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Objective: To determine the incidence and prevalence of tympanosclerosis (TS) in patients seen in a pediatric otolaryngology clinic., Design: Prospective observational study., Setting: Tertiary care, ambulatory care clinic., Patients and Other Participants: We conducted a prospective observational study to determine the incidence of TS in 218 patients seen consecutively in a pediatric otolaryngology clinic for otologic and nonotologic reasons. The patient age range was 3 weeks to 30 years; 63% were male and 37% female. Of the 218 patients, 37% (81) had undergone bilateral myringotomy and tube placement (BM&T), and 35% (21) of the 81 showed signs of TS; 63% (137) of the 218 patients had no history of otologic surgery, but 12% (15) of the 137 showed signs of TS., Method: The area of the tympanic membrane affected by TS was determined by otoscopy performed by one viewer, who drew the otoscopic findings on a standardized tympanic membrane template. The area of TS was quantified in terms of percentages by digital image analysis of the scaled drawings., Results: There was a range of 0.5-59.9% involvement of the tympanic membrane with TS, with the median percentage of involvement being 4.95%. There was an increased percentage of TS with repeat BM&T., Conclusion: This observational study shows that patients who have had BM&T have a higher incidence of TS than those who have not had the surgery. However our findings also show that 38% of the patients in this study who had TS had never undergone BM&T.

Results of tympanoplasty in children with noncholesteatomatous chronic otitis media are presented in a 16- to 27-year follow-up. During the 13-year period from 1968 to 1980, 116 children (124 ears) were operated on, and they were submitted to several follow-ups with audiometry and otomicroscopy. The attendance at the last follow-up was 70%, and the minimum time since surgery for these patients was 15 years. All dry ears were operated on transcanally with a fixed ear speculum, without any lateral incision of the ear canal skin. Cumulatively, in total, 14 ears (11%) had reperforation: 7 ears early and 7 ears late. At 6 months, there were 6% early reperforations; some were surgically closed and some reappeared later, even after several years, as late perforations. At 2 to 15 years of follow-up, there were 4% reperforations, and at 16 to 27 years, 6%. Hearing was good and stable. The results were the same in ears operated on at the ages of 2.5 to 7 years and 8 to 14 years, as well as with preoperatively positive and negative Valsalva maneuvers. In total, 14% of ears were revised during the entire observation period. It is concluded that transcanal tympanoplasty, even in young children, has good long-term stability and can definitively and permanently solve the problem of noncholesteatomatous chronic otitis in children.

In order to secure both long-lasting carefree ears and hearing-preservation/restoration, the best method to apply is the closed-method tympanoplasty, especially for cholesteatomatous otitis media in children. We agree with this method, in spite of the high percentages of postoperative residual cholesteatoma in children. Until a better way of irradicating cholesteatoma becomes available, either staged operations or periodical check-ups for many years are mandatory. While postoperative attic retraction/cholesteatoma formation seems to be preventable in most cases, the rate of residual cholesteatoma is very high in our data and in other reports. Looking for a reason, the differences between the cholesteatoma in children and those in adults are to be investigated in macro-, micro- and ultramicroscopic observations. In addition, basic rather than clinical studies on cholesteatoma in children are requested.

Objectives: The purpose of this report is to provide data on the incidence of delayed facial palsy (DFP) after tympanomastoid surgery, compare incidence among various otologic and neurotologic procedures, and discuss the possible etiology., Study Design: The study design was a retrospective case review., Setting: The study was conducted at a tertiary referral center., Patients: The records of 486 patients with normal facial function before tympanomastoid surgery were reviewed., Intervention: Patients underwent tympanomastoid surgery., Outcome Measures: Delayed facial palsy was defined as facial palsy occurring more than 72 hours after surgery., Results: Seven of 486 (1.4%) patients had DFP after tympanomastoid surgery. In two patients, the DFP was caused by a postoperative wound infection. Facial palsy in the other five patients likely was caused by viral reactivation., Conclusions: Published data for otologic surgery suggest a rising incidence of DFP with increased manipulation of the sensory branches of the facial nerve. Viral reactivation is postulated to be an important contributing mechanism in the development of DFP. A number of viruses could potentially cause this phenomenon, but observations in this study implicate the varicella zoster virus. Patients with a history of viral reactivation may be at greater risk for development of this complication.

