure, induced by variations in ambient pressure on click-evoked otoacoustic emissions (CEOAEs) in healthy individuals. It was of particular interest to elucidate whether changes in the CEOAE response in both spectral and time domains could be attributed not only to tympanic, but also to cochlear influence. DESIGN: Nine healthy subjects with normal hearing and middle ear pressure were exposed to ambient pressure changes in a pressure chamber. The pressure was progressively changed in 100 daPa steps to accomplish an increase and a decrease in tympanic pressure. Pressure equilibration of the middle ear was avoided. The relative tympanic over- and under-pressure (+/- 320daPa) was monitored by tympanometry and the CEOAEs recorded at every step of tympanic pressure change. RESULTS: There was a statistically significant reduction of the otoacoustic emission (OAE) response levels and reproducibility already at 100 daPa of ambient pressure change. The OAE response was progressively reduced by increased pressure gradients. The CEOAEs recorded during progressive tympanic over- and under-pressure also had increasingly shorter latencies. These changes of the OAE response characteristics were most pronounced in the 750 to 3000 Hz frequency bands. CONCLUSIONS: The progressive attenuation of the OAE response and the concomitant shortening of the OAE response latencies were observed during a combination of altered middle and inner ear pressure. Although the middle and inner ear influence cannot be separated we suggest, based on our findings, that the shortening of latencies may partly be caused by inner ear pressure changes and stiffening of the labyrinthine membranes. Further studies are needed to more specifically clarify the relative contribution of the tympanic and labyrinthine influence, respectively, for the various aspects of pressure influence on the OAE response. (Less)

Objective: To document that commercially available topical gentamicin-containing eardrops carry a risk of ototoxicity if they reach the middle ear through a tympanic membrane defect. Study Design: Clinical study, retrospective case-note review. Setting: Department of Otolaryngology, The Toronto Hospital, University of Toronto. Patients: Sixteen patients were identified with well-documented histories, physical findings and laboratory investigations consistent with topical gentamicin-induced ototoxicity. One patient with incapacitating unilateral Meniere's disease underwent successful intentional vestibular ablation using topical gentamicin/steroid drops. Results: In all cases of inadvertent ototoxicity, patients had used the drops for longer than 7 days (average 20.7 d) prior to symptoms developing. All patients developed vestibulotoxicity that was confirmed on ENG testing. Only 1 patient had a noticeable worsening of cochlear reserve. Deliberate and successful therapeutic ablation of vestibular function in a patient with unilateral Meniere's disease confirms the vestibulotoxic nature of commercially available topical gentamicin preparations. Conclusions: Physicians should consider the potential for ototoxicity if gentamicin-containing eardrops (and by extrapolation all topical aminoglycoside drops) are used for longer than 7 days in patients with a tympanic membrane defect. These preparations should not be used in the presence of healthy middle ear mucosa and should be discontinued shortly after the discharge has stopped. It is important to recognize that toxicity is primarily vestibular rather than cochlear.

Background—Ear thermometers are becoming popular as a method for measuring deep body (core) temperature. Aim—To determine the variability of a single user’s tympanic membrane (ear) temperature measurements. Subjects—Forty two, afebrile, healthy children, and 20 febrile children with acute burns. Results—In afebrile children measurements made in both ears (and within just a few minutes of each other) diVered by as much as 0.6°C. Operator measurement error, sw of three consecutive measurements, in the same ear, was 0.13°C. In the group of febrile, burned children, core temperature was measured hourly at a number of sites (ear, rectum, axilla, bladder). A peak in core temperature occurred approximately 10‐12 hours after the burn. Measurement error was calculated in 14 febrile, burned children with a peak temperature in excess of 38°C. For the left ear, measurement error was 0.19°C and for the right ear, 0.11°C. In the febrile children agreement between the ears was poor. The limits of agreement were 0.4°C to ˛0.8°C. It was not possible to predict the occasions when the temperature diVerences between the ears would be large or small. Conclusions—The measurement error of one recording from the next is probably acceptable at about 0.1 to 0.2°C. To limit the variations in temperature of one ear to the other, measurements should be restricted to one of the ears whenever possible and the same ear used throughout the temperature monitoring period. Nurses and parents should take more than one temperature reading from the same ear whenever possible. (Arch Dis Child 1999;80:262‐266)

