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The purpose of our study was to elucidate the course of healing of the tympanic membrane (TM) when myringotomy was performed during acute otitis media. The early and long-lasting structural changes of the TM were studied in an animal model. Rats were inoculated with Streptococcus pneumoniae (PnC) type 3 in the bulla. When the infection was manifest, myringotomy was performed. On days 4 and 12, and 3 and 6 months after myringotomy, the TM status was checked by otomicroscopy and TMs were prepared for light and electron microscopy. Comparison was made with PnC-infected TMs that were not perforated, as well as myringotomized noninfected TMs. The infection resolved more slowly in myringotomized ears compared to PnC-infected ears that were left untouched. After 6 months, the pars tensa of the myringotomized infected ears was thickened and showed a disorganized collagen structure, compared with myringotomized noninfected ears, in which TMs were normalized. The PnC-infected TMs without myringotomy were completely normalized after 2 months. We conclude that a combination of bacterial infection and myringotomy causes long-lasting changes in TM structure. This impaired structure of the connective tissue could be of importance in chronic middle ear disease as a presumptive site for retraction and perforation of the TM.

Anterior perforations of the tympanic membrane have been previously shown to have a higher failure rate than others following tympanoplasty procedures. A technique has been previously described utilizing an anterior hitch graft stabilization with avoidance of anterior blunting of the tympanic membrane. Follow-up cases in which this technique has been utilized show greatly improved results in terms of perforation closure.

Mast cells are known to reside in pars flaccida membranae tympani and other parts of the middle ear mucosa in both rats and humans. However, the normal pars tensa contains no or only a few mast cells along the manubrial vessels. We examined the pars tensa of 25 rats in an experimental model of acute otitis media and found 13 mast cell clusters in 6 membranes. A majority of clusters were located in the anterior, superior quadrant and contained from 3 to 23 cells. The mast cells resided immediately under the inner epithelial lining or in the intermediate, fibrous layer. In two membranes mast cell clusters were found in the margin of apparently healed spontaneous perforations. We conclude that mast cells in some cases infiltrate pars tensa membranae tympani in the late and receding phase of acute otitis media. As these cell clusters in some cases were found immediately around apparently healed membrane perforations, we propose that the mast cell might participate in the repair processes of tympanic membrane perforation healing. This is supported by recent studies in wound healing and functions of a number of mast cell mediators.

The tympanic membrane (TM) in adult rats was surgically exposed and laser interferometry was used to measure TM velocity at the umbo for frequencies between 1.0 and 40.0 kHz. Velocity measures were obtained for five conditions : TM intact, and four progressively larger holes cut into the posterior region of the membrane. Photomicrographs of each condition were used to calculate the percentage of pars tensa lost to the perforation. The relation between TM velocity and stimulus sound pressure level (SPL) was also examined for each of the conditions. The results revealed a systematic loss in low-frequency velocity as perforation size increased. These observations were consistent with clinical reports of low-frequency hearing loss in the perforated human TM. The rat appears to be a successful model for studying this form of conductive pathology.

The fine structures of the tympanic membrane and external auditory canal (EAC) were observed in the mouse under both the light microscope and scanning electron microscope. According to the differences

A study of myringoplasty with temporal fascia homograft employing fibronectin was conducted in 14 ears in which the same myringoplasty procedure without fibronectin (1-5 times) had failed to afford closure of tympanic membrane perforation. Closure was obtained in eight ears. These results suggest that fibronectin is effective in myringoplasty using treated temporal fascia homograft.

Morphology of the tympanic membrane (TM) and external auditory canal (EAC) was studied in healthy, intact rat ears. TM-perforated ears (3 days after making the perforation) and TM-perforation-healed ears (14, 28 and 42 days after making the perforation). In intact ears, the epidermis in the annular region of the EAC displayed a characteristic appearance with cytoplasmic protrusions. We termed these protrusions as "finger-like projections". In contrast to the rat, the annular region of the EAC in the guinea-pig did not show "finger-like projections". Following a perforation in the centre of the anterior or the posterior quadrant of the pars tensa in rats the "finger-like projections" disappeared from the annular region on the perforated side of the EAC, while the projections remained on the malleus side of the perforation edge. In perforation-healed ears analysed 42 days after the perforation, the "finger-like projections" had recurred in the annular region on the perforated side of the EAC. The "finger-like projections" are likely to express maturation (keratinization) and desquamation of epidermal cells in the pars tensa and also could constitute morphological evidence of their migration on the TM.

Chronic tympanic membrane (TM) perforation is a common problem worldwide. Recent reports have shown epidermal growth factor (EGF) to stimulate healing in approximately 80% of chronic TM perforations in chinchillas when applied in three doses over 1 week. The objective of this controlled study is to evaluate the efficacy of long-term EGF in the closure of TM perforations. Chronic chinchilla TM perforations were treated with EGF for up to 6 weeks. One hundred percent (17 of 17) of treatment group perforations completely healed. However, two new findings with this long dosing scheme were reperforation on long-term follow-up and three TMs with cholesteatomas. It is likely that reperforation was due to a progressive thinning seen with prolonged EGF application. Long-term EGF use is not recommended for the treatment of TM perforations because of possible wound healing impairment and possible cholesteatoma induction.