A retrospective study was undertaken of the results of surgery in a series of 782 patients with chronic otitis media. The recurrence rate of cholesteatoma was 20% of patients operated on by trainees and 12% operated on by the faculty. In ears with granulating otitis media, control of infection was achieved by trainees as often as by the faculty. The tympanic membrane healing rate of myringoplasty and tympanoplasty operations was 78% for trainees and 95% for the faculty (P < 0.001). Major surgical complications were relatively rare. It is concluded that the performance of trainees was fairly safe and better than expected, but some failures might have been prevented by closer supervision. Because of the decline in available patients for chronic ear surgery, it is suggested that the training programme should be restructured so that only those trainees who wish to pursue otological surgery as a career are trained in this field.

Four decades after the introduction of tympanoplasty, the goal of achieving stable and long-term hearing improvement after tympanoplasty surgery for chronic otitis media continues to be elusive. In this review, we focus on the current status of our understanding of the mechanics and pathology of the middle ear after tympanoplasty surgery. We also analyze some problems and challenges faced by clinicians and basic scientists in the quest for improved postoperative hearing results.

Proper healing after surgery of the external auditory canal and open-cavity mastoid depend on epithelialization of exposed surfaces. This may be retarded by the formation of abundant granulation tissue or cicatrix, which can be dealt with by the use of thin, split-thickness skin grafts. This technique, which has received little attention in the literature, is described in detail and nine cases treated for various disorders are illustrated. Patient ages ranged from 5 to 80 years and the mean follow-up was 17.2 years. Results, complications, and caveats for successful grafting are presented.

It is well known that sensorineural hearing loss rarely occurs after middle ear surgery. Five cases of postoperative sensorineural hearing loss were reviewed. These operations amounted to 0.9% of all middle ear operations in which the first author was involved. The causes of hearing loss were believed to be labyrinthitis through the fistula in cholesteatoma case 1, and acoustic trauma from the bone-cutting burr in cases 2 and 3. In cases 4 and 5 postoperative sensorineural hearing loss occurred several months after stapes surgery and the causes of hearing loss were unknown. On the basis of the available literature discussion focused on management of labyrinthine fistula, the acoustic effect of the bone-cutting burr and the possibility of sensorineural hearing loss caused by stapes surgery.

A total number of 281 consecutive children with recurrent acute otitis media (RAOM) or otitis media with effusion (OME) was treated with ventilation tubes (VT), inserted under local anesthesia. Patients were prospectively followed-up for post-tympanostomy otorrhea, classified as "early" if observed within 7 days of the tympanostomy procedure. The age of children ranged from 5 to 16 months (average 10.1 months). VT were placed bilaterally in 279 of 281 children. The average length of otitis media (OM) history prior to tympanostomy was 3.4 months. An episode of OM had been diagnosed 1-2 times in 18.9%, 3-4 times in 68.0%, and at least 5 times in 13.1% of the children. Middle ear effusion (MEE), most often classified as mucoid was present in 65.8% of the ears. Cultures were positive for bacteria in 41 of the 185 ears with MEE (22.2%). The mastoid air cell system was radiographically normal in 9.6% and markedly clouded in 56.6%. Early post-tympanostomy otorrhea was observed in 16.0% of ears, occurring more often when MEE, especially mucopurulent, was present at tympanostomy (p < 0.01). The risk of otorrhea was significantly increased by a positive culture for pathogenic bacteria in MEE (p < 0.01) and highly significantly by the advanced opacification of the mastoid air cell system (p < 0.001). It is concluded that early post-tympanostomy otorrhea in young children is caused by the advanced infectious process in the middle ear cleft, including mastoid cell system rather than by the tympanostomy procedure itself. It may indicate the need for more active treatment in this age group.

