Canal Wall Reconstruction Mastoidectomy

Objective To investigate the advantages of canal wall reconstruction(CWR) mastoidectomy, a single-stage technique for cholesteatoma removal and posterior external canal wall reconstruction, over the open and closed procedures in terms of cholesteatoma recurrence. Methods: Between June 2002 and December 2005, 38 patients (40 ears) with cholesteatoma were admited to Sun Yat-Sen Memorial Hospital and received surgical treatments. Of these patients, 25 were male with ages ranging between 11 and 60 years(mean = 31.6 years) and 13 were female with ages ranging between 20 and 65 years (mean = 38.8 years). Canal wall reconstruction(CWR)mastoidectomy was performed in 31 ears and canal wall down(CWD) mastoidectomy in 9 ears. Concha cartilage was used for ear canal wall reconstruction in 22 of the 31 CWR procedures and cortical mastoid bone was used in the remaining 9 cases. Results At 0.5 to 4 years follow up, all but one patients remained free of signs of cholesteatoma recurrence, i.e., no retraction pocket or cholesteatoma matrix. One patient, a smoker, needed revision surgery due to cholesteatoma recurrence 1.5 year after the initial operation. The recurrence rate was therefore 3.2% (1/31). Cholesteatoma recurrence was monitored using postoperative CT scans whenever possible. In the case that needed a revision procedure, a retraction pocket was identified by otoendoscopy in the pars flacida area that eventually evolved into a cholesteatoma. A pocket extending to the epitympanum filled with cholesteatoma matrix was confirmed during the revision operation, A decision to perform a modified mastoidectomy was made as the patient refused to quit smoking. The mean air-bone gap in pure tone threshold was 45 dB before surgery and 25 dB after(p < 0.05). There was no difference between using concha cartilage and cortical mastoid bone for the reconstruction regarding air-bone gap improvement, CT findings and otoendoscopic results. Conclusion CWR mastoidectomy can be used for most patients with acquired middle ear cholesteatoma, including children. The CWR technique provides improved exposure of the middle ear, especially the anterior epitympanum, without creating a mastoid bowl and reduces the incidence of residual and recurrent disease, including cholesteatoma and otorrhea.

Radical mastoidectomy and primary tympanoplasty under microscopy correlation analysis of therapeutic efficiency of hearing reconstruction

Objective The aim of this article is to research the radical mastoidectomy and primary tympanoplasty to attain radical cure of the mastoid focus as well as rebuilding the sound-conducting structure of the tympanic cavity to improve the audition. Method The autobone and temporal fascia were taken as the transplants after the radical mastoidectomy under microscopy, and then to carry out the operation of Portmann`s tempanoplasty of 2nd and 3rd types of 2nd class.Result Non of the cholesteatoma was relapsed after follow-up for 1～4 years.The efficiency rate of tympanoplasty is of 89.47%.The average audition increased was 19 dB HL. Conclussion Radical operation for cholesteatoma should be associated with tympanoplasty if having condition. We recommend that the opening tympanoplasty should be used, and use autobone as a artificial auditory ossicles.

A Postimplant Cholesteatoma after Modified Radical Mastoidectomy

A postimplant cholesteatoma is one of surgical complications of cochlear implantation. Hoffman and Cohen (1995) reported that only one out of 172 (0.58%) patients developed a postimplant cholesteatoma. We experienced a case of postimplant cholesteatoma after the modified radical mastoidectomy. Case: A 61-year-old man underwent left modified radical tympanoplasty with mastoidectomy for middle ear cholesteatoma at another hospital 40 years ago. We performed right open type tympanoplasty for right cholesteatoma, and at that time there was no recurrent cholesteatoma on the left side. He had already lost the sensorineural hearing in both ears. After three-year-observation with no recurrence of cholesteatoma in both ears, the patient underwent a left cochlear implantation with a Nucleus-24 channel device. After 1 year, we found new lesion of cholesteatoma in the left attic, and removed it by transcanal approach. There has been no recurrence of cholesteatoma for 12 years. Conclusion: In long-standing middle ear problems, when we perform cochlear implantation, even though there is good aeration of the middle ear and an intact tympanic membrane, we need to adequately reflect on the area which should be obliterated.

