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TTCR emphasizes the importance of preserving uninvolved, functional mastoid air cells, and anatomical reconstruction with cartilage, which may facilitate mastoid aeration and avoid cavity problems.

PURPOSE: The study was designed to assess correlations between intraoperative findings in revision tympanomastoidectomy as predictors of cholesteatoma recurrence. ----- MATERIALS AND METHODS: A retrospective single-institution cohort of 101 patients who underwent surgical treatment for recurrent chronic otitis media in a tertiary referral otology centre. ----- RESULTS: Out of 101 patients, 65 had canal wall up and 36 canal wall down revision surgery. There were 35 cholesteatoma recurrences. Sites most commonly associated with recurrent disease were residual facial ridge cells in 46 (45.5%), ossicular chain sites in 46 (45.5%) patients, posterior external auditory canal wall erosions in 38 (37.6%) patients and mastoid apex recurrence in 35 (34.7%) patients. Ossicular and posterior external auditory canal wall erosion and incomplete removal of mastoid apex cells correlate well with cholesteatoma recurrence accompanied by canal wall up surgery (p=0.009). Residual mastoid apex cells, posterior external auditory canal wall erosion and presence of residual facial ridge cells were identified as the strongest positive predictors of cholesteatoma recurrence, identifying high risk patients associated with canal wall down procedures (p=0.0036). ----- CONCLUSIONS: Correlations between intraoperative findings and cholesteatoma recurrence could improve preoperative and intraoperative planning and reduce the rates of postoperative failures1 due to mismanagement of high risk areas.

While common in the paranasal sinuses, the presence of allergic mucin within the middle ear is rare. Here we describe a case of what has been termed allergic fungal otomastoiditis (AFOM), an unusual immunologic response to the presence of fungal hyphae within the middle ear, with a unique presentation of aural polyps. A 25-year-old woman presented with recurrent right-sided aural polyps and chronic otorrhea, despite two previous tympanomastoidectomy surgeries performed in India. CT scan of the temporal bones demonstrated complete opacification of the tympanic cavity and mastoid. Canal wall down tympanomastoidectomy was performed, revealing thick otorrhea and polyps filling the external auditory canal and middle ear, eroding the entire tympanic membrane and obstructing the antrum. Pathology revealed glandular and squamous metaplasia, marked inflammation with eosinophils, as well as allergic-type mucin with non-invasive fungal hyphae highlighted by GMS stain. The histopathologic findings of AFOM are reminiscent of allergic fungal rhinosinusitis (AFRS) and suggest a similar pathophysiology. Optimal treatment in these cases may require a combination of surgical debridement and medical management. AFOM should be considered in the differential diagnosis of chronic otitis media, particularly in the presence of aural polyps and thick otorrhea.

Objective To use magnetic resonance imaging (MRI) to assess the extent of mastoid opacification after canal wall up (CWU) cholesteatoma surgery. Materials and methods Thirty-five children in whom post-operative MRI had been obtained after CWU surgery. Cholesteatoma confined to the meso- and/or epi-tympanum was removed using a transcanal approach (n=18). More extensive disease required a combined approach tympanomastoidectomy (CAT, n=17). Mastoid opacification was assessed in both ears by a neuroradiologist blind to surgical details using an ordinal scale from 0 (no opacification) to 6 (completely opacified). The primary outcome measure was presence of normal mastoid ventilation, defined by evaluation of non-operative ears as a score ≤2. The presence of normal ventilation, as well as the raw opacification scores, were compared according to type of cholesteatoma surgery: 1) transcanal, with no mastoidectomy and 2) CAT. Results Mastoid ventilation was normal in 18 post-operative ears (51%). There was no significant difference in the proportion of normally ventilated mastoids in the CAT (n=17) and transcanal (n=18) groups (p=0.318; Fisher's exact). However, mastoid opacification scores were significantly higher in the CAT group than in the transcanal group (p=0.036; Mann-Whitney U). Conclusion The mastoid frequently fails to become normally ventilated after cholesteatoma surgery. Subgroup analysis suggests cortical mastoidectomy does not increase the likelihood of normal mastoid ventilation after CWU cholesteatoma surgery. MRI provides a non-invasive tool to assess mastoid function, which contributes to the current debate on optimum surgical strategies for management of the mastoid in cholesteatoma surgery. Further research will determine whether this measure of mastoid health correlates with risk of recurrent cholesteatoma.

Osteoclasts are unlikely to be involved in bone resorption in middle ear cholesteatoma.The authors searched for osteoclasts in undecalcified bone sections in patients with middle ear cholesteatoma to determine whether and to what extent these cells are involved in this disease.Twelve patients, eight men and four women, aged 30-87 years, who underwent tympanomastoidectomy were enrolled. Six patients had primary acquired middle ear cholesteatoma (cholesteatoma group) and the other six patients had other otologic diseases including otosclerosis, non-cholesteatomatous chronic otitis media, adhesive otitis media, perilymphatic fistula and ossicular malformation (control group). The scutum bone was collected during surgery, fixed with ethanol, stained with Villanueva bone stain, and embedded in methyl methacrylate. Five-micrometer-thick sections were prepared and examined under a polarizing microscope. Images were analyzed using a semiautomatic graphics system.No osteoclasts were seen in any of the samples in either group. To avoid the risk of under-estimating the presence of osteoclasts, the number of osteoclasts was considered to be1 in each sample, and the osteoclast density was calculated. The osteoclast densities in both the cholesteatoma and control groups were significantly lower than the sex- and age-matched standard value of the normal iliac cortical bone (p = .028).

Background Giant cell tumors (GCTs) are rare osseous tumors that rarely appear in the skull. Methods We review the clinical course of a 28-year-old previously healthy woman with a complicated GCT. Results The reviewed patient presented with a middle cranial fossa tumor acutely complicated by reactive mastoiditis. Left tympanomastoidectomy was performed for drainage of the mastoiditis and for biopsies of the tumor. Due to the challenging tumor location, the patient was treated with denosumab, a fully humanized monoclonal antibody against receptor activator of nuclear factor kappa-B ligand, for 7 months, which resulted in significant preoperative tumor shrinkage. Extensive temporal craniotomy and resection of the tumor followed utilizing a temporomandibular joint total endoprosthesis for reconstruction. A recurrence of the tumor was detected on computed tomography at 19 months after surgery and treated with transtemporal tumor resection, parotidectomy, and mandible re-reconstruction. Conclusion A multidisciplinary approach resulted in a good functional result and, finally, an eradication of the challengingly located middle cranial fossa tumor.