The analysis of follow-ups shows, that the lack of success in tympanoplasty is often due to errors in operative technique and insufficient postoperative analysis of our failures. The failures has to be analysed in any case, always with exactly operative report comprises the dynamics factors of the operation and written immediately after surgery.

This study is based on the author's personal experience in a middle ear reconstructions. Errors can occur at each surgical stage--tympanic membrane and chain reconstructions, mobilisation of the footplate. At any moment the surgeon can gain or loose the dB. The operating technique is the main factor. A proper operative technic includes a good operating approach and excellent hemostasis. The tympanic membrane, should be as thin as possible, exactly and carefully dissected. Care should be taken to avoid any damage to the fascia graft fibers. Bad or unsure material should be discarded. The graft should not be too large because if it overlaps the EAC wall, it narrows the canal. If the graft is too small, secondary edge performation can occur. The shallow placement of the graft risk a bad contact. Opposite--too deep--poor ventilation of the middle ear and may lead to adhesions. The annulus should be well prepared, free of epithelial remnants. If not cholesteatoma could develop and discontinuity between the neotympanium and the ossicular chain abolish the transmission effect. The mechanical and lever principles during reconstruction of the sound transmission should be kept in mind at all times. The reconstructed system must be delicate and light. The round window reflex is the most important indice of good performed reconstruction, and should be used similar to the modern monitoring system. Try to prevent the natural structures. They are the most valuable material for the future reconstruction.

12 cases of the labyrinthine fistulae from 88 patients operated due to chronic otitis media with cholesteatoma were presented. All patients underwent canal wall dawn technique. In 3 cases the radical ear operation was performed. Other 9 patients were operated by modified radical ear operation with simultaneous tympanoplasty. The frequency and location of labyrinthine fistulae were estimated in chronic otitis media based on own material and literature. The different operating methods were analysed and their influence on the inner ear function was emphasised.

Objective: This study was conducted to gain insight into the surgical management of cholesteatomas to prevent postoperative retraction of the tympanic membrane., Design: A retrospective chart review of patients presenting between July 1988 and July 1992 was conducted., Method: Clinical observations were made on 85 ears from 81 patients who had tympanoplasty with mastoidectomy for middle ear cholesteatoma, with ossicular reconstruction if necessary, with a subsequent follow-up period of 36 to 84 months (mean, 60 +/- 13 months)., Results: The tympanic membrane in several cases became gradually retracted postoperatively; retraction generally commenced along the margin of the cartilage used for repairing the scutum defect, and was noted as early as 9 months, and after 5 years' follow-up, in as much as 66% in the 44 ears operated., Conclusions: Eustachian tube dysfunction was common postoperatively in cholesteatomatous ears; however, whether it was the etiology or the sequela of a cholesteatoma could not be deduced. Since a retraction pocket in the tympanic membrane can develop into a cholesteatoma, it may account for some cases with recurrence of cholesteatoma postoperatively. Therefore, the cartilage/perichondrium composite graft for repairing the bone defect should be as large as possible.

In patients with chronic otitis media, the aims of surgery are to eradicate middle ear disease, prevent recurrent infections, and improve hearing. In most published papers about tympanoplasty, the surgical approaches receive more attention as compared to hearing results. A total of 2015 ears with CSOM but without cholesteatoma, operated upon in a period of 9 years at King Abdul Aziz University Hospital, were studied and analyzed. The results showed 78% perforations closure rate, 19% reperforation rate, and 74% objective audiometry air-bone closure. The results of graft taking and closure of air-bone gap to within 10 dB were better using temporalis fascia compared to dura grafts. Post operative SNHL at 4000 KHz was more in cases using dura graft 6% compared with temporalis fascia 1.9%. Skill, experience, and development of medical facilities in distant areas in developing countries may prove helpful in improving the final results.