Rupture of the tympanic membrane (TM) during ear irrigation is a rare but unhappy event. In this study the maximum overpressures obtained in the deep part of the external auditory meatus (EAM) during ear irrigation were measured postmortem in 20 cadavers. The highest pressures were obtained in normal- or wide-dimension EAMs when a metal syringe was used. With this device the median maximum overpressure was 240 mmHg (range 200–300 mmHg). Experiments with simulation of an obturating wax plug did not increase the maximum overpressure. Compared with the lowest overpressures which can rupture TMs the pressures measured in this study were insufficient to rupture normal TMs but sufficient to rupture atrophic TMs with the lowest tensile strength. This finding may have medicolegal implications.

Thirty consecutive patients with permanent perforations of their tympanic membranes (TM) present from 2.5 to 50 years (mean 18.7 years) were admitted to a prospective study using two alternative methods of dressings for closure of the perforations. An adhesive-coated hydrocolloid material was compared with a conventional dressing of vaseline impregnated rice paper patch after de-epithelialization of the perforation border. Nine of the permanent TM perforations (30 per cent), five with the hydrocolloidal dressing and four with the rice paper patch had healed when followed-up after one year. The size of eight of the central perforations that had healed was equal to or less than 25 per cent of the TM. Also one perforation with a size of 65 per cent had healed. Seven perforations were located in the posterior part of the TM:Jour in the posterior-superior quadrant, one in the inferior quadrant, one had engulfed the posterior half of the TM and one included the anterior-inferior quadrant. Only two perforations out of 14, with a size of 25 per cent or less, located in the anterior-inferior quadrant, healed. No significant difference was demonstrated between the two types of dressings. Both groups noted an immediate improvement in hearing of 10.8 and 9.3 dB, respectively, after application of the dressing.The study demonstrates that application of an occlusive dressing or paper patch in 30 per cent of patients can promote the healing of long-standing perforations. The chances for healing are better if the perforation is located in the posterior part of the TM. This simple technique immediately improved hearing and should be tried before a patient is referred for myringoplasty surgery.

Purpose: Inflammation and connective tissue hyperplasia are believed to be important etiological factors in cholesteatoma pathogenesis. Previous work has shown that topically applied hyaluronic acid can reduce connective tissue proliferation in healing wounds and accelerate healing of tympanic membrane perforations. This study was undertaken to determine whether the antiproliferative effect of hyaluronic acid may inhibit propylene glycol-induced cholesteatoma in an animal model. Materials and Methods: A 60% propylene glycol solution was injected bilaterally into the middle ear cavities of 20 adult chinchillas. The control group (N = 10) received propylene glycol alone. In addition to propylene glycol injections, the experimental group (N = 10) received repeated bilateral topical applications of 1.5% hyaluronic acid onto the tympanic membranes. Animals were killed at 4 weeks for gross and light microscopic examination. Results: Seven control and 10 experimental animals survived the full l-month study period. At the end of that time, cholesteatoma was found in 71% (10114) of control ears and 70% (14/20) of experimental ears. Tympanic membrane structure did not differ significantly between groups by light microscopy and, in all animals, cholesteatomas originated by migration of hyperplastic epidermis through the tympanic membrane, as has been observed in previous studies using this animal model. Conclusion: Under the conditions of this study, topical hyaluronic acid had no significant effect on cholesteatoma formation. Copyright 0 1995 by W.B. Saunders Company

The purpose of this study was to elucidate possible relationships between the oxygen concentration of the middle ear cavity and the development of myringosclerosis. Three groups of rats with myringotomized tympanic membranes were exposed to different oxygen concentrations of 10%, 15%, and 40%, respectively, for 1 week. A fourth group was kept in ambient air. Two other groups of rats with myringotomized and intubated tympanic membranes were exposed to oxygen concentrations of 10% and 40%, respectively, for the same period of time. Otomicroscopically, all hyperoxic animals had more numerous myringosclerotic lesions compared with the ambient air group, and also displayed a pronounced hyperplasia of the keratinizing epithelium around the perforation border. By contrast, the hypoxic animals showed less pronounced myringosclerotic lesions or even completely lacked them. It is inferred that an increased oxygen concentration in the middle ear cavity will increase the likelihood of myringosclerotic deposits. The mechanism involved could be related to the formation of oxygen radicals.

A comprehensive otolaryngologic examination, including otomicroscopy, was performed for 687 school children for morphologically to study the distribution of normal and abnormal tympanic membrane findings and the association of different factors with the abnormal TM finding in 6 to 15-year-old children. Two-thirds of the children had completely healthy tympanic membranes without any visible pathological change. The findings were more often normal the older the child. In the total population, individual tympanic membrane findings were normal as follows: color 90.7%, position 93.8%, mobility 93.7%, structure 91.8% and position of pars flaccida 88.5%. Contrary to normal findings, tympanic membrane abnormalities were not in general associated with each other. The study provides new information on the occurrence of tympanic membrane changes among school-aged children.

High jugular bulb is a vascular anomaly seen in the middle ear. In typical cases, the jugular bulb is easily observed through the tympanic membrane. We report here 3 patients with nontypical high jugular bulb. Their tympanic membranes were almost normal but protruded externally with pulsation when their necks were compressed. Computed tomography (CT) revealed jugular bulb protrusion into the tympanic cavities. We propose that this condition be named 'latent high jugular bulb'. Neck compression easily detects this condition and may also be useful in the detection of other disorders of the middle ear that are related to the venous system.