Tympanic membrane (TM) stiffness changes in the pars tensa in response to experimentally induced ear canal cholesteatoma by obstruction of the ear canal were studied. To this aim TM displacement versus pressure was measured with a high resolution, differential moiré interferometer. The measurements were performed on fresh, isolated gerbil temporal bones after removal of the cholesteatoma bulk. Besides an overall stiffness reduction we found that local stiffness variations were present in nine out of 18 studied ears. The stiffness changes as a function of time after ear canal obstruction had a pattern similar to those previously shown to develop in response to various forms of otitis media, showing that the TM stiffness properties decrease in a similar way in response to different inflammatory middle ear diseases. The stiffness changes correlated with an increased overall TM thickness and increased thickness of the lamina propria in particular as measured in histology sections. The stiffness changes may play an important role in the pathophysiology of cholesteatoma.

The aim of this study is to investigate the effects of ear drum perforation on real-ear to coupler difference (RECD) in adults. RECD was measured using a probe tube microphone system in 22 patients with ear drum perforations. Twenty-two normal subjects served as controls. For normal subjects, RECD was in good agreement with the values reported in the literature. For the perforated ears, the RECD was up to 8 dB smaller in the frequency range from 0.5 to 1 kHz. There was no significant difference at frequencies below 0.25 kHz and above 1 kHz. A much larger intersubject variability was found in the experimental group. The mean intersubject standard deviation was 4.4 dB in the experimental group as contrasted with 2.2 dB in the control group. Neither the equivalent ear canal volume nor the perforation size appeared to be correlated with the degree of RECD reduction over lower frequencies. These results strongly suggest the need for individual RECD measurements, rather than using the average normal RECD, to appropriately compensate for the reduced transmission of lower-frequency sounds in fitting hearing aids for patients with ear drum perforations.

There are different hypotheses for the development of epitympanic retraction pockets. These can occur as the result of an inflammatory process and negative pressure in the middle ear spaces. Anatomic bottlenecks in the middle ear favor diminished inflation of the epitympanic space. The eustachian tube provides pressure equilibration in the middle ear. Its dysfunction involving tubal opening or closing is thought to be the main reason for a permanent negative pressure in the middle ear. A patulous eustachian tube is now claimed for prolonged negative pressure in the middle ear and is caused by a so-called "sniffing" habit. The purpose of this study was to elucidate objectively the frequency of patulous eustachian tubes in ears with epitympanic retraction pockets. We examined passive tubal function in 41 patients with 50 epitympanic retraction pockets by using dual impedance in a pressure chamber. We identified three stages of epitympanic retraction pockets. Stage 1 involved a mobile and controllable retraction pocket; stage 2 corresponded with a fixed but controllable pocket, whereas stage 3 described a fixed pocket that was developing into a cholesteatoma. Results were compared with the function tests of 100 healthy ears in 50 normal individuals. We found 27 patulous eustachian tubes in patients with epitympanic retraction pockets, 22 of which occurred in affected ears while only 2 patulous tubes were found in the group of the healthy ears. Tubal opening pressure (P < 0.001) and tubal closing pressure (P < 0.01) were significantly lower in ears with epitympanic retraction pockets than in healthy ears.

Heterodyne laser interferometry was used to measure tympanic membrane (TM) velocity at the umbo during acoustic stimulation in 2 groups of rats. The control group had a normal TM, while in the other group the TM was perforated and then allowed to heal for at least 28 days. Umbo velocity functions for constant sound pressure level stimuli were obtained for test tones between 0.3 and 40.0 kHz in each animal. The results revealed that velocity was the same in the control and healed TMs below 3.0 kHz. Above 5.0 kHz, the velocity response in the healed ear was between 3 and 12 dB smaller than in the control ears. Histologic evaluation of the healed perforation revealed a thick fibrous reaction between the epidermal and lamina propria layers. The results indicated that the added mass of the scar tissue changed the middle- and high-frequency TM responses.