Functional results of revision canal wall down mastoidectomy

In this retrospective study,we evaluated the preoperative and intraoperative findings and functional results of revision surgery after canal wall down mastoidectomy.We reviewed 34 patients(14 men,20 women;age,17–68 years)who underwent revision canal wall down mastoidectomy from March 2006 to March 2017 in the Department of Otology of the First Affiliated Hospital,Wenzhou Medical University,China.This study was approved by the Ethics Committee of the First Affiliated Hospital,Wenzhou Medical University,China(approval No.2008-05-02A11)on May 2,2008.The possible reasons for previous surgical failures were confirmed by the operative findings and included a narrow auditory meatus orifice(100%),recurrent or residual cholesteatoma(82%),high facial ridge(94%),residual air cells(47%),and labyrinthine fistula(12%).The mean time until achievement of dry ear after surgery was 5.8±2.4 weeks.After a mean 6-month follow-up,the mean postoperative air–bone gap decreased from 33.8±4.8 to 17.1±5.1dB in 30 patients who underwent mastoidectomy with simultaneous tympanoplasty.However,no significant postoperative hearing change had occurred in the other 4 patients with eustachian tube occlusion.All patients were followed up for>24 months with a disease-free dry ear and stable hearing results.The main reasons for lack of dry ears after mastoidectomy were a narrow auditory meatus orifice,recurrent or residual cholesteatoma,high facial ridge,and residual air cells.Early dry ear and hearing promotion are obtainable in most patients using revision canal wall down mastoidectomy.

改良开放和完壁式乳突根治鼓室成形术对慢性中耳病变患者听力改善效果的影响

目的探讨改良开放和完壁乳突根治鼓室成形术对慢性中耳病变患者平均纯音听阈(pure tone audiometry,PTA及骨导值的影响。方法回顾性纳入河南省中医院2015年1月~2018年1月收治慢性中耳病变患者共176例,其中84例采用改良开放乳突根治鼓室成形术治疗设为A组,另92例采用完壁乳突根治鼓室成形术设为B组。比较两组术后复发率、术后干耳率、术后PTA下降值、术后骨导下降值、术后气骨导差下降值、术后听力频率阈下降值及并发症发生情况。结果两组术后PTA下降值、术后骨导下降值及术后气骨导差下降值比较差异无统计学意义(P>0.05);两组术后250、500、1000、2000 Hz听力频率阈下降值比较差异无统计学意义(P>0.05);B组术后4000 Hz听力频率阈下降值显著小于A组(P<0.05)。结论相较于完壁乳突根治鼓室成形术,改良开放乳突根治鼓室成形术治疗慢性中耳病变可获得相近听力改善效果。

Acute Mastoiditis Clinical Course and Management in Patients Presented to Khartoumar Ear, Nose and Throat Hospital during the Period from November 2017 to November 2019