Case Details: We present a case of temporal bone mucormycosis in a 71-year-old female with diabetes mellitus who presented to the emergency department with facial nerve paresis, otorrhea, and contralateral hemiparesis. After undergoing a tympanomastoidectomy, the patient’s pathology exhibited fungal hyphae consistent with mucormycosis. Discussion: To our knowledge, there have been 9 reported cases of temporal bone mucormycosis, 3 of which presented with facial nerve paresis, all with some subsequent improvement. In this case, facial paralysis persisted at the time of last follow-up (2 months) despite surgery and intravenous antifungals. We also review and summarize the temporal bone mucormycosis literature. Conclusion: Temporal bone mucormycosis is a rare and morbid infectious disease, though its outcomes appear to be different for patients who present with isolated temporal bone disease as compared to those individuals who develop temporal bone mucormycosis secondary to a rhinologic source.

OBJECTIVES/HYPOTHESIS Cholesteatomas are epidermal inclusion cysts containing stratified squamous epithelium that arise in the middle ear and mastoid cavities resulting in a persistent inflammatory state. Complications include chronic otorrhea, granulation tissue, and bony erosion. Cholesteatoma growth patterns predict frequent involvement of the Fallopian canal of the facial nerve. Extensive disease may extend to the posterior and middle fossa dura, the otic capsule, the carotid artery, and the jugular bulb. Dehiscence of the Fallopian canal and direct involvement of the facial nerve epineurium by cholesteatoma are risk factors for intraoperative facial nerve injury during tympanomastoid surgery by exposing the facial nerve to mechanical trauma and inflammation during microdissection. We present two cases of recidivistic cholesteatoma with unusual medial involvement of the vertical segment of the facial nerve that resulted in an unsupported mastoid segment after resection. The outcomes from these two patients suggest that facial nerve function may be preserved despite circumferential exposure with appropriate preoperative planning and intra-operative techniques. STUDY DESIGN Case studies. METHODS Two patients undergoing revision tympanomastoidectomy for extensive recidivistic cholesteatoma with medial involvement of the facial nerve in the mastoid segment. In each case, the facial nerve was circumferentially exposed during the resection of the cholesteatoma. RESULTS Normal facial nerve function after surgery was confirmed in both patients at 18 months and 6 years, respectively. CONCLUSIONS Surgical resection of extensive cholesteatoma with medial involvement of the vertical segment of the facial nerve resulted in an unsupported mastoid segment in two patients with normal postoperative facial nerve function.

Conclusion Eustachian tube (ET) dysfunction, which plays a role in the pathogenesis chronic suppurative otitis media (CSOM), does not seem to be due to differences in paratubal structures. Objective The aim of this study was to compare the magnetic resonance imaging (MRI) findings of the paratubal structures of the ET between normal ears and ears in patients with CSOM. Methods The MRI records of 40 patients who underwent tympanomastoidectomy for a diagnosis of CSOM were reviewed retrospectively. The healthy ears served as the control group. The length, diameter, surface area and volume of the tensor veli palatini muscle (TVPM) and levator veli palatini muscle (LVPM) were measured, in addition to the diameter of the pharyngeal orifice of the ET, volume of the Ostmann fat pad, bimucosal thickness of the lumen of the ET, and mucosal thickness. Results In the pathological ears, the mean length of the TVPM and LVPM was 22.6 mm and 19.3 mm, the mean diameter was 3.2 and 5.3 mm, and the mean volume was 1.75 and 3.2 cm(3), respectively. In addition, the mean diameter of the pharyngeal orifice of the ET was 1.9 mm. There were no significant between-group differences in the paratubal structures (p > 0.05).

Background: The surgical management of cholesteatoma is a controversial issue, particularly regarding intact-canal-wall mastoidectomy (ICWM) versus canal-wall-down mastoidectomy (CWDM). The current experiment compared the quality of visualization in different middle ear structures using ICWM with otoendoscopy with findings of CWDM by microscopy. Materials and Methods: The patients diagnosed with cholesteatoma underwent tympanomastoidectomy, and then the patients selected for CWDM were included in the study (25 patients: 11 females and 14 males). After removing the cholesteatoma from the involved areas, otoendoscopic examination was done with a 4 mm, 0΀ endoscope by a neurootologist. All five middle ear structures (lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice) suspected of occult cholesteatoma were evaluated in terms of having or lacking the pathology. Then, CWDM was performed and all of the mentioned sites were reevaluated for diagnosing occult cholesteatoma. Results: The symmetric measures were 73%, 92%, 63%, 81%, and 100% for lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice, respectively. Conclusion: Otoendoscopy was confirmed to have a great potential to be adopted by surgeons as a less invasive procedure in the surgical management of middle ear cholesteatoma.

Objectives Complications during aural impression-taking for hearing aids are relatively rare. We present a case to highlight the need for vigilance when taking an aural impression and review the literature to identify other cases in order to assess the range of complications encountered and the sequelae of this potentially serious problem. Methods We present a case report and a review of the literature. Results The most common complication was the entry of mold material into the middle ear cavity. This frequently occurred in patients with a preexisting perforation of the tympanic membrane, although traumatic perforation occurred in 5 cases. Spread of the mold material within the middle ear cavity was frequently extensive, with 46% of cases involving the eustachian tube. There were 6 cases of ossicular chain involvement: encasement of the ossicles in 5 and extensive ossicular erosion in 1. The extent of the surgical procedures performed varied widely, ranging from simple removal of the foreign body in the mastoid cavity to tympanomastoidectomy with a facial recess approach and ossiculoplasty. In 50% of cases, the patient recovered without any complication. However, further hearing loss was observed in 36% of cases. Conclusions When mold material is impacted in the ear canal and visualization of the middle ear is obscured, we advise against simple piecemeal removal. Such cases are best managed by an experienced otologist.