In einer Studie wurden die wahrend einer Tympanoplastik entnommenen Trommelfelldefektrander von 111 Patienten mit einer chronischen Otitis media mesotympanalis histologisch untersucht. Die Aufarbeitung der Praparate erfolgte durch Paraffineinbettung und Hamatoxylin-Eosin-Farbung. Bei 67 Patienten (60%) endete die Trommelfellepidermis direkt an der Kante des Perforationsrandes; 27 Praparate (24%) zeigten eine Epithelialisierung der Trommelfellruckflache, ohne den Resektionsrand zu erreichen. Bei 17 Patienten (16%) war der gesamte Resektionsrand vollstandig epithelialisiert. Diese Patienten wiesen fast alle eine nicht nachweisbar durchgangige Tuba auditiva auf. Die Grose der Trommelfellperforation hatte keinen Einflus auf die Epithelausbreitung. Es besteht jedoch ein Zusammenhang zwischen der Migrationstendenz des Epithels und dem Auftreten permanenter Trommelfellrezidivperforationen nach Tympanoplastik. Von 17 Patienten, deren resezierter Trommelfellrand in den mikroskopischen Praparaten vollstandig mit Plattenepithel bewachsen war, wiesen 4 (23%) einen dauerhaften Rezidivdefekt auf. Die Zahl der postoperativen Rezidive war bei den Patienten, welche keine oder nur geringe Epithelmigration in Richtung der Trommelfellinnenflache aufwiesen, signifikant kleiner.

Object. The authors assessed the accuracy and repeatability of the tympanic membrane displacement (TMD) test, an audiometric technique that is used to evaluate changes in intracranial pressure (ICP) in children with shunted hydrocephalus. Methods. A prospective comparative evaluation of 31 clinical episodes of shunt malfunction was made by using the serial TMD test and direct ICP measurement in eight children with shunted hydrocephalus between January 1995 and February 1996. The volume displacement of the tympanic membrane (Vm) on stapedial contraction was inward for raised ICP in 11 instances and ranged from −120 to −539 nl (mean −263.5 nl). This was confirmed by direct ICP monitoring, which showed values ranging from 20 to 30 mm Hg (mean 26 mm Hg). The TMD test measurement (Vm) in 18 instances of low ICP ranged from 263 to 717 nl (mean 431.3 nl); this was corroborated by direct ICP measurement, which ranged from 3 to 7 mm Hg (mean 4.2 mm Hg). The normal baseline Vm values obtained when patients were asymptomatic ranged from −98 to 197 nl (mean 110 nl). As a noninvasive diagnostic tool used in predicting changes in ICP, the TMD test had a sensitivity of 83% and specificity of 100%. The positive predictive value of the test was 100% and the negative predictive value was 29%. Conclusions. The TMD test can be used on a regular basis as a reproducible investigative tool in the assessment of ICP in children with shunted hydrocephalus, thereby reducing the need for invasive ICP monitoring. The equipment necessary to perform this testing is mobile. It will provide a useful serial guide to ICP abnormalities in children with shunted hydrocephalus.

The gradient between temperatures measured at different body sites is not constant; one factor which will change this gradient is rapid changes in body temperature. Measurement of this gradient was done in patients undergoing rapid changes in body temperature to establish the best site to measure temperature and to compare two brands of commercial tympanic thermometers.A total of 228 sets of temperatures were measured from probes in the oesophagus, rectum, and axilla and from two brands of tympanic thermometer and compared with pulmonary artery (PA) temperature in 18 adults during cardiac surgery.Measurements from the oesophageal site was closest to PA readings (mean difference 0.0 +/- 0.5 degree C) compared with IVAC tympanic thermometer (mean difference -0.3 +/- 0.5 degree C), Genius tympanic thermometer (mean difference -0.4 +/- 0.5 degree C), axillary (mean difference 0.2 +/- 1.0 degrees C) and rectal (mean difference -0.4 +/- 1.0 degree C) readings. When data during cooling were analysed separately, all sites had similar gradients from PA except for rectal, which was larger. On rewarming, oesophageal readings were closest to PA readings; tympanic readings were closer to PA than were rectal or axillary readings. Readings from the two brands of tympanic thermometer were equivalent.Oesophageal temperature is more accurate and will reflect rapid changes in body temperature better than tympanic, axillary, or rectal temperature. When oesophageal temperature cannot be measured, tympanic temperature done by a trained operator should become the reading of choice.