The tympanic membrane displacement technique (TMD) is aimed at evaluating intracochlear and intracranial pressure changes non-invasively. Therefore, the present paper describes the findings in patients with Meniere's disease where an increase in volume of the endolymphatic spaces is discussed. It should be investigated to which extent a change in the intracochlear pressure corresponds to different stages of the disease. It could be described that the intracochlear pressure does change over a certain period of persisting Meniere's, but that there is no extensive increase in intracochlear pressure between the attacks. The glycerol test as well as the acute attack (case report on one patient) are, however, characterised by distinct patterns. The same holds true for the late-stage Meniere's. It could be demonstrated that the functional patency of the cochlear aquaeduct in patients with long-term Meniere's history is reduced. This finding is surprising and should be investigated further. In essence, the TMD technique enables to better characterise Meniere patients, but it should not be a tool of routine diagnosis of the disease. In some audiological patients, it can also be beneficially applied (10).

Glomus tumours are the most common primary neoplasms of the middle ear, typically benign and slowly progressive. Pulsatile tinnitus and ipsilateral hearing loss are the most common symptoms at presentation by far; otalgia, aural fullness and otorrhoea being less frequent. A case of primary glomus tympanicum presenting with recurrent epistaxis, previously unreported in the literature, is described and associated imaging presented.

Objective: 1) To evaluate the relationship between cholesteatoma and the degree of mastoid pneumatization. 2) To assess the relationship between the location of cholesteatoma and mastoid pneumatization.Method: A prospective analysis on all patients undergoing mastoid exploration for cholesteatoma during 1993-2011 was performed. The degree of mastoid pneumatization and the site of cholesteatoma were recorded. All patients were operated on and graded by the same surgeon. Revision surgery and atticotomy, where pneumatization could not be assessed, were excluded.Results: A total of 393 (222: male, 171: female) patients underwent surgery for cholesteatoma; 203 were left sided, and 190 were right sided. The mean age of the patients was 37 years (range 6-79). Pneumatization of the mastoid was: sclerotic 23% (90), diploic 16.7% (66), and cellular 60.3% (237, P < .001), respectively. Attico-antral cholesteatoma was present in 88.9% sclerotic, 95.4% diploic, and 91.1% cellular mastoids. Middle ear (ie, sinus tympan...

Purpose: Basic fibroblast growth factor (bFGF) is mitogenic for the cell types that constitute the tympanic membrane and has been shown to potentiate tympanic membrane healing. The purpose of this study is to investigate the direct effect of bFGF application on normal tympanic membrane. Materials and Methods: bFGF was applied to the normal tympanic membrane of 10 guinea pigs via either the external auditory external canal or the middle ear. The drug (400 ng) was delivered on days 0, 1, and 2. The contralateral ear was used as a control. The effects were assessed on day 3. Results: The cumulative area and the average area of blood vessel in each session of TM was greater after bFGF application than placebo. The number of vessels remained unchanged. A proliferation of keratinocytes was observed. Conclusion: These results suggest that bFGF induces a vasodilatation in the tympanic membrane thereby increasing blood supply. This might explain the acceleration of healing of TM perforations after bFGF application.

Clinical studies have supported a relationship between otitis media with effusion in children and chronic otitis media in adults. Although clinical studies are numerous, relatively little is known about the histopathologic changes of the tympanic membrane in otitis media with effusion. Tympanic membranes were taken from the intermediate zone of the anteroinferior quadrant of the tympanic membrane during surgery for placement of tympanostomy tubes in 30 children (age range, 4 to 10 years) who did not show any improvement after 3 months of conservative treatment for otitis media with effusion. Control specimens were taken from normal temporal bones at autopsy. All specimens were observed with light and electron microscopy. Histologic degeneration of the tympanic membrane of patients with otitis media with effusion occurred most often in the lamina propria and the submucosal layer. There was an increase in the thickness of the tympanic membrane as a result of edema and fibrosis of the submucosal layer. A decrease in the thickness of the outer and inner fibrous layers occurred in the lamina propria. The histopathologic changes observed in the lamina propria may result in a change in the elastic properties of the tympanic membrane. (Arch Otolaryngol Head Neck Surg. 1994;120:815-819)

Objective: To identify factors affecting the surgical success rate and reperforation rate in type 1 tympanoplasty. Controversy continues regarding the advisability of this procedure in young children, largely because of the likelihood of recurrent middle ear disease and eustachian tube dysfunction. Design: Retrospective medical record review of a case series. Setting: Pediatric hospital that serves both as a primary care and referral center. Patients: All private patients younger than 18 years, undergoing type 1 tympanoplasty from 1985 through 1989, for whom at least 6 months' follow-up was available. Two hundred nine tympanoplasties on 183 patients were included; 22 patients were excluded for insufficient follow-up. Main Outcome Measures: Surgical success was defined by confirmation of an intact tympanic membrane at least 6 months postoperatively. Procedures were deemed long-term successes if the tympanic membrane remained free of perforation to the end of follow-up. Results: The overall short-term surgical success rate was 92%, with 87% of ears remaining free of reperforation to the end of follow-up. If the perforation involved the margin, the surgical success and long-term success rates dropped to 86% and 77%, respectively. Although reperforation was more likely in patients younger than 6 years or in those with contralateral otitis media at surgery, even these groups had long-term success rates of 81% and 74%, respectively. Conclusions: Tympanoplasty may be considered at any age. Even in young children, there is a high likelihood of return to normal function. (Arch Otolaryngol Head Neck Surg. 1994;120:487-490)