Background To describe the clinical features of intratemporal complications of acute otitis media (AOM) in children, a retrospective study was carried out for 2 years. Methods We considered acute mastoiditis, presence of postauricular swelling, erythema and tenderness, and anteroinferior displacement of the auricle; labyrinthitis, presence of vestibular symptoms (spontaneous nystagmus and ataxia with or without vomiting; and facial nerve palsy, absence or decreased motility in hemiface. All children underwent otomicroscopy for evidence of coexistent or recent AOM. Cultures were obtained by tympanocentesis and myringotomy, drainage of subperiosteal abscess, or from granulation tissue during tympanomastoidectomy. Results From January 2008 to December 2009, 17 patients fulfilled the entry criteria. Median age: 54.2 months. Of the 17 cases, 30% were infants younger than 12 months and most were boys (70.6%). 8/17 were receiving antimicrobial treatment. Diagnoses included 9/17 (52.9%) acute mastoiditis, 7/17 (41.2%) labyrinthitis, and 1/17 (5.9%) facial nerve palsy. Intracranial complications were present in 17.6%. All required intravenous antimicrobial treatment. Myringotomy was performed in 16/17, drainage of subperiosteal abscess in 3/17, and tympanomastoidectomy in 2/17. Bacteriology was positive in 9/17 cases, isolating Streptococcus pyogene s ( S. pyogenes ) in 44% of patients. Secuelaes: One unilateral sensorineural hearing loss. Conclusions Acute mastoiditis is the most common complication. Labyrinthitis was diagnosed in 41.2% of cases. S. pyogenes was prevalent in these serious invasive infections in our area. Associated intracranial complications were present in 17.6% cases. Resolution of AOM complications required surgical procedures in all cases (myringotomy, drainage of subperiosteal abscess, or tympanomastoidectomy).

Aim: The aim of our study was to describe an effective technique for mastoid cavity obliteration in canal wall down tympanomastoidectomy for chronic otitis media and to review its efficacy in producing a dry, low-maintenance, small mastoid cavity. Material and Method: A retrospective clinical study of 56 consecutive patients undergoing procedures for active chronic otitis media with cholesteatoma has been carried out. All surgical interventions involved partial mastoid obliteration and restoration of the middle ear space by use of cartilage reconstruction of the tympanic membrane. Ossicular reconstruction was achieved with either a partial or total ossicular replacement prosthesis. Results: A completely dry cavity was achieved in 49 of 56 patients (approx. 88%, 95% confidence interval 77–95%). An overall statistically significant improvement in hearing (p < 0.05) was obtained, with the mean pure-tone average air-bone gap decreasing from 33.4 ± 8.2 dB (average ± SD) to 18.3 ± 9.7 dB. There were no residual or recurrent cholesteatomas. Conclusion: Cartilage reconstruction of the tympanic membrane proved to be a useful adjunct in the surgical management of the chronically draining cavity.

Clin. Otolaryngol. 2011, 36, 543–549 Objectives: To compare two titanium total ossicular replacement prosthesis (TORP) stabilisation techniques in canal wall down mastoidectomy presenting with footplate only and absent malleus handle. Design: Prospective, controlled, randomised study. Setting: Tertiary Otology Department. Participants: Patients operated on with canal wall down mastoidectomy between 1999 and 2009 were randomised into two groups. Two techniques enhancing the TORP stability were compared: Huttenbrink’s method (63 patients, Group 1) and author’s (GB) procedure (62 patients, Group 2). Huttenbrink’s technique consists in placing a cartilage shave with a hole in the middle over the footplate. Through this hole, the end of the TORP is accommodated. The author’s method involves using a cartilage split in the middle, to lodge the TORP’s shaft at one end and to lay the opposite end over the fallopian canal. Main outcome measures: Mean postoperative air–bone gap, hearing gain and air–bone gap closure within 20 dB. Auditory outcomes were evaluated at 1 year postoperatively. Results: Postoperative air–bone gap closure within 20 dB (successful outcome) at 1 year was achieved in 59% of patients in Group 1 and 72% in Group 2 (P = 0.03). Mean postoperative air–bone gap was 24.4 ± 10.8 dB for Group 1 and 20.17 ± 9.8 dB for Group 2. The difference is 4.23 dB (95% confidence interval, 0.65–07.81), statistically significant: P = 0.02. Hearing gain was 20.3 ± 9.5 in Group 1 and 25.1 ± 10.2 in Group 2, significantly superior: P = 0.007. Conclusion: Better hearing outcomes for author’s method could be demonstrated, but our sample size cannot exclude small and possible trivial, group differences.

The coaxial circle system helps prevent heat loss during surgery, and it also acts as a humidifier. This study aimed to compare the coaxial breathing system and the conventional system in their ability to warm and moisturize inhaled gases, and we also analyzed lung function protection and saccharin clearance time in patients who underwent tympanomastoidectomy (TMT) with the aid of these two systems.Forty adult patients of ASA physical status I-II were scheduled for elective TMT. A standard volume-dependent ventilator setting was used to establish normocapnia. The coaxial circle system was used in the treated group (n=20), whereas the conventional circuit system was used in the control group (n=20). Saccharin clearance, VC (vital capacity), FRC (functional residual capacity), FEV1 (forced expiratory volume in 1 second), airway pressure, relative humidity and temperature of inspired gas, body temperature and adverse and hemodynamic effects were measured at different perioperative periods.The relative humidity (mg H2O Lt -1) of inspired gas in the treated group was higher than in the control group at 5, 15, 30, 45, 60 and 90 minutes after anesthesia induction. The temperature of inspired gas (Centigrade) in the treated group was higher than in the control group (p0.05) after 5, 10, 15, 30, 45, and 90 minutes of anesthesia. Postoperative saccharin clearance time was lower than before the operation in the treated group (p0.05). Postoperative FRC was lower than preoperative FRC in the study and control groups (p0.05).The coaxial circle system decreased postoperative saccharin clearance time and increased postoperative FRC, relative humidity and the temperature of inspired fresh gas, without any adverse perioperative effects in patients who underwent TMT.Koaksiyel halka sisteminin kullanılması cerrahi sırasındaki ısı kaybını önler. Ki o bir nemlendirici olarak rol oynar. Bu çalışma timpanomastoidektomi (TMT) operasyonu geçiren hastalarda Konvensiyonel sistem ve koaksiyel sistemin, sakarin klirens zamanı ve akciğer fonsiyon testlerinin korunması ve inhale edilmiş gazın ısınma ve nemlenmesinin karşılaştırılmasını amaçlamıştır.Elektif timpanomastoidektomi yapılan ASA I–II fiziksel statüsünde yetişkin 40 hasta seçildi. Normokapniyi sağlamak için standart volüm ayarlı ventilatör kullanıldı.Tedavi grubunda (n=20), koaksiyel halka sistemi, kontrol grubunda (n=20) Konvensiyonel halka sistemi kullanıldı. Farklı peroperatif dönemlerde, Sakkarin klirens zamanı, VC, FRC, FEVİnspire edilmiş gazın nisbi nemi anestezinin 5, 10,15, 30, 45 ve 90. dakikalarında tedavi grubunda kontrol grubundan daha yüksek bulundu. İnspire edilmiş gazın ısısı anestezinin 5, 10,15, 30, 45 ve 90. dakikalarında tedavi grubunda kontrol grubundan daha yüksek bulundu (p0.05). Tedavi grubunda postoperatif sakkarin klirens zamanı preoperatif değerden daha düşük bulundu (p0.05). Çalışma ve kontrol grubunda postoperatif FRC preoperatif FRC’den daha düşüktü.TMT yapılan hastalarda Koaksiyel halka sistemi herhangi bir peroperatif yanetki yapmadan Postoperatif sakkarin klirens zamanını azaltmış, inspire edilmiş taze gazın postoperatif FRC’yi, nisbi nemini ve ısısını arttırmıştır.