Introduction: Acute mastoiditis is the most common complication of Acute Otitis Media (AOM) and it’s the cause of serious morbidity. There is no standard universally agreed-upon management approach to acute mastoiditis. This study aims to view the clinical presentation and management approaches in Khartoum Ear, Nose and Throat Hospital. Methodology: This is a prospective case series and a hospital-based study conducted at Khartoum Ear, Nose and Throat Hospital during the period from November 2017 to November 2019. A total of 61 patients were included in the study. Results: The median age at presentation is 5 years old, males are more affected than females with a ratio of 1.35:1, and the mean duration of symptoms prior to hospital admission was 9.6 days. The most common presenting symptoms were otalgia (83.3%), ear discharge (83.3%) and post-auricular swelling (83.3%), and the most common signs at admission were tenderness over the mastoid (95.1%), retroauricular swelling and protrusion of the auricle (82%), and redness over the mastoid (77%). The abnormal tympanic membrane was found in all patients with central perforation being the commonest finding (73.8%), and bulging tympanic membrane (21.3%). 34.4% of patients received oral antibiotics before admission and the mean duration of symptoms prior to admission increased significantly in those who received antibiotics 12.7 days in comparison to those who didn’t 8.3 days. Only 52.5% of patients had a past history of recurrent acute otitis media, and 8.2% had a past history of acute mastoiditis. All the patients with recurrent mastoiditis had a past history of recurrent acute otitis media. Computed Tomography (CT) scans were obtained for 50.8% and 83.9% of those scans showed coalescent mastoiditis. Further evidence of intracranial extension was found in 6.5% and Magnetic Resonance Imaging (MRI) was obtained for them. Of the study group, 67.2% presented with subperiosteal abscess, 4.9% with facial nerve palsy and 3.3% with brain abscess. Thirteen patients with no complications were managed initially with injectable and topical antibiotics and were successful in only 6 of them (46%), abscess incisions and drainages were needed in 46 patients and were successful in 34 of them (73.9%). Eighteen patients (29.5%) needed mastoidectomy and all of them were managed successfully (100%). One patient (1.6%) was referred for intracranial abscess drainage in a specialized hospital, also one patient (1.6%) initially presented with intracranial abscess died on the second day of admission and 96.8% were discharged in good condition. The mean duration of hospital stay was 7.5 days. Conclusion: Patients present to the hospital after a prolonged period with a higher rate of complications, and the delayed presentation increased significantly in patients who received oral antibiotics prior to admission. Conservative medical treatment in non-complicated acute mastoiditis was ineffective in more than half of the patients and abscess incision and drainage and/or mastoidectomy are often necessary for the management.

Persistent Pseudomonas Infection Mastoiditis—Local Antibiotic Treatment Is Superior than Systemic

Mastoiditis is a common complication of acute otitis media. It is common in younger age compared to adulthood. Mastoiditis occurs when an otitis media infection spread directly to involve the bone of mastoid air cell causing osteitis. Cholesteatoma can contribute to the development of mastoiditis. This typically leads to breakdown of some of the fine bony trabeculae of mastoid cells producing a coalescent mastoiditis with an emphyema in mastoid antrum. Cholesteatoma can contribute to the development of mastoiditis. The common treatment for mastoiditis is intravenous antibiotic. Our cases show that local antibiotic treatment is superior compared to systemic antibiotic in treating multi-drug resistant chronic. Pseudomonas mastoiditis compared to intravenous antibiotic. However, if it presents together with cholesteatoma the main treatment is still early mastoidectomy.

耳内-耳甲腔切口在开放式乳突根治术中的应用

乳突根治术是目前治疗中耳胆脂瘤的主要方法,手术目的是将乳突、鼓窦、上鼓室、外耳道形成一个统一的开放性结构,由于术后乳突腔扩大,增加术后术区通气可以加速术区上皮化已成为共识[1]。目前一般采用耳后切口,病变切除后再行耳甲腔成形术。这种方法较繁琐同时也增加了手术时间。我科采用耳内-耳甲腔切口行中耳胆脂瘤手术治疗,依据术前颞骨CT显示的病变范围,

Mastoid obliteration and reconstruction techniques:A review of the literature

Objective To review the published literature related to the different obliteration and reconstruction techniques in the management of the canal wall down mastoidectomy.Methods A PubMed(Medline)and LILACS databases as well as crossed references search was performed with the following Mesh terms:“cholesteatoma”,“cholesteatoma-middle ear”,“otitis media”,“otitis media,suppurative”,“mastoiditis”,“mastoidectomy”,“canal wall down mastoidectomy”,“radical mastoidectomy”,“mastoid obliteration”and crossed references.Inclusion criteria were adult patients subject to mastoid cavity obliteration and posterior canal wall reconstruction.The technique and materials used,anatomic and functional results,complications,recurrence rates,and changes in quality of life,were analyzed.A total of 94 articles were screened,38 were included for full-text detailed review.Results Twenty-one articles fulfilled the inclusion criteria.Techniques and materials used for canal wall reconstruction,tympanoplasty,and ossiculoplasty were varied and included autologous,biosynthetic,or both.Auditory results were reported in 16 studies and were inconsistent.Three studies reported improvement in the quality of life using the GBI scale.Follow-up time ranged from 1 to 83 months.Eleven articles used imaging studies to evaluate postoperative disease recurrence.The highest recurrence rate reported for cholesteatoma after obliteration was 19%.The most frequently reported complications were retraction pockets and transient otorrhea.Conclusion Plenty of techniques combining grafts and other materials have been used to overcome mastoidectomy cavity problems.So far,it is still not possible to standardize an ideal procedure.The available level of evidence for this topic is low and limited.