An otitis media with effusion algorithm developed by Paradise et al has become the basis for many studies of otitis media. However, it has been shown to be too ambitious (low specificity) and too optimistic (absence of fluid does not necessarily mean normal ears). We developed a four-point profile to characterize the condition of the middle ear, but it cannot be used when the eardrum is perforated (with a functioning tube or chronic perforation). We propose a three-point profile for use without an intact tympanic membrane, and we report the validation of the profile by findings at myringotomy and by the preoperative profile. This postoperative profile and the previously described profile for ears with an intact tympanic membrane should increase the accuracy of middle ear assessment in following the course of otitis media over time. (Arch Otolaryngol Head Neck Surg. 1994;120:513-516)

The effects of aging on the preoperative and postoperative hearing results of tympanoplasty were assessed in 642 patients with chronic suppurative otitis media (COM) or cholesteatoma (CHL). Analysis focused on the correlation between hearing results and age for each disease and type of tympanoplasty. Data were evaluated by calculating the regression line, mainly using second order polynomial regression analysis. Averaged air and bone conduction thresholds (PTA) in patients were appreciably poorer in younger patients and increased with age, compared with physiological hearing impairment in old age (presbyacusis). Regression lines for PTA of air and bone conduction in patients and for normal data (air conduction) separated from each other after the age of 30 and hearing impairment gradually accelerated with age. Means of air-borne gap, however, were almost the same in each age group, though hearing thresholds in individual patients were distributed widely. This was more dominant in patients who had undergone type III or IV tympanoplasty than those with type I tympanoplasty, and in patients with COM than with CHL. Labyrinthine function thus appears to be gradually aggravated with age in patients with chronic inflammatory ear disease. Patients with chronic otitis media should be thus recommended to undergo tympanoplasty at an early age.

Normal ears and ears affected by various pathologies were studied with a clinical middle-ear analyzer according to the multifrequency tympanometric concept, by which the resonance frequency of the tympanic membrane/middle-ear system can be determined. This frequency varies considerably in normal ears with a mean value close to 1 kHz. Ears with pathologies in the tympanic membrane and otosclerotic ears have resonance frequencies differing significantly from those of normal ears. The effects may be explained by considering mass and stiffness components.

A 73-year-old patient was addressed to our department of medical imaging for combined CT imaging of the head and petrous bone. The patient had fallen from his height on his mandibula and reported pain in the area of the left temporo mandibular joint. The pain was associated by external otorrhagia. At physical otoscopic exam there was some narrowing of the external auditory canal in which blood was visible. Neurootologic symptoms were absent.

Régulièrement mentionnées dans les publications relatives au tympan du portail occidental de la cathédrale Saint-Lazare d’Autun, les inscriptions qui y figurent semblent a priori bien connues. Les travaux de restauration effectués en 2009 ont permis de les examiner de près et d’en réaliser une couverture photographique, ce qui a fait apparaître quelques éléments épigraphiques nouveaux. Mais nous avons aussi constaté avec surprise, à l’examen d’une bibliographie plutôt abondante, que le texte n’avait jamais fait l’objet d’une étude complète – contrairement au tympan de Sainte-Foy de Conques. Notre travail vise donc à en proposer une première analyse systématique ; il mériterait toutefois d’être poursuivi sur deux points au moins : les rapports entre texte et images et la comparaison avec le tympan de Conques – qui partage avec celui d’Autun la particularité d’être le principal tympan roman consacré au Jugement dernier et qui comporte également un riche ensemble épigraphique.

We studied the postnatal development of the middle ear (ME) in New Zealand White rabbits. Bullae were scanned using a desktop X-ray microtomograph and 3D models of the ME ossicles as well as the tympanic ring (TR) were prepared. In 0, 1, 2 days old rabbits the ossification process was incomplete. We can therefore present quantitative data obtained from older rabbits (ages: 4–180 days) and a qualitative description at the earlier ages. For a number of the measured parameters an exponential curve could be fitted to the data, and the time constant (at which 63% of the final value was obtained) was calculated. The length of the manubrium increased rapidly in a period of about 15 postnatal days, from 1.73 mm to 4.08 mm. The distance between the tip of the malleus and the TR increased rapidly until day 30, from nearly 0 to 1.40 mm. The increase of the surface area within the TR was small as compared to inter-specimen variance, but the ratio [tympanic membrane area]/[TR area] clearly increased (from 1.00 to 1.11), with a time constant of 8.3 days. The area of the stapes footplate (FP) increased rapidly in about 15 days (from 0.72 mm2 to 1.49 mm2, time constant 4.8 days). The TR was nearly developed at birth whereas the stapes footplate was quite underdeveloped. The distance between the tip of the malleus and the incudomallear rotation axis increased rapidly until day 20 and varied between 3.47 mm and 5.00 mm. The distance between the tip of the incus and the rotation axis increased until day 133, from 1.39 mm to 1.69 mm. Our study shows that in rabbits the ME is underdeveloped at birth and that the functional geometry develops over the same time course as the ability to hear. The conical shape of the tympanic membrane (TM) is formed by retraction and growth of the manubrium, mainly during the first 40 days after birth.