Failures and pitfalls in chronic ear surgery have been studied. The material consists of a retrospective study of 616 cases of tympanoplasty. The results were mainly analysed into cases of iatrogenic cholesteatoma (23), labyrinthine fistulae (25) and disruption of ossicular chain (46). The incidence of fistula into the semi-circular canal is high with cholesteatoma, and careful removal of the matrix is recommended to prevent sensorineural hearing loss. Disarticulation of the incudo-stapedial joint is performed to eradicate attic cholesteatoma and protect the cochlea. However, this procedure gives a risk of damage to the inner ear. The frequency and nature of sensorineural losses following chronic ear surgery have been discussed. Surgical precautions are advocated to prevent inner ear damage or other iatrogenic complications.

Loss of a single nerve function in the peripheral network responsible for taste perception is traditionally considered clinically insignificant. However, we report the case of a 27-year-old woman who experienced significant selective taste loss for salt after manipulation of the chorda tympani during tympanoplasty. This effect may be explained by disorder of the functional neuroanatomy of salty taste perception together with strong lateralization of mastication to the affected side in this patient. Recently described inhibition of cranial nerve IX by cranial nerve VII is hypothesized as contributing to the contradiction between this case and the commonly accepted role of the chorda tympani in taste perception.

Tympanoplasty for sinus tympani retraction may result in delayed recurrence of the original problem. This is especially true in children with marginal eustachian tube function. Autogenous tragal cartilage, scored on one surface with perichondrium attached on the other, produces a "natural bend" in the cartilage. When placed in the middle ear, with the scored convex surface facing the promontory, retraction into the sinus tympani can be prevented. This simple, yet effective, surgical technique is outlined.

Perhaps the most devastating complication in otologic surgery is that of inadvertent injury to the facial nerve. A review of 22 patients who had sustained an iatrogenic facial nerve injury was conducted. Although the most common procedure being performed during the injury was mastoidectomy (55%), a surprising number of patients had injury during tympanoplasty (14%) or during removal of exostoses (14%). The most common area of injury to the facial nerve in this series was in the tympanic segment. In 79% of the patients, the facial nerve injury was not detected at the time of surgery. All patients underwent surgical exploration of the facial nerve. Otologic surgeons are cautioned to be familiar with the normal course of the facial nerve and to be aware of the potential for facial nerve injury when performing transcanal surgery.

We report a case of otomycosis due to Scopulariopsis brevicaulis in a patient who has undergone tympanoplasty 3 months before. Mycological finding led us to consider this fungus as the causative agent. Whereas in vitro studies show a better efficiency of azole derivatives, cure was obtained with nystatine after two treatment failures in our patient.

In the early period after chronic ear surgery, the reasons for conductive hearing loss may be difficult to determine. Patients who cannot autoinflate the middle ear after 3 weeks, or who have a negative Rinne test result with the 512 Hz tuning fork, are treated with a transtympanic injection of 0.5 cc of air with a 27-gauge needle and tuberculin syringe. This represents 20% of patients who had chronic ear surgery. Results show that hearing may be immediately improved, the sensation of pressure in the ear may be reduced, and fluid may be cleared from the middle ear. Other benefits may include the release of adhesions. The surgeon is better able to assess the thickness of the graft, and the status of the ossicular chain reconstruction can be determined. There have been no complications of middle ear infection or failure of the micropuncture site to heal. In our practice, middle ear air injection is a routine procedure in patients with inadequate eustachian tube function after chronic ear surgery. This report describes the results of 100 patients over 14 years who received middle ear air injections after chronic ear surgery compared with a control group of 100 patients who did not meet the criteria for requiring air injection. Hearing was immediately improved in 74% of patients as determined by Rinne testing. Audiograms were performed in 25 of these patients, documenting a mean improvement in pure-tone average of 16 dB. The long-term hearing results in patients undergoing air injection, who by definition had evidence of poor eustachian tube function, are similar to the results in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Manipulating the mobile stapes is a central procedure during tympanoplasty, i.e., mounting a prosthesis onto the stapedial head or dissecting cholesteatoma matrix off the oval window niche. An excessive displacement of the stapedial suprastructure as caused by these manipulations with hand-held instruments might result in a rupture of the annular ligament. Bacteria invading through this perilymphatic fistula threaten the inner ear. In experiments with temporal bones, the author investigated the rupture mechanisms of the annular ligament with definite stapedial manipulations. Leaks, which became detectable by exerting pressure on the inner ear fluid, occur only when all suspension fibers are completely ruptured. Further clinical aspects with different directions of stapedial manipulations are demonstrated.