急性化脓性中耳炎合并乙状窦周围脓肿1例

急性化脓性中耳炎是中耳黏膜的急性化脓性炎症,80%以上与细菌感染有关,少数与病毒感染有关[1]。常见致病菌为肺炎链球菌、流感嗜血杆菌和卡他莫拉菌,其中以肺炎链球菌感染最为多见且症状最严重,如治疗不规范或不彻底,有可能会引起颅内外并发症[2,3]。

Role of endoscopy in surgical management of cholesteatoma:A systematic review

Endoscopes are increasingly being used in cholesteatoma surgeries either as an adjunct to microscopes or sometimes exclusively.Their role at present is more as adjunct to microscope which still remains the work-horse for mastoidectomy.However,as endoscopy and endoscopic instruments are increasingly getting refined,role of endoscopy in management of cholesteatoma is continuously being appraised with progressively newer studies.This review aims to assess outcomes of several studies in which endoscopic techniques were used in cholesteatoma surgery and recognize common trends.An extensive review of literature on this theme was performed.Sixteen studies comprising of 1685 patients treated endoscopically either exclusively or in combination with microscope were included.Intra-operatively,in 267(15.82%)cases,residual cholesteatoma was identified by endoscope in hidden areas after completion of surgery with microscope.On follow-up,recidivism was identified in 108 cases(6.4%)in second look procedures.Common sites of recurrence were hidden areas like sinus tympani.This review while acknowledging the value of microscope,highlights the merit of endoscope usage in cholesteatoma surgery and its role in reducing recurrence.

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.

An Extensive Cholesteatoma with Bezold’s Abscess

Cholesteatoma has been known to be associated with multiple complications either extracranially or intracranially. Among the extracranial complications, mastoiditis and mastoid abscess are the most common. Bezold’s abscess formation with cholesteatoma is a rare occurrence but when present can lead to sinister sequalae if not properly managed. The treatment of cholesteatoma is mainly by surgical exploration namely mastoidectomy. The aim of treatment is to eradicate the diseased mastoid and to prevent subsequent complications. Beside surgical intervention, the patient will also require intensive systemic and topical antibiotic therapy. With proper treatment patient will be hindered from experiencing unwanted complications.

Post Operative Sensorineural Hearing Loss Following Middle Ear Surgery—A Study of 100 Cases

Background: Drill and surgical tools can cause noise induced hearing loss when used on or adjacent to the ossicular chain and stapes footplate or while working on the mastoid bone. Therefore the drill generated noise has been incriminated as a cause of sensorineural hearing loss in the operated ear. Objective: This study has been undertaken to estimate the proportion of sensorineural hearing loss following middle ear surgery and to assess the bone conduction thresholds of operated ear following middle ear surgery at different follow up periods. Methods: 100 cases of chronic suppurative otitis media posted for middle ear exploration surgery were included in the study. Results: Sensorineural hearing loss was present in 3 cases out of 100 cases (3%) after undergoing mastoid surgery. There was a mean increase in bone conduction thresholds of 0.75 dB at 500 Hz, 1.4 dB at 1 kHz, 1.7 dB at 2 kHz and 2.7 dB at 4 kHz at 6th month of follow up period after surgery with statistical significance at 2 kHz (p = 0.011) and 4 kHz (p Conclusion: Post mastoidectomy hearing loss is of high frequency in nature.