This case report describes five cases of acute granulomatous myringitis treated during the nine-year period from 1987 to 1996. Otorrhoea and slight otalgia were the two major complaints. Findings included the appearance of a granulomatous bulge along the handle of the malleus or on the eardrum. No cases displayed eardrum perforation. No similarities were noted in patient age, sex or affected side. Treatment consisted of removal of the granuloma with a small cup forceps plus cauterization with 20 per cent trichloracetic acid. Two or three treatments resulted in complete healing, and average time to healing was 30 days, with no recurrences. Because it differs so distinctly from the more common chronic myringitis – characterized by mild symptoms, erosion and perforation of the eardrum with little granulomatous change, and a longer time to healing with frequent recurrence – the authors conclude that acute granulomatous myringitis should be regarded as a separate entity.

A prospective, randomized study was carried out comparing the effect of two surgical modalities in the treatment of patients with Meniere's disease: insertion of an endolymphatic sac shunt and insertion of a ventilating tube in the tympanic membrane. A total of 29 patients, 12 males and 17 females, age 27-71 years, were operated on in two ear, nose and throat (ENT) departments. Of these patients, 15 had an endolymphatic shunt inserted and 14 had a ventilating tube inserted in the tympanic membrane. Postoperative follow-up was carried out in the department in which the patients had not been operated. The severity of the disease was scored pre- and postoperatively, and the results evaluated under the guidelines of the Committee on Hearing and Equilibrium (1995) for the diagnosis and evaluation of therapy in Meniere's disease. The patients in both groups had a statistically significant reduction in dizzy spells, measured 6 and 12 months postoperatively, and there was no difference between the groups. The pathophysiological explanation for the reduction in dizzy spells in each of the treatment modalities is debatable and the effect is non-specific. The patients' hearing and tinnitus were statistically unaffected by the treatment in both groups, though 2 patients in the shunt group developed severe hearing loss (anacusis/70 dB).

This study evaluates the causes for a persistently discharging mastoid cavity and attempts to weight the importance of each identified factor. It consists of a temporal bone dissection to evaluate the anatomy of the facial nerve and a clinical prospective study measuring the factors that contribute to a wet cavity. The factors measured were height of the facial ridge, the size of the meatus, state of the tympanic membrane, and size of the mastoid cavity. The height of the facial ridge and the kidney shape of the cavity were found to be the most significant factors contributing to the state of the cavity. The tympanic membrane and size of the meatus were also found to significantly influence the state of the cavity, whereas the size of the cavity was not significant. These results illustrate the importance of the facial ridge in mastoid surgery and that most poor results in mastoid surgery are due to the surgeon, not the disease.

Ring graft is a modified cartilage-perichondrium composite graft (CPCG) with only a peripheral ring shaped cartilage. In this series, tympanic membrane perforations were repaired using (ring graft) during treatment of 18 cases of non-cholesteatomatous chronic suppurative otitis media (CSOM).This study showed that ring graft has the advantages of both CPCG and perichondrial graft but without their disadvantages. Complete closure of the perforations was achieved in all cases without delay in hearing improvement.It is recommended to use the ring graft whenever needed to repair central tympanic membrane perforations even with difficult anterior or total perforations.

A case of piercing of the tympanic membrane, resulting in unusual consequences, is described. This is the first reported case of the long process of a dislocated incus resulting in trauma to the horizontal portion of a dehiscent facial nerve. Simultaneous depression of the stapes footplate resulted in a perilymph leak, but with delayed presentation.

Earlier studies have revealed a relationship between the development of myringosclerosis and oxygen-derived free radicals. The latter can be blocked by the anti-inflammatory drug fenspiride. The present study was undertaken to test the ability of fenspiride to prevent myringosclerosis from developing during healing of the tympanic membrane. Myringotomized rats were treated with either topical applications or intraperitoneal injections of fenspiride for 12 days, after which the tympanic membranes were examined by otomicroscopy and studied histologically by light microscopy. Topically applied fenspiride was found to inhibit the development of sclerotic lesions, whereas intraperitoneal injections were ineffective.