Osteomas of the middle ear are extremely rare lesions. Of the nine cases reported, eight presented with conductive hearing loss. We recently treated two patients whose osteomas, of the promontory and of the posteroinferior tympanic wall, were asymptomatic. We suggest that middle ear osteomas need not be removed when they do not impinge on the sound conduction system.

We made a retrospective study of 419 cases, who had undergone otological surgery for different reasons. In 55 of them we judged, that the pathology, may have been due to the previous surgery carried out in different hospitals. The disease encountered may have been iatrogenic. We have proceeded analyse of the probable cause and to suggest some techniques for dealing with the problem. We have also suggested criteria for the surgery and for the prevention of this occurrence.

Otorrhea is one of the most common ear complaints and is usually responsive to office treatment. The various causes of this condition are discussed and appropriate treatment options are detailed in this article. Topics include otorrhea from typanostomy tubes, chronic otitis media, external otitis and otorrhea, otorrhea after trauma, congenital anomalies and otorrhea, and neoplastic otorrhea.

Drilling during mastoid surgery may result in temporary noise-induced hearing loss. This has practical implications for both the patient and surgeon. In a prospective study of 40 patients, audiometric testing was done both preoperatively and postoperatively to try to detect any significant hearing loss in the immediate postoperative period. The data were analyzed using the Student's paired t test. No statistically significant difference was found. A sensorineural hearing loss soon after mastoid surgery is not due to the noise generated by the drill. In the event of any hearing loss during this period, other causes should be sought.

During tympanoplasty, the stapes is often exposed to considerable manipulations, i.e. the dissection of cholesteatoma matrix from the oval window niche or the insertion of a prosthesis for ossicular chain reconstruction. Too much strain may rupture the annular ligament resulting in an opening of the inner ear. Furthermore it is conceivable that microperilymphatic fistulas, which remain undetected, may develop prior to a visible luxation of the stapes. Therefore, temporal bone experiments with definite manipulations on the stapes were performed to study the rupturing strength of the annular ligament. Increasing the pressure of the methylene blue dyed perilymphatic fluid facilitated the detection of even smallest ruptures. A leakage occurs only in case of a complete rupture of all fibres. Further findings of clinical interest, gained from these experiments with different directions of stapedial manipulation, are discussed.

Fifty-seven of 98 children with cholesteatoma treated between 1976 and 1985 were available for long-term follow-up. The clinical records of the 57 children were analyzed retrospectively. The purpose of this study was to compare the incidence of recurrent and/or residual cholesteatoma, postoperative otorrhea, and hearing results between two groups of patients. One group (n = 40) of children was treated with a radical mastoidoepitympanectomy (RMET) and the other group (n = 17) was treated with intact canal wall tympanoplasty/mastoidectomy (ICWT). Residual cholesteatomas were twice as frequent (17% versus 7.5%) in the ICWT group while recurrent disease was the same. There was no difference in postoperative otorrhea between the two patient groups. Hearing results were equally good in the Type III and in the ICWT group with staged TORP. It is concluded that a Type III tympanoplasty is an excellent one-stage method of hearing reconstruction in patients with good eustachian tube function and an intact stapes and that a correctly performed RMET offers a safe trouble free alternative to ICWT. In selected patients with limited disease and a well pneumatized mastoid, ICWT is still used.

