Middle Ear Implants:Historical and futuristic perspective

Technological advancements are continuously changing the paradigm of human existence.Human beings are constantly engaging in various measures to reduce the extent of sensory and motor impairment.This has been in the form of various devices,e.g.orthopedic prosthesis,visual aids (spectacles) and hearing aids.Countless attempts throughout the centuries have been made in an effort to improve sound amplification in patients.This article seeks to highlights the technological journey of one such implant,the middle ear implant,from its inception to the more technological advanced futuristic proposals.While there are many amplification devices available presently,there still remains a group of patients who have not experienced adequate amplification for their hearing loss and this subset may gain the greatest benefit from middle ear implants.

Middle ear osteoma causing Eustachian tube obstruction:A case report and literature review

Middle ear osteoma is an extremely rare benign tumor of the middle ear.Due to its very slow growth rate and benign nature,osteoma of the middle ear can be found incidentally without causing any symptoms.The most common clinical signs are conductive hearing loss,the sense of fullness in the ear,tinnitus,and otorrhea.Small-sized osteomas can be misdiagnosed as otosclerosis without showing any signs other than conductive hearing loss.When the mass becomes very large,and symptoms caused by the tumor increase,treatment also becomes difficult.In this paper,we report a case of middle ear osteoma causing conductive hearing loss and effusion due to the effect of pressure on the middle ear ossicles and the Eustachian tube.We also present a review of the pertinent literature.

A Study on the Instructional Design of Interdisciplinary Thematic Learning in Middle School Physical Education Based on the CASES-T Model

With the deepening of educational reform,interdisciplinary thematic learning,as an emerging educational model,has become a focus of attention in the field of educational research.Based on the STEM(science,technology,engineering,and mathematics)education concept and CASES-T(Content,Activity,Situation,Evaluation,Strategy-Target)model,this study provides a theoretical basis for the teaching design and implementation of interdisciplinary thematic learning in middle school physical education.Through the analysis of specific interdisciplinary thematic learning cases,it aims to provide theoretical support and practical guidance for the reform of middle school physical education through the CASES-T model-based interdisciplinary thematic teaching design research in middle school physical education,in order to enhance students’learning effects,cultivate core literacy in physical education,and promote students’all-round development.

Intra-operative hearing monitoring methods in middle ear surgeries

Hearing loss is a condition affecting millions of people worldwide. Conductive hearing loss(CHL) is mainly caused by middle ear diseases.The low frequency area is the pivotal part of speech frequencies and most frequently impaired in patients with CHL. Among various treatments of CHL, middle ear surgery is efficient to improve hearing. However, variable success rates and possible needs for prolonged revision surgery still frustrate both surgeons and patients. Nowadays, increasing numbers of researchers explore various methods to monitor the efficacy of ossicular reconstruction intraoperatively, including electrocochleography(ECoch G), auditory brainstem response(ABR), auditory steady state response(ASSR), distortion product otoacoustic emissions(DPOAE), subjective whisper test, and optical coherence tomography(OCT). Here,we illustrate several methods used clinically by reviewing the literature.

Tophaceous gout of the middle ear

We present a very rare case of tophaceous gout of the middle ear causing conductive hearing loss,with special emphasis on Computed Tomography presentation.

Hearing loss due to urate deposition in the middle ear:A case report and literature review

Gout is the most common cause of monoarthritis in men occurring classically in the great toe and the knee.Extra-articular gout manifestations are rare.Only a few cases of head and neck urate crystals deposits have been described in the literature.Precipitations in the middle ear cause conductive hearing loss with common otoscopic anomalies and difficult imaging diagnosis.We report a case of a healthy 58-years-old man with a middle ear urate deposit causing a progressive hearing loss as the very first symptom of gout.The nature of the deposit was unsure on computer tomography(CT)due to atypical density.The final diagnosis was revealed after surgical procedure and histologic examination.A review of the literature is also presented.Seven cases of middle ear urate deposit as the first symptom of gout were found and compared.Progressive conductive hearing loss in middle-aged patients with abnormal otoscopy and middle ear atypical density mass on CT scan must lead to a minimal surgical procedure with a histologic examination to exclude urate crystals deposits.