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3-year-old nor 14-year-old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.

Basic fibroblast growth factor (bFGF) is a polypeptide mitogen which stimulates proliferation of epidermal and connective tissue cells. When applied to tympanic membrane perforations it has been reported to enhance healing and produce connective tissue hyperplasia. Previous work with animal models has shown that hyperplastic alterations of the tympanic membrane play an essential role in cholesteatoma development. This study was designed to further investigate the hyperplastic effects of bFGF and to determine if it might induce cholesteatoma formation during the healing process. Ten chinchillas received bilateral tympanic membrane perforations. In each animal, three doses of bFGF (400 nanograms per dose) were applied to the perforated tympanic membrane on one side; the opposite (control) ear received saline alone. The animals were terminated at either two or four weeks and studied histologically. Although the dosage and administration schedule used were consistent with previous studies utilizing other rodent species, there was little evidence that bFGF affected tympanic membrane healing in chinchillas. In both control and bFGF-treated ears, dense connective tissue occupied the lamina propria of the tympanic membrane, providing an effective barrier against ingrowth of skin toward the middle ear. No cholesteatomas developed in any animals included in the study. The results of this work indicate that the risk of cholesteatoma formation following administration of bFGF is minimal when it is applied short-term to acute perforations.

Objective: To assess whether a correlation exists between the degree of pars flaccida (PF) retraction and the degree of mastoid pneumatization. Design: The degree of PF retraction was defined by means of an operating microscope and a pneumatic otoscope. Degree of mastoid pneumatization was assessed planimetrically, using mastoid x-rays. Setting: Private otologic clinic. Participants: A total of 595 ears, with intact pars tensa, of 332 adult patients. Results: The degree of PF retraction was found to be inversely correlated to the level of mastoid pneumatization. Poorly pneumatized mastoids were associated with PF retractions. The poorer the pneumatization, the deeper the retraction. Well-pneumatized mastoids were associated with normal position of the PF. Conclusions: This study lends further support to the possibility that the mastoid pneumatic system functions as a middle ear pressure buffer. This possibility gives further explanation as to why ears with poorly pneumatized mastoids tend to develop tympanic membrane retractions and perforations, incus necrosis, or retraction pocket cholesteatoma, while ears with a large pneumatic system are rarely at such risk. Arch Otolaryngol Head Neck Surg. 1997;123:584-588

Purpose: The immunological potential of the murine tympanic membrane was studied under normal and inflammatory conditions. Materials and Methods: Experimental otitis media was induced by injecting keyhole limpet hemocyanin into the tympanic cavity of systemically sensitized mice. The animals were killed from 1 day to 2 weeks after the injection, and the distribution of the immunocompetent cells in the tympanic membrane was compared with those in normal animals, by immunohistochemical and toluidine blue staining. Results: Tympanic membranes under normal conditions showed few immunocompetent cells, except mast cells and la-positive dendritic cells (presumably Langerhans' cells) in the pars flaccida and in the annular and manubrial regions of the pars tensa. After the induction of otitis media, lymphocytes migrated into these regions, although the other regions of the pars tensa showed few of these cells. la-positive cells migrated into both pars tensa and pars flaccida. Mast cells did not show obvious changes between the normal and inflammatory conditions. Conclusion: The pars flaccida and the annular and manubrial regions of the pars tensa are considered to be the immunologically potential sites, responsible for the immune responses. The remaining greater part of the tympanic membrane can recognize antigens by the migrated Langerhans' cells.