No unanimity of opinion exists in regard to staged operations in tympanoplasty. The controversy centers around the degree to which one should attempt to obtain hearing improvement in badly diseased ears. The major factor is the extent of the mucous membrane disease. We review the history of staging, the mucous membrane indications for staging, and the variations involved in canal-wall-down (CWD) procedures. The opinions of nineteen other otologists also are presented, nine of whom do not regularly or ever stage tympanoplasty.

Type V tympanoplasty with fenestration of the oval window and protection of the round window in a residual hypotympanic cavity can be considered as the last-chance procedure for rehabilitation of hearing in ears with 'canal wall down' or other conditions. The review of 64 cases suggests that restoration of hearing can be adequate in the majority of cases.

Over the last few years, we have increasingly reduced the use of open techniques in favour of combined approach tympanoplasty by adopting a strategy enabling the prevention of genuine recurrences of cholesteatoma. Recurrences due to the development of a residual cholesteatoma moving outwards towards the meatus can be considerably reduced by a careful eradication at the time of exeresis, and by early screening and exeresis of the residual cholesteatoma by a practically systematic second-look operation (two-stage tympanoplasty). To prevent further penetration of the skin into the new middle ear, an effective barrier has to be created between the skin and the mucosa (repair of the wall of the attic, reconstruction of the tympanum by a xenograft (Parmatymp), and proper drainage and airing the new cavity must be assured. To help with the proper regeneration of the mucosa and the maintenance of the drainage and airing pathways within the cavity, the use of silastic proved to be fundamental. This new strategy has enabled us to treat, with the combined approach, 84% of the 1,465 cases of cholesteatoma operated upon between 1975 and 1989.

Movements of the tympanic membrane caused by changes in air pressure are conducted to the ossicles of the middle ear. The gliding mechanism of the malleus-incus articulation converts in-and-out movements of the eardrum into up-and-down movements of the stapes, thereby protecting the inner ear from static pressures. In certain ear operations, the replacement of a middle ear ossicle by a prosthesis disjoints the malleus-incus articulation or makes it rigid. Pressure is then transmitted in unattenuated form from the eardrum through the oval window to the inner ear. Impairment of pressure equilibration, for example due to obstructed eustachian tubes, can lead to prosthesis displacement with severe injury to the vestibulocochlear apparatus. Thus, patients should be advised to begin equilibration of pressure at the beginning of descent of commercial airlines or civil aviation flights, and to repeat it a brief intervals.

Staging of tympanoplasty is important in the management of patients with chronic otitis media. It allows establishment of an air-containing middle ear space and adequate postoperative hearing levels in a large proportion of patients with severely diseased ears. The results of 400 staged procedures performed over a 3-year period at the House Ear Clinic, Los Angeles are reported. Staging was performed in 75% of tympanoplasty with mastoidectomy cases and in 15% of ears not requiring mastoid surgery. Closure of the air-bone gap to 20 dB or less occurred in 68% of patients with intact stapes. Mucous membrane problems were the most common reason for staging. Almost one third of cases with middle ear cholesteatoma at the first stage had residual disease on reexploration. Staging of tympanoplasty continues to be an important technique in management of severely diseased ears.

Reconstruction of the middle ear, after eradication of evolutive lesions, consists of the functional restoration of the transmission components, i.e. the ossicles and the tympanic membrane. Several materials and forms of assembly are available both for the ossicles and for the tympanic membrane. The essential features of ossiculoplasty by columella effect are its simplicity, efficacy and safety. There are also indications, for partial or total anatomic assemblies by tympano-ossicular allografts. The choice of the type ot tympano-ossicular reconstruction will depend on the pathological context, to obviate the creation of an iatrogenic pathology. The results for each type of reconstruction are presented together with the short and long term evolution, through the evaluation of failures.