Finite Element Dynamics of Human Ear System Comprising Middle Ear and Cochlea in Inner Ear

A human middle ear consists of an eardrum and three ossicles which are linked by each other, and connect with the eardrum and an inner ear. The inner ear consists of a cochlea and a vestibular system. An abnormality of the human middle ear such as ossicular dislocation may cause conductive hearing loss. The conductive hearing loss is generally treated by surgery using artificial ossicles. The treatments of conductive hearing loss require a better understanding of characteristics and dynamic behaviors of the human middle ear when the sounds transmit from outer inner to inner ear. The purpose of this research is to simulate the dynamic behaviors of a human ear system comprising the middle ear and the cochlea in the inner ear using the finite element method (FEM). Firstly, the eigen-value analysis was performed to obtain the natural frequencies and vibration modes of the total ear system. Secondly, the frequency response analysis was carried out. Thirdly, the time history response analyses were performed using human voices as the external forces. In the time history response analyses, the sounds created as input sound pressures were used. Human voices, for example vowels “I”, “u” and “e” as input sound pressures were created by using the sound pressures downloaded from the opening samples of human voices as wav files in a website. Then it was clarified that the high frequency components of sounds are reduced by the middle ear system.

Endoscopic ear surgery in middle ear cholesteatoma

Objective:Endoscope has been used as diagnostic tool for recidivism and as an adjunct to microscopic technique in the management of cholesteatoma.At present transcanal endoscopic ear surgery(TEES)is being used as a minimally invasive alternative for microscopic approach.We aim to evaluate the feasibility,structural,functional and quality of life outcomes of endoscopic technique in middle ear cholesteatoma.Method:This prospective study was conducted at a tertiary care hospital from January 2017 to January 2018 including 32 adult patients who were treated by TEES for middle ear cholesteatoma.Feasibility of endoscopic technique was assessed by the conversion rates,visualization of middle ear structures and complications.Structural outcomes were evaluated in terms of graft uptake at the third month follow-up and presence of residual or recurrent disease.Functional outcomes were evaluated in terms of postoperative air-bone gap closure at third month follow-up.Patient outcomes in terms of post-operative pain,cosmetic score,day of return to daily activities and patient comfort scores were evaluated.The quality of life outcomes were evaluated using chronic ear survey(CES)and short form questionnaire12 version 2(SF-12V2)which are disease specific and general quality of life assessment tools respectively.Result:Out of 32 patients,endoscopic intact canal wall mastoidectomy was done for 28 and endoscopic canal wall down mastoidectomy in 4 patients.One(3.1%)patient had to be converted to microscopic technique.Median follow-up period was 32.8 months(9e46 months).There were no post-operative complications in any of our patients.The mean middle ear structural visibility index score was 8.4±1.4 with the use of zero-degree endoscope.Graft uptake rate at third month follow-up was 100%.Two(6.3%)patients had recurrent disease at 6 months follow-up and were treated by revision endoscopic surgery.The air conduction(51.3±20.2 dB vs.34.5±20.4 dB,p<0.001),and air-bone gap(33.5±11.1 dB vs.16.9±11.8 dB,p<0.001)has been significantly improved.The mean pain score at 0 hours,6 hours and 24 hours after surgery were 2.5/10,1.6/10 and 0.75/10 respectively.At the discharge,the mean patient comfort score was 9.3±0.6 out of 10.Mean cosmetic score was 9.3±0.5 at the third month follow-up.There was significant post-operative improvement in the sub-scale and total scores of CES and SF-12V2.Conclusion:Endoscopic approach to middle ear cholesteatoma is feasible and confers excellent structural,functional as well as patient related quality of life outcomes.