Objective: Postoperative nausea and vomiting (PONV) are of the most common complications after anesthesia and surgery that affects 20%–30% of patients. This study aimed to examine the efficacy of dexmedetomidine (DEXM), dexamethasone (DEXA), and metoclopramide (METO) on the reduction of PONV after tympanomastoidectomy. Materials and Methods: In a clinical trial study, 90 patients who undergoing tympanomastoidectomy surgery were assigned to DEXM (1 μg/kg/intravenous [IV]), DEXA (0.1 mg/kg/IV), and METO (0.15 mg/kg/IV) groups by block randomization method. The initial vital signs and vomiting score as responses to treatment were assessed using visual analog scale through 24 h (6, 12, 18, and 24) after the end of surgery. The vomiting score varied from 0 (no vomiting) to 100 (the worst possible vomiting). One-way analysis of variance (ANOVA), paired t-test, and repeated measure ANOVA was used for statistical analysis in SPSS version 12.5 (SPSS Inc., Chicago, IL, USA). Results: The incidence of PONV was 10%, in DEXM 0%, DEXA 6.7%, and 23.3% in METO. Vomiting score is much lower for the DEXM than for the other two groups, and rather rapidly declined 18 h after the intervention. The difference of time 6–24 was significant among three groups (P

Phialemonium infection in humans is rare. We report a 7-year-old healthy boy who presented with chronic otorrhea, which persisted despite adequate antibiotic therapy and four preservative tympanomastoidectomy operations. Following 3 years of intermittent topical antibiotic therapy, cultures eventually grew Phialemonium, which necessitated a more extensive operation, combined with systemic/topical anti-fungal agent to achieve clinical cure.

Most ears that were treated with a new surgical method were rendered dry and safe, with cavity problems minimized by this simple technique. This technique is also valid in terms of medical economy because it shortens the hospitalization period and subsequent outpatient care is not required frequently.Canal wall-down tympanomastoidectomy was a well established procedure for severe chronic otitis media, especially cholesteatoma. However, this procedure has some defects, so-called cavity problems, caused by non-epithelialized bony wall. The aim of this study was to evaluate the early epithelialized technique for the surface of widely formed external acoustic meatus after canal wall-down tympanomastoidectomy.Twenty-five patients who had been diagnosed with cholesteatoma were divided into two groups. Group I consisted of 15 patients who underwent a new method in which the open cavity was lined with a pedicle periosteal flap of the postauricular region together with free temporal fascia grafts. As a control, 10 patients in group II underwent the standard operation that uses only free temporal fascia grafts.A comparison of the two groups showed that it took only 1 month on average for the entire surface of the external auditory meatus of the patients in group I to epithelialize and dry up perfectly, although the same area in all the patients in group II was not dried up perfectly until over 80 days.

We herein report a 59-year-old male patient with a recurrent carcinoid tumor of the middle ear 7 years after a tympanomastoidectomy. The CT and dynamic MRI demonstrated an extensive tumor close to the carotid artery canal and the jugular bulb, and the tumor was removed by a partial petrosectomy with a transmastoid approach. The histopathological findings revealed a solid and trabecular tumor with cells positive for cytokeratin, chromogranin A, synaptophysin, and CD56. The MIB-1 antibody for the Ki-67 antigen was positive in 6.6% of the tumor cells. The relevant literature is reviewed in regard to the present case.

Although it abolishes the incudostapedial joint, use of glass ionomer cement to repair the defect between the stapes head and the long process of the incus is a successful procedure when the hearing results are considered.To compare the hearing results obtained by a fixed, stiff reconstruction with glass ionomer cement, and a flexible, springy pseudo-joint built with autologous cortical bone in patients with a small defect between the long process of the incus and the stapes head.A total of 66 patients who had canal wall up tympanomastoidectomy due to chronic otitis media and incus long process defect between January 1996 and February 2008 were analyzed retrospectively. Their incudostapedial joints were reconstructed using either glass ionomer cement (n=31) or autologous cortical bone (n=35).The mean follow-up period was 22.8 months for all cases. The mean postoperative air bone gap (ABG) was 29.2 dB and it reduced to 11.8 dB at the end of the follow-up period. Preoperative and postoperative ABGs were 27.4 dB and 10.6 dB in the glass ionomer cement group and 30.9 dB and 12.8 dB in the cortical bone group, respectively. The ABG closure was 16.8 dB in the glass ionomer cement group and 18 dB in the cortical bone group.