The postoperative formation of attic retraction pockets following tympanoplasty, with or without mastoidectomy, has often been a significant cause of recurrent disease accompanied by decreased hearing levels. Nasal septal cartilage is recommended as a successful homograft material for attic support. The basis and indications for its use are discussed. Preparation and storage of the homograft materials and surgical technique are described. Long-term results are reported, including a special group in which the status of the homograft material was assessed during revision surgery. Minimal complications have been encountered. Conclusions support the overall advantages of this technique utilizing homograft septal cartilage as an effective means of posterosuperior canal wall support, an aid in preventing retraction pocket formation.

There are presently two schools of thought on the proper surgical management of cholesteatoma associated with chronic ear disease: one feels that the ear should be exteriorized and left "open"; the other takes the position that the disease can be removed, and the ear left in its normal anatomical and functional state. The latter group are known to favor a "closed" or more conservative procedure. The purpose of this paper is to review a series of patients who have had cholesteatoma managed by an intact canal wall procedure that prevents a postoperative cavity. Out of a series of 590 chronic ear surgeries performed between January 1, 1970, and December 31, 1974, there were 179 done for cholesteatoma (30 percent). There were 153 patients, 26 of whom had bilateral disease. Twenty-three patients were lost to follow-up, giving an overall total of 154 surgeries with from one to five-year information. The overall follow-up rate was 85 percent. Recurrent cholesteatoma was the most bothersome complication and occurred in 14 percent of the series. Residual cholesteatoma was managed by doing all procedures in two stages. The authors feel that the intact canal wall tympanoplasty is a procedure that will gain acceptance and will be more widely used in the future.

Absorbable gelatin sponge (Gelfoam)--commonly used in otosurgery--was gently inserted or firmly packed into the middle ear cavities of rats. The postoperative changes were evaluated 2 to 3 months later when, apart from some air-filled canals leading from the tympanal orifice of the Eustachian tube towards the attic, the middle ear cavity had become filled with newly formed bone and an amorphous mass of adhesions and bridles. The mass consisted of loose connective tissue, with fibroblasts, vessels and inflammatory cells. The tympanic membrane was retracted and fixed to the promontory. There were no signs that any Gelfoam had been removed through the Eustachian tube. The authors proposed that similar tissue reactions may occur in tympano-plasties.

The complication of retraction and lateralization of the graft after a tympanoplasty operation is described, and the underlying mechanism discussed. This complication occurs mainly when using the overlay procedure and causes a severe conductive hearing loss. A surgical technique for correcting this problem is described. It consists of removing all of the former graft, positioning the new graft medial to the eardrum remnants and covering the denuded ear canal bone with split-thickness skin graft. The results of 7 cases successfully treated by the technique described are presented.

Advances in neurotologic diagnosis and surgery has pointed to the need for a complete reassessment of the relationship and significance of the jugular bulb and sigmoid sinus is discussed and selected temporal bone sections presented to illustrate the varying locations of the jugualr bulb. Considerations in differential diagnosis are presented and examples of surgical procedures are discussed wherein the jugular bulb was encountered and the methods of management are detailed in these instances.

Closed tympanoplasty techniques greatly increase the risk of recurrent cholesteatoma. This is obvious as many surgeons using these methods insist on a necessary obligatory control operation as a "second look". In this paper cholesteatomata are classified according to their tendency to extend within the petrous pyramid and the subsequent danger of invading semicircular canals, cochlea or cranial fossae. The predisposition to this type of growth is present in the well defined "medial" type of epitympanic cholesteatoma, and more in the anteriorly than the posteriorly placed ones. As infection becomes less prominent in countries with advanced medical services, especially otology, the cholesteatoma hidden behind a small dry epitympanic perforation and those even with no perforation termed "hidden primary cholesteatoma" become more frequent. They cause their own special symptomatology, not infrequently a slowly progressive facial palsy. Every cholesteatoma requires mandatory prophylactic surgery. This means the complete exposure of the danger area, the epitympanum, and nowadays the possibility of the syncronous complete reconstruction of a normal middle ear and external canal, i.e. osteoplastic epitympanotomy.