A Novel Surgery Classification for Endoscopic Approaches to Middle Ear Cholesteatoma

This study aimed to develop a novel surgery classification for an endoscopic approach to middle ear cholesteatoma.We retrospectively analyzed the surgical approaches and outcomes of patients with middle ear cholesteatoma.Middle ear cholesteatoma surgeries were divided into four types and two special types as follows:type I,attic retraction pocket,which only requires tympanostomy tube placement or retraction pocket resection and cartilage reconstruction;typeⅡ,cholesteatoma which is limited to the attic or in which endoscopy can confirm complete removal of mastoid cholesteatoma lesions,including type Ⅱa,requiring only use of a curette,and type Ⅱ b,requiring use of an electric drill or chisel;type Ⅲ,cholesteatoma not limited to the attic,in which endoscopy cannot confirm complete removal of mastoid cholesteatoma lesions,requiring the combined use of endoscope and microscope to perform endoscopic tympanoplasty and"Canal Wall Up"mastoidectomy;type Ⅳ,extensive involvement of mastoid cavity cholesteatoma lesions and/or cases with a potential risk of complications,removal of which can only be performed under a microscope for"Canal Wall Down"mastoidectomy.In addition,there were two special types:"difficult external auditory canal"and congenital cholesteatoma in children.In our system,type I and type U middle ear cholesteatoma surgery was completely performed under an endoscope alone.However,estimating the extent of the lesions,determining the choice of mastoid opening and reestablishing ventilation are the key points for an endoscopic approach to middle ear cholesteatoma.The classification of endoscopic middle ear cholesteatoma surgery may benefit the selection of surgical indications.

Disagreement in middle ear volume estimation between tympanometry and three-dimensional volume reconstruction in the context of tympanic membrane perforation

Introduction: Middle ear volume(MEV) is a clinically relevant parameter across middle ear diseases. MEV values between these techniques have never before been tested for agreement in ears with perforated tympanic membranes(TMs).Methods: Middle ears were identified from 36 patients ranging 18-89 years of age with TM perforations who underwent tympanometry and temporal bone computed tomography(CT) between 2005 and 2015. MEVs calculated by both tympanometry and three-dimensional volume reconstruction(3DVR) were analyzed for agreement using Bland Altman plots. The differences between tympanometric and 3DVR MEV values for each given middle ear were characterized across MEV quartiles(1= smallest; 4= largest) and across increasing states of middle ear disease using Kruskale Wallis and Wilcoxon testing with Bonferroni correction.Results: Bland Altman plots demonstrated significant disagreement between MEV measurement techniques. Differences between tympanometric(T) and 3DVR MEV values were significantly greater with increasing average(i.e.(Tt3DVR)/2)) MEV per linear regression(p < 0.0001). Significance was demonstrated between fourth and first average MEV quartiles(p= 0.0024), fourth and second quartiles(p= 0.0024), third and first quartiles(p= 0.0048), and third and second quartiles(p= 0.048). Absolute MEV difference was not significantly different across varying states of middle ear disease(p= 0.44).Conclusion: Statistically and clinically significant disagreement was demonstrated between tympanometric and 3DVR MEV values. Studies that vary in MEV estimation techniques may be expected to demonstrate significantly different results. These preliminary results suggest that clinicians should endeavor to seek further confirmation when interpreting high tympanometric MEV values.