This paper presents evidence on how the pars flaccida of the tympanic membrane affects the acoustic input to the middle and inner ear. Measurements of middle-ear acoustic input admittance and sound-pressure levels in both the ear canal and the middle-ear cavity were made in ears of eight gerbils before and after manipulations of the middle ear and tympanic membrane. The results are interpreted in terms of a model proposed by Kohlloffel [Hear. Res. 13 (1984) 83–88]. The input-admittance measurements show that the pars flaccida of gerbil acts as a resonator with a resonance frequency of approx. 500 Hz. The admittance of this resonator appears in parallel with the input admittance of the pars tensa and its ossicular and cochlear load. At frequencies below the resonance, the pars flaccida admittance is compliance-like and its magnitude is comparable to that of the pars tensa and its load; consequently, the presence of pars flaccida increases the overall middle-ear input admittance and decreases the pressure difference across the tympanic membrane. At higher frequencies, the admittance of pars flaccida is mass-like and small in magnitude, and it has negligible influence on the overall middle-ear input admittance and the pressure difference across the tympanic membrane. These results suggest that the presence of pars flaccida reduces low-frequency acoustic input to the middle- and inner-ear and consequently decreases hearing sensitivity in this frequency range. Our measurements suggest that with a constant sound pressure stimulus, stiffening the gerbil pars flaccida would increase the motion of the pars tensa by 3–10 dB at frequencies below the normal flaccida resonance. © 1997 Elsevier Science B.V. All rights reserved.

Resume L'otorrhee purulente est la complication la plus drequente les aerateurs transtympaniques. Population et methodes. — Nous presentons ici les resultats d'une etude bacteriologique de 33 cas consecutifs d'otorrhee sur aerateurs translympaniques. Resultats. — Les germes les plus frequents etaient Pseudomonas aeruginosa (45% des prelevements). Haemophilus influenzae (24% des prelevements). Staphylococcus aureus (21% des prelevements) et Streptoccus pneumoniae (15% des prelevements). Ces resultats sont similaires a ceux obtenus il y a 4 et 8 ans dans la meme consultation. Alors que H influenza et S pneumoniae sont souvent responsables d'oties moyennes aigues, P aeruginosa et S aureus se voient surtout dans les otites extrenes et les poussees de rechauffement d'otities chroniques. Conclusion. — L'etude de l'antibiogramme des germes retrouves dans le otorrhees sur aeraterurs transtympaniques fait proposer en traitement de premiere intention des gouttes auriculaires plutot qu'un traitement antibiotique per os.

The authors studied the overall microscopical anatomy of the middle ear and of the eustachian tube in 20 tympanic bullae of 10 Wistar rats. Large hexagonal epithelial flat cells covered the roof of the bulla, the two upper thirds of both lateral walls, the upper half of the eustachian tube, and the upper third of the tympanic orifice; ciliated and secretory cells lined the inferior thirds of both walls of the bulla while a ciliated epithelium with strong cilia, all directed towards the tubal orifice, located on the floor of the tympanic cavity together with groups of non-ciliated cells was detectable near the tubal and antral areas and on the floor of the eustachian tube. Non-ciliated cells covered by microvilli were found near the pharyngeal orifice. These observations seem to demonstrate the following: (1) the ciliated elements present a well-defined topographic distribution; (2) a preferential pathway for mucociliary clearance made up of strong ciliated cells located on the floor of the bulla is clearly detectable, and (3) the roof of the bulla seems to be mainly involved in the ventilatory function.

The homeostasis of inner-ear fluids is essential for the functions of hearing and equilibrium. Inner-ear disorders, such as Ménière's disease, are affected by inner-ear pressure. The displacement of the human tympanic membrane can be studied by means of the MMS-10 Tympanic Displacement Analyser (Marchbanks Measurement Systems Ltd., UK) and is thought to be a measure for perilymphatic pressure variations. This measurement was performed in 18 patients with Ménière's disease (20 affected ears) at regular intervals, in order to investigate possible pressure variations in relation to the following symptoms: hearing loss, vertigo, tinnitus and pressure sensation. Symptoms changed independently; changes in symptoms were not significantly related to changes in perilymphatic pressure, as measured by means of the MMS-10 analyser.

Objective Tympanic temperature can be obtained instantaneously using an infrared emission detection (IRED) thermometer. Its accuracy has been documented in a variety of clinical settings, but its performance at low body temperatures is still unknown. In this study we evaluated its performance during coronary artery revascularization surgery in which mild hypothermic cardiopulmonary bypass (CPB) was used.