Objective: To compare the effectiveness of bioactive glass implants and conchal cartilage in reconstructing the posterior canal wall during tympanomastoidectomy. Study design: Prospective cohort clinical study. Setting: Teaching hospital. Patients: Patients with clinically diagnosed chronic suppurative otitis media and cholesteatoma awaiting tympanomastoidectomy were recruited. Intervention: All patients underwent tympanomastoidectomy by the same surgeon. A first cohort of 12 patients underwent posterior canal wall reconstruction with autogenous conchal cartilage. A second cohort of 12 patients underwent such reconstruction with prefabricated bioactive glass. Main outcome measures: Primary– All patients underwent out-patient review at 1, 3, 6 and 12 months postoperatively, after which a second-look procedure was performed. Reconstructions were inspected for evidence of epithelialization, granulation, infection, stenosis, depression and extrusion. Secondary– All patients had perioperative serial pure-tone audiometry to check for any change in hearing levels upto 1 year postoperatively. Results: By 1 year postoperatively, both reconstructive graft materials showed good epithelialization, no granulation, no infection, no ear canal stenosis, no depression and no extrusion. At operative second-looks, bioactive glass particularly showed good tissue bonding, including both neovascularization and connective tissue integration. Overall clinical outcome was equivalent for both materials. Both graft materials showed no statistically significant difference in postoperative hearing levels. Conclusions: Bioactive glass and conchal cartilage showed equivalent clinical outcome in reconstructing the posterior canal wall without significantly affecting hearing levels. As bioactive glass does not require second site morbidity and thus also reduces operative time, we prefer it for reconstructing the posterior canal wall following tympanomastoidectomy.

Inflammatory myofibroblastic tumors, also known as inflammatory pseudotumors, include a diverse group of lesions characterized by inflammatory cell infiltration and variable fibrotic responses. Their occurrence in the temporal bone is unusual. We present a case of an inflammatory myofibroblastic tumor of the mastoid bone in a 55-year-old female who complained of repeated otorrhea and a hearing impairment. On an otoscopic exam, her tympanic membrane was perforated. The computed tomographic imaging revealed a soft-tissue density-filled middle ear and mastoid with sclerotic bony change. The initial clinical diagnosis was chronic suppurative otitis media and mastoiditis, and the patient underwent a canal-wall down tympanomastoidectomy through a retroauricular approach. A histopathologic examination showed the presence of myofibroblastic spindle cells with mixed inflammatory infiltrates, and the pathologic diagnosis was inflammatory myofibroblastic tumor.

BACKGROUND The primary goal in chronic otitis media is the creation of a dry, safe ear with hearing preservation and reconstruction. This study was designed to evaluate the authors' experience using autologous bone pate and conchal cartilage for mastoid obliteration in canal wall down tympanomastoidectomy. METHODS A retrospective long-term review in 2003 of thirty-nine ears was performed, which underwent mastoid obliteration in canal wall down tympanomastoidectomy between 1993 and 2002 performed by the senior author. Data included questionnaire results, clinical observation as well as pre- and postoperative audiometry. RESULTS Long-term follow-up shows, that 38 out of 39 ears maintained a small, dry, healthy mastoid cavity. Recurrent cholesteatoma occurred in a single patient. A self-cleaning mastoid bowl was achieved in 90 %, resulting in reduced follow-up visits. Postoperative vertigo in canal wall down revision surgery is clearly diminished due to the mastoid obliteration. Overall, 92 % of patients are satisfied with the surgical result. CONCLUSION Obliteration of a canal wall down mastoid cavity by autologous bone pate and conchal cartilage is a reliable and effective technique that results in a dry, trouble free mastoid cavity in 90 % of the patients with chronic otitis media.

Summary The new cavity created after an open cavity tympanomastoidectomy (OCTM) is filled with an antibiotic impregnated cotton pack (cotton tape, umbilical tape, gauze). The removal of this pack usually causes some bleeding and discomfort for the patient. We propose the use of a latex biomembrane to cover the cavity, which will act as an interface between the raw bone surface and the packing. Study design: clinical prospective. Aim: To study the performance of the latex biomembrane as an interface between the raw bone surface and the pack, and to analyze its role in cavity epithelization. Material and Methods: 64 ears of patients submitted to OCTM were studied. The biomembrane was used in the packing of 54 ears and in the 10 remaining ears the regular cotton tape packing was used. Results: In the majority of the cases where the biomembrane was used the packing was removed much easier with no bleeding or pain for the patient and also showed an earlier cavity epithelization. Conclusion: The use of the latex biomembrane has proven to be an effective method to cover the mastoid cavity facilitating epithelization and removal of mastoid cavity packing.

Objective: Acquired cholesteatoma is a severe middle-ear pathology affecting both adults and children. The clinical behavior of cholesteatoma depends on the histopathological characteristics of the disease. The present study aimed to compare the histophathological characteristics of acquired cholesteatoma in patients who had undergone tympanomastoidectomy. Patients and Methods: This retrospective chart analysis was conducted on 370 patients who had undergone tympanomastoidectomy presenting with the pathological indication of cholesteatoma. All cholesteatoma specimens were collected intraoperatively and were preserved for histopathological examination. The patients were divided into two groups according to the histopathological findings: 1- patients with pure cholesteatoma 2- patients with cholesteatoma plus other pathologies. Then, the two groups were compared regarding the clinical variables, including age, gender, duration of disease, occurrence of relapse, and complications. Results: No significant difference was found between the two groups regarding the clinical variables. Nevertheless, the incidence of pure cholesteatoma was higher among the patients who had experienced the recurrence of the disease and underwent tympanomastoidectomy one more time. Conclusion: In the present study, no significant difference was observed between the two histopathologically different groups regarding the clinical variables, except for recurrence rate. Keywords: Acquired cholesteatoma, Clinical and histopathological features, Tympanomastoidectomy