The effects of keeping rat tympanic membranes with an artificially made pars tensa perforation in tissue culture were observed under a scanning electron microscope. After one day and onwards, spreading and thickening of the keratinizing, outer squamous epithelium (OE) was noted. In addition, ballooning of the innermost cells of the outer epithelium apposing the inner tympanic epithelium (IE) was seen. No appreciable reaction was noted in the connective tissue layer of the drum. The inner tympanic epithelium appeared to be swollen, containing spherical structures in the cytoplasm, especially close to the area of contact with the outer meatal epithelium. No complete cover of the drum defect was seen after 14 days of tissue culture. Hyperplasia and spreading of the keratinizing, outer squamous epithelium of the drum is not sufficient to achieve covering of a drum perforation and complete healing cannot take place unless supported by granulation tissue formation.

This study aims to elucidate the morphological difference between the noncollapsible physiologic tympanic membrane (TM) and the collapsible atelectatic TM. Histologic examination of atelectatic TMs obtained at surgery from 16 ears revealed inflammatory changes and destruction of the pars tensa collagenous “backbone.” The disappearance of the organized collagenous layer seen in atelectatic TMs explains their conversion from the stiff physiologic membrane to a flexible one. This in turn will convert the middle ear from a noncollapsible gas pocket to a partially collapsible gas pocket, in which minimal pressure of only a few millimeters of water can cause retraction or ballooning of the atrophic TM. These pressure differences are too small to equilibrate automatically the difference created with the atmospheric pressure. Integrity of the pars tensa collagenous layer thus appears to be essential for the proper mechanical functioning of the physiologic TM.

Purpose: The development of the umbo response in the gerbil was studied in order to further elucidate the contribution of the middle ear to the development of auditory function. Materials and Methods: Laser interferometry was used to study the development of umbo velocity in Mongolian gerbils between 10 days after birth and maturity. Results: Before 15 days after birth, immaturities in the middle ear prevented any reliable measures of middle-ear motion. However, between 15 and 20 days after birth, a 10 dB improvement in umbo velocity was noted in the low-frequency (0.5 to 2.0 kHz) region of the umbo response. This improvement in sensitivity was correlated to an increased admittance due to an expanding bulla volume. Interestingly, umbo velocity remained relatively constant in the mid- and high-frequency regions of the response curve between 15 and 42 days after birth. The umbo response in the adult gerbil was decidedly different when compared with the response at 42 days after birth. Conclusion: We speculate that a decrease in bulla volume along with increased ossicular mass contributed to the changes in the adult umbo response. When the maturation of the umbo response was compared with more central ontogenetic measures, it became apparent that structures more central to the middle ear continued to develop well past the time the middle ear was structurally and functionally mature.

The influence of topical anaesthesia of the tympanic membrane on Eustachian tube function was investigated using the pressure chamber impedance method, thus obtaining quantitative data. Anaesthesia was performed by application to the tympanic membrane of small cotton balls containing lidocaine and dimethylsulfoxide. We did not observe significant alterations of tubal parameters after unilateral or bilateral anaesthesia. Our observations are in contrast to investigations published by Nagai. We suppose that differences in methods of topical anaesthesia are responsible for this discrepancy. Our technique of topical anaesthesia of the tympanic membrane excludes any effect on the Eustachian tube, thereby avoiding negative consequences of middle ear pressure on wound healing.

The size of the overpressure in the ear canal which causes rupture of the tympanic membrane (TM) in man (rupture pressure, RP) was determined in 90 subjects 7-112 h post mortem in connection with the autopsy. The equipment allowed an overpressure in the ear canal to be applied either gradually or suddenly. In 144 normal TMs it was demonstrated that the tensile strength of the TM increases post mortem. Corrected to the time 0 post mortem, RP of normal TMs ranged 0.5-2.1 kp/cm2, median 1.2 kp/cm2. It was found to be correlated to the age of the patient, i.e. RP decreased with increasing age. No correlation was found between RP and the application speed of the overpressure. Ninety-nine percent of the ruptures were localized to the pars tensa (63% to the anterior part of this structure) and typically had the shape of a minor tear. The RP of 23 TMs with atrophic scars was significantly lower, 0.3-0.8 kp/cm2, and the rupture typically had the shape of a larger defect. The results of this study indicate large intersubject variability of the tensile strength of the human TM. Some individuals are at increased risk of TM rupture at minor overpressures in the ear canal (e.g. during certain watersports, such as diving) which may carry medicolegal implications.

Objectives/Hypothesis To study the efficacy and safety of topical tetracaine anesthesia for office myringotomy and myringotomy with a tube. Study Design Retrospective review of patients undergoing office myringotomy, with or without tube insertion, performed over a 4-year period. Methods A topical solution of 8% tetracaine base in 70% isopropyl alcohol was used in 381 ears. Five to 10 drops of the solution were applied to the tympanic membrane for 10 to 15 minutes and aspirated. Myringotomy was performed either with a myringotomy knife or with a CO2 laser (OtoLAM). Results Topical tetracaine was used in all 231 ears (100%) undergoing myringotomy without a tube and 150 of 212 ears (71%) undergoing myringotomy with a tube. Tetracaine alone was effective in providing tympanic membrane anesthesia in 95% of myringotomy without a tube (220 ears) and in 93% of myringotomy with a tube (139 ears). There were six complications, including five cases of severe vertigo and one unusual prolonged, transient facial nerve weakness. Conclusion Topical tetracaine is efficacious and safe for use in office myringotomy.