Contrairement à l’approche d’un édifice religieux sur lequel on peut concentrer un travail de quelques jours, de quelques semaines, l’approche de l’habitat civil, hormis des sites abandonnés qui ont par exemple permis dans les années 1960 les premières fouilles de villages médiévaux en France à Rougiers (Var) et à Dracy (Baubigny, Côte-d’Or), est longue. Si l’on ne veut pas se contenter d’un signalement à partir des seules façades qui sont accessibles à tous, il faut pénétrer à l’intérieur de...

Le prieuré situé au lieu-dit Le Monastier sur la commune de Vagnas, au sud du département de l’Ardèche, apparaît dans une charte de Cluny du XIIe siècle (Charrié 1979, p. 354, Villa Vanniacum). Il est dans la dépendance des bénédictins de Cruas, abbaye d’origine carolingienne située dans la moyenne vallée du Rhône, sur la rive droite du fleuve. Les vestiges du prieuré ont été fouillés à partir de 1961 par la Société d’études et de recherches archéologiques et historiques de Vagnas (SERAHV). P...

The results after simultaneous bilateral fat graft myringoplasties in children have not been previously reported in the literature. We report on 28 children who underwent bilateral fat graft myringoplasties as outpatient procedures under general anesthesia. The success rate was 91% at final follow-up, with only 16% of children requiring insertion of pressure-equalizing (PE) tubes following surgery. No complications were documented. We conclude that bilateral fat graft myringoplasties are safe to perform, with an excellent success rate, and are suitable as outpatient procedures.

A 14-year old white male presented with a 2-year history of bilateral otorrhea. Purulent otorrhea with very stenotic external auditory canals (EAC) were found, and the patient was treated with topical otic solutions. Bilateral conductive hearing loss was found on audiometric studies. Biopsies were taken after the patient failed medical treatment. The results were consistent with granulation tissue and chronic inflammation. A CT scan revealed complete bilateral EAC stenosis. At surgery the patient was found to have bilateral retained Goode T-tubes, which were placed at 2 years of age. After removal of the tubes, the patient made a good recovery with improved hearing. This case illustrates a severe complication of retained tympanostomy tubes. Patients with these tubes require close long-term follow-up with careful management of problems such as granulation tissue or otorrhea to prevent this type of complication.

The sequelae of secretory otitis media (SOM) were monitored in 72 adult patients with SOM who were followed up for an average of 33 months. It was found that SOM became chronic and retraction of the tympanic membrane appeared as a function of the pneumatization of the mastoid. Ears with poor pneumatization (less than 6 cm2) developed chronic SOM in 52.2% of cases, as compared with 20% in cases with well-pneumatized ears (6 cm2 and above). Atelectasis developed in 37.3% of poorly pneumatized ears, and in only 5.7% of well-pneumatized ears. These sequelae may therefore be linked pathogenetically to the extent of pneumatization, as both the SOM and the sequelae appeared many years after formation and maturation of the pneumatic system. This study supports other studies that view the mastoid pneumatic system as an organ, as a middle ear pressure buffer. Well-pneumatized ears rarely develop a negative pressure and are seldom associated with chronic sequelae. Ears with poorly pneumatized mastoids lack the physi...