In mastoid surgeries, contralateral ear noise exposure is a known, identified factor leading to high-frequency hearing loss due to the wide variety of surgical devices that may be used during the surgery. However, the hearing threshold recovery time after this trauma was uncertain. The present study aimed to assess this time. In this prospective survival analysis study, 28 consecutive patients with chronic otitis media who were undergoing tympanomastoidectomy were assessed. Standard pure-tone audiometry (PTA) and distortion-product otoacoustic emission (DPOAE) were measured in all contralateral ears before and 6 h, 24 h, 48 h, 72 h, and 96 h after the surgery. Based on the PTA postoperative hearing loss, survival rates at frequencies of 3000 Hz, 4000 Hz, 6000 Hz, and 8000 Hz were 44.4%, 36.4%, 51.7%, and 47.4%, 24 h after surgery; 11.1%, 9.1%, 10.3%, and 13.2%, 48 h after surgery; and 0%, 0%, 3.4%, and 2.6%, 72 h after surgery, respectively. Based on the PTA and DPOAE, survival rates at all frequencies were 0%, 96 h after the surgery. According to the PTA, mean hearing recovery times were 61.98 ± 26.76 h (3000 Hz), 62.73 ± 26.50 h (4000 Hz), 67.08 ± 25.90 h (6000 Hz), 70.70 ± 24.13 h (8000 Hz), and with regard to DPOAE the recovery times were 58.58 ± 28.39 h (2000 Hz), 63.32 ± 28.83 h (4000 Hz), 65.22 ± 29.13 h (6000 Hz), and 75.14 ± 22.70 h (8000 Hz), respectively. To conclude, high-frequency hearing loss usually occurs following mastoid surgeries that is mainly temporary and reversible after 72 h.

The aim of our study was to compare the difficulty in performing a posterior tympanotomy in chronic otitis media (COM) versus the same procedure in a normal mastoid. The study included 122 patients who underwent tympanomastoidectomy for unilateral chronic otitis media with contralateral normal mastoid pneumatization. We evaluated the anatomical relationships between the mastoid segment and neighboring structures by analyzing axial temporal bone computed tomography scans. A vertical line (line A) was drawn tangential to the most lateral end of the posterior semicircular canal (point A). Three distances were measured: the distance (D1) between the point A and the most lateral end of the mastoid segment of the facial nerve (point B), the distance (D2) between the line A and the point B, and the distance (D3) between the point B and the posterior end of the bony annulus of the external auditory canal. The average measurements of D1 and D3 were 3.79 ± 0.55 and 2.63 ± 0.51 mm, respectively, in the normal mastoid ears and 3.47 ± 0.59 and 2.35 ± 0.44 mm, respectively, in the COM ears. The measurements of D1 and D3 were statistically shorter in the COM ears than in the normal ears. These findings suggest that the facial recess in COM may be narrower than in a normal mastoid and that performing a posterior tympanotomy may be riskier in COM than in a normal mastoid due to the potential for injury to the neighboring structures and the facial nerve.

Objective: Butterfly graft inlay tympanoplasty is a well-established technique for the repair of small perforations. However, the efficacy of the technique for medium and large tympanic membrane perforations remains unknown. Study Design: Retrospective case series. Methods: Postauricular tympanoplasty and tympanomastoidectomy using a large butterfly cartilage inlay graft (>4 mm diameter to total drum replacement) were analyzed in 90 pediatric patients (99 ears). Results: Patient ages ranged from 2 to 20 years; mean follow-up duration was 27.6 months. Successful closure occurred in 92% of the ears. No graft lateralized nor displaced into the middle ear. No retraction pocket occurred during the follow-up period. In 62 cases, intact canal wall or canal wall window tympanomastoidectomy was performed; Fifty-one (82.2%) of the patients having mastoidectomy procedures had chronic otitis media with cholesteatoma. The mean preoperative to postoperative four-tone air-bone gap improved from 23 to 21 dB; the number of patients with 0 to 10 dB hearing results increased from 16 ears preoperatively to 32 ears postoperatively. Postoperative suboptimal results included eight patients with postoperative perforations in the residual tympanic membrane adjacent to an intact cartilage graft; two of these patients were the only individuals who exhibited otorrhea. Conclusions: Cartilage butterfly graft inlay tympanoplasty is effective in the vast majority of patients with moderate to large perforations. The closure rate exceeded 90% with no graft displacement, postoperative adverse events were respectably low, and hearing results improved or remained stable despite the need for concurrent mastoidectomy in the majority of patients.

Osteomas in the middle ear are extremely rare and are generally solitary and small. We present a case of a 28-year-old female patient with multiple middle ear osteomas which arose from the promontory, epitympanum, and lateral semicircular canal. The osteomas were successfully removed by tympanomastoidectomy. This is the first reported case of a patient with middle ear osteomas arising from multiple sites.

Objectives: To investigate posterior external ear canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for open mastoids.Study design: Retrospective case review.Setting: Tertiary referral centre.Methods: As a preliminary study, 15 selected patients underwent reconstruction of a posterior ear canal wall defect with titanium mesh. Large defects of the posterior external auditory canal wall, resulting from canal wall down tympanoplasty or present in revision surgery, were eliminated by reconstruction using a titanium mesh. The mesh was covered with conchal cartilage and attached to the cortical mastoid bone using 3-mm titanium screws.Results: All patients maintained a normal contour of the external ear canal, without depression, extrusion or infection. There were no failures, based on short-term post-operative controls. However, two procedures had to be revised due to incomplete coverage of the titanium mesh.Conclusions: This study shows that reconstruction of the posterior ear canal wall with a composite cartilage titanium mesh is a valuable method for preserving the morphology of the external auditory canal in selected cases. Problems occurring in canal wall down tympanomastoidectomy and radical cavities may therefore be avoided. However, long-term results have yet to be evaluated.

Facial nerve palsy after ear surgery is a troublesome postoperative complication for both patient and the surgeon. Though most of the palsies occur in the immediate post-operative period, in rare instances patients may develop facial nerve palsy anywhere from several hours to several days after ear surgery. We hereby present a case of delayed facial nerve palsy, after 5 days following surgery, in 48 year old women operated for tubotympanic type of chronic suppurative otitis media. Patient recovered well with oral steroid therapy. Delayed facial nerve palsy is a very rare

Objectives: This study was designed to evaluate the authors' experience with canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma. Study Design: Institutional review board approved retrospective case review. Methods: Retrospective review was performed of all patients undergoing CWR tympanomastoidectomy with mastoid obliteration from 1997 to 2004. Data included pre- and postoperative audiometry, findings at second look surgery with ossiculoplasty, and postoperative complications including wound infection and canal wall displacement. Results: One hundred thirty ears in 127 adults and children underwent the procedure. Mean time postoperative was 48 (range 2-94) months. A second look ossiculoplasty was performed in 102 (78%). Percentage of ears that remain safe without evidence of recurrence was 98.5. The postoperative infection rate decreased from an initial rate of 14.3% to 4.5% for the last 88 ears after protocol modification. Recurrence occurred in two (1.5%) patients, requiring conversion to a canal wall down mastoidectomy. Conclusions: A CWR technique can provide improved intraoperative exposure of the middle ear and mastoid without creating a mastoid bowl and reduces the incidence of recurrent disease. A single procedure is used for all patients with acquired cholesteatoma, including children.