Comparison between Outcome of Myringoplasty with and without Ensuring the Patency of Aditus ad Antrum

Background: Myringoplasty is a technique for the closure of the simple perforation of the tympanic membrane. For the better outcome, myringoplasty combined with cortical mastoidectomy has been tried in many studies. Objectives: To compare the outcome of repair of tympanic membrane perforations with myringoplasty alone versus myringoplasty with opening of blocked aditus if any by doing antrostomy. Methodology: This was a prospective study. Patients included in the study were randomly allocated into 2 groups, the group I and the group II. The group I included 17 patients undergoing myringoplasty with antrostomy and the group II included 17 patients undergoing only myringoplasty. The blocked aditus was made patent if it was found blocked during antrostomy procedure. Graft uptake rate and improvement in conductive hearing loss were measured as success rate. Results: Mean age of the patients in the group I was 23.12 ± 7.55 years. The mean age of patients in the group II was 25.53 ± 8.79 years. In the group I unilateral disease was present in 6 (35%) cases. In the group II unilateral disease was present in 12 (70.5%) cases. In the group I subtotal perforation was present in 9 (52.9%) cases and moderate to large perforation was present in 8 (47%) cases. In the group II subtotal perforation and moderate to large perforation were present in 9 (52.9%) and 8 (47%) cases respectively. Aditus was found to be blocked in eleven (64.7%) patients in the group I. Successful graft uptake was seen in twelve cases (70.58%) in the group I and eleven cases (64.7%) in the group II with all of them showing improvement in hearing. The success rate of the group I was 70.58% while success rate of the group II was 64.7%. The mean of pre-operative and post-operative air-bone gap was 31.94 ± 11.7 dB and 24.8 ± 10.55 dB respectively in the group I with the mean hearing gain of 7.06 ± 3.9 dB. Similarly, the mean of pre-operative and post-operative air-bone gap was 28.24 ± 10.5 dB and 17.9 ± 0.08 dB respectively in the second group with the mean hearing gain of 10.29 ± 4.83 dB. Conclusion: There was no difference between success rate of myringoplasty with antrostomy group and myringoplasty alone group in the treatment of mucosal tympanic membrane perforation;however in majority of cases where aditus patency was checked (group I) it was found to be blocked (64.7%).

Modification of closed tympanoplasty in middle ear cholesteatoma

Background Classic mastoidectomy and modified mastoidectomy are traditional surgical procedures for middle ear cholesteatoma with goals of eradicating diseases, creating dry ears and preventing severe complications. However, the drawback of these procedures is the lack of hearing improvement. Therefore, our study aimed to investigate the effects and safety of a modification of closed tympanoplasty for middle ear cholesteatoma. Methods Eighty-three patients were recruited in this study based on the following two criteria： each patient had middle ear cholesteatoma in one ear; the affected ears had a functional eustachian tube and had neither intracranial nor extracranial complications. All the patients received a modification of closed tympanoplasty which included ossicular reconstruction with total ossicular replacement prosthesis （TORP） or partial ossicular replacement prosthesis （PORP） and membrane repair with conchal cartilage-perichondral complex. Results All the 83 cases had dry ears with membranes healed within 4-6 postoperative weeks. After 6 postoperative months, there were 3 cases with re-perforation at the tympanic membrane center and after 1.5 postoperative years, there were 5 cases with cholesteatoma recurrence （6.02%）. Function tests after one postoperative year exhibited an improvement of pure tone audiometry （PTA） in 27 cases that was more than 30 dB, in 33 cases between 20-29 dB, 14 cases with improvement between 10-19 dB, and in 9 cases there was no improvement. Conclusions The modified closed tympanoplasty procedure for middle ear cholesteatoma in the present study has all the advantages of both close-cavity and open-cavity procedures. It has low recurrence rate and good hearing improvement.

Emergent and urgent otologic surgeries during the SARS-CoV-2 pandemic: a protocol and review of literature

Objective:To review guidelines for otologic procedures during the SARS-CoV-2 pandemic and to present a protocol for emergent or urgent mastoidectomy at our institution.Data sources:Guidelines regarding emergent and urgent otologic procedures from otolaryngo-logic societies are reviewed.We described a protocol for emergent or urgent mastoidectomy at our institution.Conclusion:Patients requiring urgent or emergent mastoidectomy during the COVID-19 pandemic require prompt treatment.We make the following recommendations:Emergent or urgent otologic procedures should be performed in a contained environment,such as a tent created by the microscope drape.The surgical team should practice using instruments in the tent setup to prepare for real cases.Otologic procedures should adhere to guidelines set for high-risk procedures.