Classification of facial nerve aberration in congenital malformation of middle ear:Implications for surgery of hearing restoration

Objectives: Facial nerve aberration is the most troublesome situation in congenital malformations of middle ear.The aim of our study is to investigate its imaging and clinical features as well as relevant choice of surgical techniques for hearing improvement.Methods: A retrospective study involving review of clinical data of 227 patients(256 ears) with congenital middle ear anomaly was undertaken, including preoperative computed tomography(CT) data, surgical records and videos.Results: Aberration involving intratemporal facial nerve was found in 82/256 ears(32.03%) with congenital middle ear anomaly. The most common forms of aberration included overhanging over the oval window(50/82 ears, 60.98%), bifurcation(3/82 ears, 3.66%) and transverse over the promontory(3/82 ears, 3.66%), counting for 68.29%(56/82) of the cases with facial nerve aberration. Concomitant stapes malformation was found in 76/82 ears(92.68%) and atresia or stenosis of the oval window in 27/82 ears(32.93%). In 9/82 ears(10.98%) both stapes and oval window was absent. Elective surgeries for the purpose of hearing improvement included stapodotomy + piston implantation, labyrinthotomy, labyrinthotomy + total ossicular replacement prosthesis(TORP) implantation and Vibrant Soundbridge(VSB) implantation.Conclusion: The majority of facial nerve aberration in congenital malformation of middle ear involves displacement of facial nerve, in addition to concomitant malformations of the stapes and/or oval window, which may influence the choice of surgery for hearing improvement. VSB implantation may be considered as a useful option.

Congenital cholesteatoma of the middle ear-a report of 10 cases

Objectives To study clinical, imaging features and treatment outcomes of congenital cholesteatoma of middle ear (CCME). Methods This is a retrospective review of 10 CCME cases selected from 952 cholesteatoma cases treated between January 1995 and December 2005 at the Department of Otolaryngology-Head and Neck Surgery, Chinese PLA General Hospital. The main outcome measures were the site of origin, clinical features, surgical findings, imaging characteristics and hearing results. Results The mean age of the 10 patients was 16 years(ranged from 10 to 24 years), with 6 being older than 18 years. There were 7 males and 3 females. The average delay to diagnosis was longer than 2 years. The mean preoperative PTA was 55 dB HL, with a mean ABG of 45 dB. Typical cholesteatomas were seen behind the tympanic membrane in the superoposterior quadrant on otoscopy only in 2 patients. High resolution CT was completed in all patients. Most of the patients(8/10) were diagnosed with otosclerosis or ossicular abnormality before operation. All patients underwent a one-stage tympanoplasty following transmeatal explorative tympanotomy and complete cholesteatoma removal, except one, who underwent a CWU mastoidectomy due to extensive cholesteatoma involvement. The choleasteatoma lesion was confined to the superoposterior mesotympanum in all patients. The mean postoperative PTA was 20 dB HL. All patients were followed-up for at least 1.5 years postoperatively. Revision procedures were performed in 2 patients for hearing deterioration. No residual or recurrence of cholesteatoma was found. Conclusion CCME is a rare disease that often gets delayed diagnosis. Residual lesions and the prognosis mainly depend on the extent of the lesion.

Spatial and temporal synthesized probability gain for middle and long-term earthquake forecast and its preliminary application

IntroductionThemodelofspatialandtemporalsynthesizedgainforastrongearthquakeoccurrenceisdevelopedasthebasisofTheDynamicSoftwareSystemforMiddle-andLong-termEarthquakeForecast.Themodelisestablishedaccordingbothtothestatisticalprincipleandtotheobservatio...

The Last 15,000 Years: Climate-Controlled and “Rare-Event”-Triggered/Rise and Fall of Holocene Cultures in the Near/Middle East and in Central Europe—Evidence and Background