Several theories have been proposed with respect to the origin and pathogenesis of cholesteatoma behind an intact tympanic membrane.The authors describe a case of cholesteatoma behind an intact tympanic membrane in a 71-year-old man with a history of tympanic membrane retraction fixed to the incus without evidence of a perforation. The membrane eventually became detached, and remnants of keratinizing squamous epithelium were found on the incus.Mechanisms such as metaplasia, ectopic epidermis rests, or ingrowth of meatal epidermis have been proposed to explain the pathogenesis of cholesteatoma behind an intact tympanic membrane. These findings, based on temporal bone histopathology, support the role of an acquired epidermal rest.This case report provides evidence that cholesteatoma behind an intact tympanic membrane can be established from a resolved retraction of the pars tensa of the tympanic membrane.

Objective:The authors present an extremely rare case of carcinoma of the tympanic membrane.Method:A case report and review of the literature concerning carcinoma of the tympanic membrane and temporal bone are presented and discussed.Results:The authors present a patient with recurrent otorrhoea and an abnormal tympanic membrane. Biopsy was inconclusive, but resection demonstrated squamous cell carcinoma of the tympanic membrane. We also discuss the investigation, diagnosis, natural history and management of this rare condition, as well as the staging and management of tumours of the temporal bone and the differences between these closely related but prognostically different entities.Conclusion:This rare entity can be managed by primary surgical resection if there is no evidence of metastasis.

The objective of the study was to assess the functional results after type I tympanoplasty with temporal muscle fascia, perichondrium/cartilage island and cartilage palisades. The records of 120 patients who underwent type I tympanoplasty operation between January 2003 and June 2007 were retrospectively reviewed. This study aimed to comprise a homogeneous group of patients to make the comparisons as accurate as possible. For this purpose, primary tympanoplasty cases with subtotal perforations, intact ossicular chain, dry ear for a period of at least 1 month, and normal middle ear mucosa were included in the study. Patients younger than 15 years of age and patients with cholesteatoma were excluded. Temporal muscle fascia was used in 67 (55.8%), perichondrium/cartilage island flap was used in 34 (28.3%), and cartilage palisades were used in 19 (15.8%) of the patients. Pre- and postoperative otoscopic examinations, pure-tone averages, and air-bone gaps were compared pre and postoperatively. Concerning all of the cases, the graft take rate was 85% (102/120). In the perichondrium/cartilage island flap group, the graft take rate was 97.7%, whereas the graft take rates for the fascia group and cartilage palisades group were 80.6 and 79.0%, respectively. In the perichondrium/cartilage island flap group, the pure-tone average was 36.36 dB, whereas the pure-tone averages for the fascia group and cartilage palisades group were 36.07 and 39.79 dB, preoperatively. The postoperative pure-tone averages were 24.54 dB fort he perichondrium/cartilage island flap group, 24.51 dB for the fascia group and 23.23 dB for the cartilage palisades group. Cartilage grafting is not only more enduring against infection and negative middle ear pressure but also it has low re-perforation rates on long-term follow-up. Thus, cartilage may be preferred more often for primary tympanoplasties with high graft rate and hearing improvement.

Objective:This study aimed to evaluate the anatomical and audiological outcomes of primary type one tympanoplasty performed with a modified cartilage–perichondrium composite ‘ring’ graft, and to compare them with results for primary type one tympanoplasty performed with temporalis fascia, in children.Study design:Retrospective clinical study.Setting:Otolaryngology department, Tanta University Hospital, Egypt.Patients and methods:Records were evaluated for 82 children with dry tympanic membrane perforation (any size) and intact ossicular chain, and with no history of previous ear surgery except for tympanostomy. Patients of similar age and middle-ear pathology were selected to make the two groups as homogeneous as possible. An underlay type one tympanoplasty, using either a ring graft or temporalis fascia, was performed: 40 children were included in the ring graft group and 42 in the temporalis fascia group. All procedures were performed by the same surgeon. A successful anatomical outcome was considered to comprise full, intact healing of the graft without perforation, retraction, lateralisation or blunting, for at least one year post-operatively. Patients' post-operative pure tone average air–bone gap and speech reception threshold were compared with pre-operative levels, within and between the two groups.Results:Type one tympanoplasty using a ring graft technique resulted in a significantly greater graft acceptance rate (95 per cent) compared with the temporalis fascia technique (76.2 per cent;p p p > 0.05), although there was a trend towards better post-operative results in the ring group.Conclusion:In our paediatric patients, type one tympanoplasty with a modified cartilage–perichondrium composite ring graft yielded good anatomical and functional results. The anatomical results obtained using this graft (with its unique appearance and stability during and after surgery) were superior to those for temporalis fascia. The ring graft group had equivalent, if not better, post-operative audiometric results, compared with the temporalis fascia group. Thus, the ring graft is believed to be effective in enabling both tympanic membrane closure and rapid hearing improvement, in the paediatric population.

Objective:To explore the feasibility of a novel surgical management technique for severe, chronic granular myringitis with diffuse granulation tissue over the tympanic membrane, with or without involvement of the external auditory canal.Study design:This was a retrospective design.Method:A surgical technique combining tympanic epithelial avulsion with overlay myringoplasty was used to treat 21 severe cases.Results:All 21 cases were cured after one operation. Three months after surgery, patients' tympanic membranes had returned to normal, and their air–bone gaps were less than 10 dB.Conclusion:This new surgical procedure represents improved treatment for severe, chronic granular myringitis.