To undertake cost-utility analysis for tympanomastoid surgery to analyze its cost-effectiveness in treating adult chronic suppurative otitis media (CSOM).Seventy-seven patients with CSOM were evaluated with the Chronic Ear Survey (CES) before and 1 year after tympanomastoid surgery. Direct health care cost data during the 1st year after operation were retrieved. The utility gain was defined as change in the CES total score. The cost-utility ratio (CUR) was defined as cost per utility gain. Patients were stratified by disease type into wet-ear and dry-ear groups.The average total direct cost attributable to tympanomastoid surgery is (in New Taiwan dollars) 45,716.3 in the 1st postoperative year, and the average CUR is 1850.9 New Taiwan dollars. The lower CUR of 1280.9 New Taiwan dollars for the wet-ear group is due to the greater utility gain (37.6 +/- 3.4 versus 24.4 +/- 6.8, P0.05) despite its higher cost (48,163.2 New Taiwan dollars versus 38,419.7 New Taiwan dollars, P0.05).Treating continuously or intermittently draining ears is more cost-effective, as compared with managing a quiescent infection, because of its favorable utility gain.

Objectives/Hypothesis To evaluate the correlation between the surgeon's intraoperative findings and histopathologic diagnosis of cholesteatoma specimens and the associated health care cost in requesting pathologic evaluation. Study Design Retrospective chart analysis. Methods Chart data were collected at a tertiary neurotology referral center from patients undergoing tympanomastoidectomy for chronic otitis media, with specimens submitted for pathologic review between 2010 and 2011. Correlation between the surgeon's intraoperative findings and the pathologic diagnosis was evaluated using a kappa statistic. Cost analysis for pathologic consultation was also reviewed. Results A Cohen's kappa value of 0.93 (P

To propose management options for cochlear implantation in chronic otitis media based on our experiences.A retrospective review of 418 cochlear implantations performed by the 2 senior authors between November 1988 and February 2004 was conducted. Nine patients who had chronic otitis media in the ear to be implanted were included. Of these, three showed active inflammation at presentation; the other six cases had undergone previous tympanomastoidectomy surgery and did not show active inflammation at presentation.Five patients with active inflammation or without an adequate soft tissue layer in the mastoid bowl underwent a two-stage procedure. Four cases who showed inactive inflammation and had an adequate tissue layer to protect the electrode array underwent a single-stage technique, although two of them showed dry tympanic membrane perforation. No local or intracranial inflammation recurred. The electrode was exposed in the mastoid bowl in one case, who was managed with revisional mastoid obliteration with soft tissue.Complete eradication of inflammation and the securing of a strong protective soft tissue layer over the electrode are prerequisites for cochlear implantation in ears with chronic otitis media.

Objectives: Standard procedures for hearing aid fitting performed in accordance with established guidelines are well tolerated, safe, and effective. In this article, we present unusual complications after hearing aid fitting that required surgical management. Methods: Four otologists at a major university center with a combined 65 years of experience performed a retrospective analysis of their surgical practice. Six patients were identified that had encountered severe complications from improper earmold fitting that required surgical intervention. Results: One patient had a perforation of the tympanic membrane with earmold material found to have migrated into the middle ear cleft. The tympanic membrane healed spontaneously, resulting in persistent otalgia and a maximum air-bone gap. The earmold cast was successfully removed by means of a tympanomastoidectomy. Two patients with presbycusis and normal ear canals developed eardrum perforations and conductive hearing deficits. In both patients, earmold material was found partially occupying the middle ear cleft and removed by way of a transcanal approach. Three patients with prior canal wall down mastoidectomy defects and narrow external ear canals required microtoscopy under general anesthesia or canaloplasty for removal of impacted material. Conclusion: Proper fitting of hearing aids performed by well-trained medical professionals results in a very low incidence of significant complications. Perforation of the tympanic membrane with impaction of earmold material in the middle ear or mastoid bowl may occur and can be successfully managed by standard otologic surgical techniques.

Objective. Bilateral congenital cholesteatoma is a very rare condition. We describe the first case of an adult patient presenting with bilateral congenital cholesteatoma with labyrinthine fistula. Case report. We present a 34-year-old woman of bilateral congenital cholesteatoma with labyrinthine fistula, inducing left- sided mixed conductive-sensorineural hearing loss and vertigo, subsequently accompanied by right-sided conductive hearing loss. Otoscopic examination and computed tomography scan revealed bilateral congenital cholesteatoma with a fistula in the left lateral semicircular canal. Tympanomastoidectomy was performed, and both congenital cholesteatoma were completely removed, and membranous fistula of the left lateral semicircular canal was covered with a graft. Conclusion. Congenital cholesteatoma is usually detected in childhood not but in adulthood. With delay in diagnosis, the risk of cholesteatoma complications increases. Greater attention should be paid to complications such as labyrinthine fistula resulting from long-term exposure to congenital cholesteatoma in adults.

Objective Our goal was to evaluate the use of topical mitomycin-C (MMC) in the prevention of scar tissue formation in the postsurgical external auditory canal (EAC). Study design and setting We conducted a prospective pilot study at a tertiary care institution. Methods Six patients with recurrent postoperative granulation tissue after canaloplasty, tympanomastoidectomy, or lateral temporal bone resection were included. MMC (0.5 mg/mL) was applied topically for 5 minutes to the EAC/mastoid cavity. Results Outcomes were measured at initial MMC application and 1 and 3 months thereafter using a visual analog scale score based on the degree of EAC occlusion by granulation tissue. Need for debridement of recurrent granulation tissue on follow-up was noted. Three (50%) patients had improved VAS 1 month after treatment. Two (33%) had improved visual analog scale score at 3 months. Five (83%) required at least one debridement procedure. Repeat MMC application was performed in 2 patients. Conclusion Topical MMC was ineffective in preventing scar formation in the postsurgical EAC.