Pushed by the results of a preceding publication on the possibly Quaternary Jebel Waqf as Suwwan Meteorite Crater, Jordan [5], where an amazing coincidence of Rapid Climate Changes (RCCs) with Rise and Fall of Neolithic and Bronze Age Cultures became evident for the Near/Middle East, this paper deals with the same subject, however, relating to the complete Holocene period in the same area and, additionally, in Central Europe as well. By application of modern climatic data [6] comprising isotope analysis (δ18O, 14C, 10Be), acid and aerosol events, and greenhouse gases (CO2, CH4) Greenland ice cores as well as other astro-/geophysical and geological parameters, an overwhelming coincidence/relation/interdependence of both natural and cultural evidences becomes obvious throughout the last 15,000 years across the Northern Hemisphere. Apart from solar output and other astrophysical processes, most important climate- and Earth-related parameters are Mega-Volcanism (i.e.Santorini Greece: ~3640 yr cal. B. P.), Impact Events (i.e. during Mesolithic: ~9600 yr cal. B. P), rapid oceanic current change (DO-Events), and Plate Tectonics (possibly Atlantis-Event: ~11,500 yr cal. B.P. = Pleistocene/Holocene boundary). The most essential parameter is a significant temperature change related to more or less restricted latitude realms of the Northern Hemisphere. Thus, glacier advance/retreat controls the mobility of peoples (i.e. Nations' Migration, Teutonic Empires) and the access to ore deposits (Au, Ag, Cu, Sn, Zn, Pb, Fe) located in Alpine Mountain Ranges (i.e. End-Neolithic, Early Bronze Age). Myths like the Gilgamesh Epos and John Apocalypse convincingly reveal realistic contents relating to natural hazards like tsunamis, impact and flooding events. They unmisunderstandably make obvious that Myths may provide valuable contributions, especially to Geosciences. Some of the controlling parameters interrelate with others or present a kind of hierarchy: Mega-Volcanism/impact events à ejecta à wildfires, heat storms à cosmic winter, sint winter à stop of photosynthesis à mass extinction environmental pollution à greenhouse effects. Significant events (21 cases in total) occurred on i.e.

UTILITY OF VIBRANT SOUNDBRIDGE IN PATIENTS WITH CONGENITAL MIDDLE AND OUTER EAR DEFORMITIES

Objective To report use of the Vibrant Soundbridge (VSB) in patients with congenital deformation of the middle and outer ears and investigate its utility in this patient population.Method Four patients with congenital deformation of middle and outer ears underwent VSB implantation. All were male (aged 3-18 years,average 13.5 years) and operated on the left side.Malformation was bilateral in 3 patients and unilateral in 1 patient. Surgical techniques were modified to accommodate each patient's unique conditions and needs.The implant site was approached via the facial recess in 3 patients and through a retro-facial nerve route in 1 patient. The VSB implant was connected to either the stapes (2 cases) or the round window (2 cases).Pure tone and speech audiometry results and daily communication capabilities before and after VSB activation were compared.Results The operations were successful in all patients, with no complications. The patient communication level improved significantly after VSB activation. Average air conduction pure tone threshold or conditioned reflex audiometry threshold improved by 35 dB in the 0.25-4 kHz range,from 69 dB HL before VSB activation to 34 dB HL after.The sentence recognition rate in quiet at 65 dB SPL went up to 86% from 0% without VSB for patients with bilateral deformation and remained at 100% for the patient with unilateral deformity. However, for the latter patient, the rate improved to 20% from 0% without VSB in noise (-8 dB SNR).Conclusion VSB is an excellent solution for improving hearing in patients with congenital deformation of middle and outer ears.Operation can be completed and good results can be achieved even in patients with unique conditions and needs.

Carcinoid Tumors in the Middle Ear:a Case Report and Literature Review

Middle ear carcinoid tumor (MEC T) is rare. Only 46 cases of MECT have been reported in the literature since the first case of MECT was described in 1980. We present here a case of primary MECT initially diagnosed as inflammatory aural polyp. The case was a 43-year-old women complaining of right ear chronic otorrhea and hearing loss over a period of five years, with a blockage sensation in the right ear for two years. Audiometry showed conductive hearing loss in the right ear. Physical examination and CT scans showed a mass in the right external auditory canal and middle ear, surrounding the ossicular chain. Pathologic study of surgically removed specimen revealed features of carcinoid tumor with positive staining to chromogranin A and synaptophysin in tumor cells. Local radiation of 60 Gy was applied. The patient has been followed up for more than one year. Postoperative histopathological examination showed no evidence of MECT recurrence one year after surgery, but inflammatory changes in the middle ear. Relevant literatures were reviewed. Clinical, histopathological, immunohistochemical and ultrastructural features of MECT, and strategies in MECT diagnosis and management are discussed.