Objective: To locate fibroblast growth factor receptor (FGFRs) 1–4 in human chronic tympanic membrane (TM) perforation. Methods: A sample of human chronic TM perforation was harvested during myringoplasty. The sample was immediately fixed in 4% paraformaldehyde and embedded in OCT compound. Immunohistochemistry was performed with FGFR 1–4 polyclonal antibodies. Results: FGFRs 1–4 were strongly and weakly expressed in the epidermal and mucosal layer of the TM perforation, respectively. Conclusions: As it is impossible to perform quantitative analysis based on the fluorescence intensity of each immunoreactivity, the presence of FGFRs 1–4 in the human chronic TM perforation is shown. The expressions of FGFRs 1–4 indicated that the clinical use of bFGF agent is useful for myringoplasty.

• The epidemiological nature of acquired cholesteatoma in children has shown that it occurs more often in the posterosuperior quadrant of the pars tensa and in the pars flaccida. This type of cholesteatoma is rarely seen before the age of 3 years, and serous otitis media is the most important risk factor for its occurrence. In an attempt to present a pathological rationale for these clinical findings, tympanic membranes from 11 temporal bones with purulent otitis media and 13 with serous otitis media were evaluated light microscopically and compared with 14 temporal bones without disease. Ages ranged from newborn to 3 years 6 months. The persistence of mesenchyme and greater inflammatory reaction observed in the pars flaccida and the posterosuperior quadrant of the pars tensa and changes in collagen and elastin observed in purulent otitis media and serous otitis media may represent a pathological rationale for the epidemiological nature of cholesteatoma in children. ( Arch Otolaryngol Head Neck Surg . 1992;118:1298-1305)

Results of a series of 228 spontaneous retraction pockets in chronic otitis media are reported and a classification is proposed. Under medical therapy, 78 retraction pockets of stage I and II (out of 95) were followed for five years. Sixteen percent deteriorated into stage III and were operated on; the others stabilized or improved towards normal tympanic membrane (23%). Different methods of surgical therapy were used in 150 retraction pockets (all the stages III and many stages II). Even with silastic sheeting and strengthening of the tympanic membrane, a recurrent retraction pocket was observed in 24 cases (16%). Functional results were obviously better when the ossicular chain was rebuilt from an intact malleus to an intact stapes and either from an intact malleus to a mobile footplate or from the tympanic membrane to an intact stapes. Surgery of retraction pockets must be used not only to prevent cholesteatoma formation but also to prevent erosion of the stapes.

Because of the difficulties in studying the mechanical properties of the human tympanic membrane in situ, structural data from the cadaveric tympanic membrane samples is used for simulation of the surface structure of the tympanic membrane with the help of a computer. The hitherto poorly understood contour of the tympanic membrane is available for the development of a tympanic membrane and middle ear model.

The ontogeny of various middle-ear structures was examined in 11 groups of chicks between 10 days embryonic and adult. Measurements of the tympanic membrane surface area and height, columella length, and that of the columella footplate, annular ligament, and oval window area were obtained using video micrographs and computer digitization techniques. The oval window matures first at 53 days post-hatching, whereas the columella achieves adult size at 74 days. The tympanic membrane surface area is the last middle-ear variable studied to reach adult size (79 days post-hatch). The columella increases its length from 0.63 mm (10 days embryonic) to 2.73 mm in the adult. The tympanic membrane area expands by 280% whereas the columellar footplate area increases by 11x. As a result, the pressure amplification of the middle ear due to the tympanic membrane/columellar footplate area ratio improves by over 400%. These data further contribute to our understanding of the functional development of the middle ear.

Objectives We sought to compare the long-term functional results of tympanic membrane reconstruction with temporalis fascia and cartilage shield grafting. Methods This study includes 113 patients who had tympanoplasty type I tympanic membrane reconstruction between 1997 and 2007, 47 with tragal cartilage and 66 with temporalis fascia. Fourteen patients in the cartilage group and 9 patients in the temporalis fascia group also had mastoidectomy. The average follow-up was 3.2 years. The hearing threshold was calculated as the mean value of the thresholds for 500, 1,000, 2,000, and 3,000 Hz. A paired-samples t-est was used for comparison of the preoperative and postoperative air and bone conduction hearing thresholds and air-bone gaps. Results Significant recovery was found in the postoperative air conduction threshold and air-bone gap in both the temporalis fascia and cartilage groups as compared to those before surgery (p < 0.001). However, the average air and bone conduction thresholds and air-bone gap were found to be statistically different after surgery in the cartilage group as compared to those in the temporalis fascia group. There was no significant difference in hearing parameters before and after surgery in patients with or without mastoidectomy in either the cartilage group or the temporalis fascia group. Conclusions The hearing gain in patients with cartilage shield grafting was better than that in those who had temporalis fascia tympanoplasty, although experimental analysis shows loss of acoustic energy for thick and large shield cartilage grafts.