BACKGROUND, APPLICATION OF STATIC PRESSURE AT THE TYMPANIC MEMBRANE: Cleland in London (1741) presumed that the pressure of a strong sound wave would push the tympanic membrane inward, thereby causing deafness. He recommended correcting this situation by applying suction to the auditory canal, and he demonstrated a small tube suitable for this purpose. Toynbee in London (about 1860) realized that, following a malfunction of the Eustachian tube, a negative pressure would develop in the middle ear and draw the tympanic membrane inward, thus causing hearing loss. This concept resulted in efforts to actively support the aeration of the middle ear via the Eustachian tube. In addition to these measures, Politzer in Vienna (1867) suggested blocking the external auditory canal tightly so that resorption of the air would produce negative pressure, counteracting the low pressure in the middle ear. Lucae in Berlin (1874) proposed the theory that the two small muscles in the drum would act as antagonists on the tympanic membrane and accommodate the ear for high and low-pitched sounds respectively. He tried to correct malpositions of the tympanic membrane due to a misbalance of the two muscles by applying static positive or negative pressure in the auditory canal. APPLICATION OF ALTERNATING PRESSURE AT THE TYMPANIC MEMBRANE: Siegle in Stuttgart (1864) put forward the idea that repeated strong movements driven by the pneumatic ear speculum that he had invented would be able to loosen adhesions in the middle ear. Lucae (1884) later devised an elastic probe to be placed on the short process of the malleus for massage of the ossicular chain. Delstanche in Brussels (1885) presented two instruments called "rarefacteur" and "masseur du tympan et des osselets" which in the auditory canal would produce negative pressure or alternating pressure respectively. The next step were suggestions and devices enabling the patient to treat himself for reduced mobility of the tympanic membrane or the ossicular chain, such as alternating pressure on the tragus, or tubes to conduct pressure from the mouth or a rubber bag to the ear. With the aim of speeding up the frequency of the pressure impulses, mechanic pumps were constructed, which were first driven by hand, later on by electric power. CRITICAL EVALUATION: At the turn of the century numerous attempts were made to evaluate the effectiveness of the pneumatic massage of the middle ear and to specify the indication for this kind of treatment. Although no convincing and predictable results could be demonstrated and even harmful effects had been observed in animal experiments, the massage of the tympanic membrane continued its triumphant march for half a century. The reason for this seems to be the suggestive and plausible therapeutic approach to a well known pathology of the middle ear. Since the middle of this century it has been regarded as obsolete and is no longer mentioned in text books. The history of this episode is presented in detail.

BACKGROUND The cochlear aqueduct is a route for direct pressure transfer between intracranial and intracochlear fluids. In patients with Meniere's disease, intracochlear pressure is presumably disturbed. The "Tympanic Membrane Displacement Analyser (TDA)" is a new system which provides a useful noninvasive method of detecting intracranial and intracochlear pressure changes. PATIENTS In this study TDA measurements in combination with a glycerol test were performed in nine patients with Meniere's disease and in seven normal persons. RESULTS Before ingestion of glycerol, no significant difference in pressure was found between the two groups. After ingestion of glycerol a temporary decrease in intracochlear pressure was detected in both groups without any significant difference between the two groups. CONCLUSION These results show that the combination of glycerol testing and TDA measurements does not seem to be helpful for the differential diagnosis of Meniere's disease.

The histopathologic changes observed in 40 normal and inflamed temporal bones of infants and children are reported. The tympanic membranes of patients with acute and secretory otitis media underwent considerable swelling compared to those of normal controls. Tympanic membranes with acute otitis media were thicker than those with secretory otitis media, but the difference was not statistically significant. The epithelial layer showed an increase in the number of cell layers. The lamina propria demonstrated the most significant changes of all layers with a marked swelling due to edema, engorged blood vessels, and inflammatory cell infiltration. Increased numbers of distended capillaries were present, predominantly in the subepithelial connective tissue layer, while infiltration of inflammatory cells was mainly in the submucosal connective tissue layer. By contrast, the involvement of the mucosal layer was modest and was composed of cuboidal cells, except for small islands of metaplastic mucosa with mucus production occasionally encountered in specimens with secretory otitis media.

BACKGROUND The human temporal bone preparation is a common model for research of physical processes of the ear canal and middle ear. In the past decade only a few reports were published discussing changes of the vibration behaviour of the tympanic membrane, as well as the ear canal resonance, during the time between death and preparation of the temporal bone. The aim of our study is to verify whether measurements at the temporal bone of dead humans can be really applied to the in vivo situation. METHODS We investigated whether changes of the ear canal resonance and the vibration of the tympanic membrane depend on temperature and time after death. In a female human body we defined the resonance of the outer ear and the impedance of the tympanic membrane using a tympanometer and a real ear measurement system during nine hours post mortem. RESULTS We were able to prove that before the preparation of the temporal bone none of the parameters changed significantly. CONCLUSIONS In conclusion, the method of preserving the bone after its preparation is decisive for the validity of measurements at the isolated (post mortem) human temporal bone.