Capillary Hemangioma of the Middle Ear and External Auditory Canal:a Case Report

We report a case of capillary hemangiomsa that involved the entire middle ear space,external auditory canal(EAC) and tympanic antrum.Symptoms in the case included ear fullness,hearing loss,otalgia and otorrhea.The case was misdiagnosed as recurrent chronic otitis media with granulation preoperatively.A diagnosis of capillary hemangioma was established by postoperative histological examination.The management of capillary hemangioma of the middle ear and external auditory canal is discussed,with a review of the literature.Because of its variable and sometimes misleading clinical presentation,hemangioma can initially be misdiagnosed as other lesions.Therefore,a high index of suspicion is necessary for early and accurate diagnosis.

Inflammatory responses to Hydroxyapatite implants in middle ear in rats

Objective To study local inflammatory response after implantation of hydroxyapatite synthetic ossicular prosthesis. Methods Hydroxyapatite granules were implanted in the bulla in 32 rats. Sham surgical procedures were performed in 10 rats as the control. Animals were sacrificed at 1 to 300 days after surgery. Bulla sections, stained with HE and Mallory's azan, were examined for numbers and percentages of various inflammatory cell types. Results Slightly more inflammatory reaction was seen in animals with the implant than in the controls, mostly during the early stage following the implantation procedure. Few inflammatory cells were observed at later times. There were satisfactory fibrosis in both implanted and control ears. Conclusion The results indicate that hydroxyapatite synthetic prosthesis is a biocompatible implantation material in the middle ear. Nonetheless, the presence of inflammatory reaction immediately following implantation implies that control of infection is important in the early times after the implantation procedure.

Bacteriolgy before and after total middle ear reconstruction

Objectives To investigate pre-and post-total middle ear reconstruction bacteriological changes in order to facilitate prevention and treatment of surgical infections. Methods Specimens from 128 ears in 124 patients with problematic mastoid cavities who underwent revision total middle ear reconstruction were studied. Results Bacteriological tests were positive in 87(68.0%) pre-operative specimens, despite local treatment, and in 74 (57.8%) specimens collected 10 days after operation. Common organism strains in pre-and post-operative specimens were slightly different and included: coagulase-staphylococcus, GRAM+ rods, staphylococcus aureus, pseudomonas aeruginosa and fungi. At the time of patient discharge(15-20 days post-operative), only 3 ears (2.3%) were tested positive which responded well to and became dry after local treatment. At one year, 4 ears (3.1%) showed recurrent otorrhea which again responded to local treatment. Conclusion For infection of problematic mastoid cavities after an open cavity procedure, revision total middle ear reconstruction is effective in controlling infection and promoting a dry ear. Infection prevention and treatment is important considering the relatively high rates of peri-operative local infections.

Pediatric Middle Ear Congenital Cholesteatoma: A Case Report

Congenital cholesteatoma(CC)is a rarely seen benign tumor of the temporal bone. There are five general sites of extradural occurrence: the middle ear, external auditory meatus, mastoid, squamous portion and the petrous apex of the temporal bone. CC grows slowly and presents no symptoms at the early stage. Delayed and mis-diagnosis are common with this condition^1. Case report A 10-year-old boy presented with a 3-month history of hearing loss on right side. There was no history of otorrhea, facial palsy, previous otological procedures or trauma. Otoscopy revealed a bulging posterosuperior quadrant in the otherwise intact right tympanic membrane (Fig.1). Pure tone audiometry showed an average threshold of 51 dB for 500, 1000, 2000 and 4000Hz, with a 40 dB air-bone gap, suggesting a moderate conductive hearing loss(Fig.4). CT scan of the temporal bone showed an isolated soft tissue density lesion in the middle ear(Fig.2).