Objectives:We evaluated the results of mobile, one stage, bilateral ear surgery conducted in Greenland, where chronic otitis media with and without suppuration is prevalent. The study aimed to increase the number of operations conducted and to reduce the cost of ear surgery in remote areas.Materials and methods:The study was longitudinal and prospective, with a two-year follow up. Seventeen East Greenlandic patients with bilateral chronic suppurative otitis media or chronic otitis media were selected. Their median age was 16 years; 53 per cent were female and 47 per cent male. Hearing was assessed using median air conduction pure tone average gain, and the ‘take rate’ (i.e. the percentage of total ears with a closed perforation) was evaluated.Results:All patients attended for follow up. Eighty-two per cent had at least one perforation closed, and the overall take rate was 65 per cent of the 34 ears. The median air conduction pure tone average gain after two years was 18 dB and 13 dB for the right and left ears, respectively. Fourteen patients (82 per cent) obtained an air conduction pure tone average hearing level of ≤25 dB in at least one ear. In total, 71 per cent of the patients were satisfied. There were no hearing hazards.Conclusions:The results of mobile, one stage, bilateral ear surgery conducted in Greenland for long-lasting chronic suppurative otitis media and chronic otitis media were acceptable and safe, and more ears underwent surgery at reduced cost compared with unilateral ear surgery.

The sinus tympani in the middle ear have been the focus of clinical interest because of its tendency to be invaded by a cholesteatoma. Due to its visual obscurity, and the lack of a straightforward surgical approach, it can be diYcult to address [1]. Most residual cholesteatoma present in the sinus tympani [2]. It can be visualised by intra tympanic mirrors, Oto-endoscopes, or with techniques like, removal of the lateral lip of bone and tilting the patient’s head and/or microscope. Removal of the disease from sinus tympani is also inXuenced by surgical approaches, which include the anterior to posterior and the retro facial approach [3]. While using the intra tympanic mirror to visualise the sinus tympani, the mirror tends to fogs up. To prevent this from occurring, anti-fogging solutions or warming up the mirror are techniques that are readily used. We describe the following simple method to prevent fogging. A microsuction tip could be kept intermittently 2–3 mm away from the mirror. The turbulence of the air Xow generated by the suction would prevent the fogging. Microsuction is readily available on the operating table (Fig. 1). References

Objectives: To determine the differences between tympanic and extratympanic electrodes regarding recording technique, comfort and ease of execution of the exam, and quality of auditory potential tracings. Study Design: Prospective cross-section investigation. Methods: Determination of the summation potential/action potential (SP/AP) ratio by electrocochleography (EchoG) using tympanic and extratympanic electrodes and separate analysis of SP and AP regarding the amplitude recorded. Results: Twenty-three subjects (15 men and 8 women; mean age: 33.17 years) with normal tonal threshold audiometry were evaluated. EchoG analysis revealed no significant difference between the two tympanic electrodes. Eleven of the 23 subjects reported discomfort with the insertion of the tympanic electrode even with the use of topical xylocaine, whereas no complaints of discomfort were reported with the use of the extratympanic electrode. Conclusions: Both electrodes were effective for EchoG evaluation, but the extratympanic one was easier to insert and did not cause discomfort. However, the tympanic electrode produced tracings of greater amplitude and of better reproducibility. Laryngoscope, 119:563–566, 2009

Background:Congenital cholesteatoma occurring behind the tympanic membrane is typically located in the anterior middle ear.Objective:To investigate the location, clinical features and treatment of cholesteatomas located behind an intact tympanic membrane in adults.Methods:Review of a series of 265 consecutive, new, adult cases of previously untreated cholesteatoma seen by the author over a 22-year period.Results:Seventeen (6 per cent) cases were located behind an intact tympanic membrane without any evidence of a retraction pocket of the attic or pars tensa. Ten (59 per cent) of these patients had undergone previous ear surgery and therefore the disease could reasonably be considered to be iatrogenic. The most common presentation was conductive deafness with no other symptoms (71 per cent). In all of the cases, the disease was located in the posterior half of the middle-ear space. The most common surgical management was simple excision of the disease via a tympanotomy. Two cases (12 per cent) developed residual disease.Conclusion:The majority of the cases in this series were likely to be acquired cholesteatomas. This type of disease often presents with conductive hearing loss alone.

Conclusion. The endoscopic approach to attic cholesteatoma allows clear observation of the tensor fold area and consequently, excision of the tensor fold, modifying the epitympanic diaphragm. This permits good removal of cholesteatoma and direct ventilation of the upper unit, preventing the development of a retraction pocket or attic cholesteatoma recurrence, with good functional results. Objectives. An isthmus block associated with a complete tensor fold is a necessary condition for creation and development of an attic cholesteatoma. During surgical treatment of attic cholesteatoma, tensor fold removal is required to restore ventilation of the attic region. Use of a microscope does not allow exposure of the tensor fold area and so removal of the tensor fold can be very difficult. In contrast, the endoscope permits better visualization of the tensor fold area, and this aids understanding of the anatomy of the tensor fold and its removal, restoring attic ventilation. Patients and methods. In all, 21 patients with limited attic cholesteatoma underwent an endoscopic approach with complete removal of the disease. Patients with a wide external ear canal were operated through an exclusively endoscopic transcanal approach; patients with a narrow external ear canal or who were affected by external canal exostosis were operated through a traditional retroauricular incision and meatoplasty followed by the endoscopic transcanal approach. Results. In 18/21 patients, the endoscope permitted the discovery of different anatomical morphologies of the tensor fold. Sixteen patients presented a complete tensor fold (one with an anomalous transversal orientation), one patient presented an incomplete tensor fold and one patient presented a bony ridge in the cochleariform region. In all 16 cases of complete tensor tympani fold, the fold was removed and anterior epitympanic ventilation was restored. The ridge bone over the cochleariform process was also removed with a microdrill. © 2009 Informa UK Ltd.