Iatrogenic implantation of squamous epithelium during middle-ear surgery may cause epidermoid cyst (EC) development. These cysts may arise in different localizations of the head and neck following otological surgery. In this rare case, a giant EC with a size of 56 mm × 30 mm, which appeared in the preauricular area growing in the past 1 year in a 40-year-old male patient who underwent type 1 tympanomastoidectomy due to chronic otitis media without cholesteatoma 8 years ago, was discussed with the literature in terms of clinical findings and differential diagnosis.

The aim of this study was to retrospectively review the long-term hearing results and the impact of mastoid exclusion/obliteration in patients with cholesteatoma (102 ears) who underwent retrograde tympanomastoidectomy and in whom bone chips/paté were applied as the sole materials during the procedure. In 79 ears, this was combined with ossiculoplasty in a single-stage procedure. In >71% of ears, the results of audiometric testing were monitored for more than 2 years. The results suggested there was a significant gain in hearing following surgery, with respect to the postoperative change in both air-conduction thresholds and air-bone gaps (P<0.001). Linear regression analyses of pure-tone averages at different frequencies, before and after surgery, demonstrated that patients benefitted from a postoperative hearing gain at low and middle frequencies, but their hearing often deteriorated at frequencies of 8000 Hz. As for the impact of the type of tympanoplasty on hearing outcomes, type III-interposition markedly increased hearing gain. The overall rate of postoperative adverse events was 8.8%. We conclude that reconstruction of the ear canal and mastoid via mastoid exclusion/obliteration using bone chips/paté can be considered as an alternative procedure following retrograde mastoidectomy. It gives excellent surgical results and has fewer postoperative adverse events.

Objective Chronic ear surgery is difficult. The management of such a disease either with or without cholesteatoma and in an only hearing ear is particularly challenging. Consequences of disease or unintended outcomes of therapy can both result in patient lifestyle alterations of major proportion. This report offers a diagnostic and treatment plan for chronic otitis media with and without cholesteatoma in the only hearing ear. Methods More than 10,000 charts of patients with chronic otitis media were retrospectively reviewed. Twenty-seven charts of patients with chronic otitis media in an only hearing ear who underwent surgical treatment were identified. The patients were followed for an average time of 43 months. Results Overall, the chronic otitis media was well controlled, and there was no change in the average discrimination or hearing thresholds when comparing preoperative and postoperative results. Conclusions Chronic otitis media with and without cholesteatoma in an only hearing ear can be treated successfully with hearing preservation. Canal wall down tympanomastoidectomy is performed in most cases. Manipulation of the ossicular chain is avoided, and cholesteatoma that lies over a potential fistula is exteriorized.

In this retrospective study, we evaluated the audiometric results after using the retrograde mastoidectomy technique with open mastoid cavity for the removal of extended attic cholesteatomas. The described technique was used for cholesteatoma removal in 168 adult patients with an average follow-up time of 12 months. Due to cholesteatoma extension far into the mastoid, the disease was eradicated by the canal wall down (CWD) technique with the creation of an open mastoid cavity. Primary surgery was carried out in 47% of ears, with the remaining 53% representing revision surgery. In all cases, a classical CWD with an open mastoid cavity and partial obliteration with cartilage was created. A dry ear was achieved in 94% of cases. A postoperative air-bone gap ≤20 dB was achieved in 42.9% of the operated ears. 9.3% (n = 15) of the operated ears showed a postoperative air-bone gap >30 dB. Important factors leading to significantly better hearing restoration were an intact malleus, the use of alloplastic titanium prostheses and primary surgery. Although most cholesteatomas nowadays can be eradicated with the canal wall up technique, in far advanced cholesteatomas, the CWD technique can be applied with acceptable postoperative hearing results.

Objective We investigated the electrical impedance of and the expressions of tight junction molecules in the cholesteatoma epithelium to provide supporting evidence for the acid lysis theory of bone resorption in middle ear cholesteatoma. Methods Study subjects were patients with primary acquired middle ear cholesteatoma and those with non-cholesteatomatous chronic otitis media who underwent tympanomastoidectomy. The electrical impedance of the cholesteatoma epithelium was measured during tympanomastoidectomy by loading alternating currents of 320 Hz and 30.7 kHz. The expressions of tricellulin (MARVELD2), claudin-1 (CLDN1) and claudin-3 (CLDN3) were examined by fluorescence immunohistochemistry and quantitative reverse transcription-polymerase chain reaction. Results The electrical impedance of the cholesteatoma epithelium was significantly lower than that of the post-auricular skin and external auditory canal skin at both 320 Hz and 30.7 kHz. Immunoreactivity for MARVELD2, CLDN1 and CLDN3 was localised mainly in the granular layer, and to lesser degree, in the horny and spinous layers in both the cholesteatoma tissue and post-auricular skin. Fluorescence intensity was moderate for MARVELD2, weak for CLDN1 and strong for CLDN3. The expressions of MARVELD2, CLDN1 and CLDN3 mRNA were significantly lower in the cholesteatoma tissue than in the post-auricular skin. Conclusions These results indicate the increased permeability of the cholesteatoma epithelium and suggest that this change is, at least partially, dependent on the decrease in the expressions of the tight junction molecules. This evidence supports the acid lysis hypothesis of bone resorption in cholesteatoma.

This article discusses the Envoy Esteem implantable hearing system, a completely implantable hearing device. The device is indicated for patients older than 18 years with stable moderate to severe sensorineural hearing loss and good speech discrimination. The device is placed through an intact canal wall tympanomastoidectomy with a wide facial recess approach. The implant is typically activated at 6 to 8 weeks postoperatively and usually requires several adjustments for optimal performance. The sound processor/battery lasts 4.5 to 9.0 years and can be replaced through a minor outpatient procedure.

Objectives:Analyze outcomes of tympanomastoidectomy for chronic otitis media in children at a tertiary care referral center with a high prevalence of patients with genetic syndromes, craniofacial a...