Effects of cavity reconstruction on morbidity and quality of life after canal wall down tympanomastoidectomy / Efeitos da reconstrução da cavidade da timpanomastoidectomia com técnica aberta na morbidade e qualidade de vida

Abstract Introduction: Canal wall down tympanomastoidectomy is commonly used to treat advanced chronic otitis media or cholesteatoma. The advantages of canal wall down mastoidectomy are excellent exposure for disease eradication and postoperative control of residual disease; its disadvantages include the accumulation of debris requiring life-long otological maintenance and cleaning, continuous ear drainage, fungal cavity infections, and the occurrence of dizziness and vertigo by changing temperature or pressure. Objective: To evaluate whether cavity-induced problems can be eliminated and patient comfort can be increased with mastoid cavity reconstruction. Methods: In total, 11 patients who underwent mastoid cavity reconstruction between March 2013 and June 2013 comprised the study group, and 11 patients who had dry, epithelialized CWD cavities were recruited as the control group. The study examined three parameters: epithelial migration, air caloric testing, and the Glasgow Benefit Inventory. Epithelial migration, air caloric testing, and the Glasgow Benefit Inventory were evaluated in the study and control groups. Results: The epithelial migration rate was significantly faster in study group (1.63 ± 0.5 mm/week) than control group (0.94 ± 0.37 mm/week) (p = 0.003, p < 0.05). The mean slow component velocity of nystagmus of the study group (13.33 ± 5.36°/s) was significantly lower when compared to control group (32.11 ± 9.12°/s) (p = 0.018). The overall the Glasgow Benefit Inventory score was −7.21, and the general subscale, physical and social health scores were −9.71, −21.09, and +20.35, respectively in the control group. These were +33.93, +35.59, +33.31, and +29.61, respectively in the study group. All but the social health score improved significantly (0.007, 0.008, 0.018, and 0.181, respectively). Conclusions: Cavity reconstruction improves epithelial migration, normalizes caloric responses and increases the quality of life. Thus, cavity rehabilitation eliminates open-cavity-induced problems by restoring the functional anatomy of the ear.

Resumo Introdução: A timpanomastoidectomia com a técnica Canal Wall Down, ou técnica aberta, é comumente utilizada para tratar otite média crônica avançada ou colesteatoma. As vantagens da mastoidectomia pela técnica aberta são uma excelente exposição para a erradicação da doença e controle pós-operatório da doença residual; suas desvantagens incluem o acúmulo de detritos que requerem manutenção e limpeza otológica ao longo da vida, drenagem contínua da orelha, infecções fúngicas na cavidade e a ocorrência de tonturas e vertigem com alterações de temperatura ou pressão. Objetivo: Avaliar se os problemas induzidos pela cavidade podem ser eliminados e o conforto do paciente aumentado com a reconstrução da cavidade mastoide. Método: No total, 11 pacientes submetidos à reconstrução da cavidade mastoide entre março de 2013 e junho de 2013 constituíram o grupo de estudo, e 11 pacientes com cavidades secas e epitelizadas, operadas pela técnica aberta, foram recrutados como grupo controle. O estudo analisou três parâmetros: migração epitelial, prova calórica com estimulação a ar e o questionário Glasgow Benefit Inventory. A migração epitelial, a prova calórica e o Glasgow Benefit Inventory foram avaliados nos grupos de estudo e controle. Resultados: A taxa de migração epitelial foi significativamente mais rápida no grupo de estudo (1,63 ± 0,5 mm/semana) do que no grupo controle (0,94 ± 0,37 mm/semana) (p = 0,003, p < 0,05). A velocidade média do componente lento do nistagmo no grupo de estudo (13,33 ± 5,36°/s) foi significativamente menor se comparada ao grupo controle (32,11 ± 9,12°/s) (p = 0,018). O escore global do Glasgow Benefit Inventory foi de -7,21 e os escores da subescala geral, saúde física e social foram -9,71, -21,09 e +20,35, respectivamente, no grupo controle. Esses escores foram +33,93, +35,59, +33,31 e +29,61, respectivamente, no grupo de estudo. Todos, exceto o escore de saúde social, melhoraram significativamente (0,007, 0,008, 0,018 e 0,181, respectivamente). Conclusões: A reconstrução da cavidade melhora a migração epitelial, normaliza as respostas da prova calórica e aumenta a qualidade de vida. Assim, a reabilitação da cavidade elimina os problemas induzidos por cavidades abertas ao restaurar a anatomia funcional da orelha.

Obliteração de cavidades mastoideas com aloenxerto ósseo particulado congelado em cirurgias revisionais de otite média crônica colesteatomatosa / Mastoid cavity obliteration with particulated frozen allograft bone in revisional surgery for chronic otitis media with cholesteatoma

Avaliar o controle da supuração de cavidades mastoideas após cirurgia revisional e obliteração de mastoide com aloenxerto ósseo particulado congelado (AOPC). Desenho do estudo: Exploratório, prospectivo, tipo série de casos. Pacientes: Dez adultos selecionados entre pacientes já submetidos à cirurgia de mastoidectomia cavidade aberta ou fechada para tratamento de otite média crônica colesteatomatosa e que tinham indicação de cirurgia revisional. Intervenção: Revisão de mastoidectomia e obliteração da cavidade com AOPC, material de preenchimento de baixo custo obtido de um banco de tecidos. Desfecho(s): Desfecho primário: controle da supuração. Desfechos secundários incluem: integração do AOPC na cavidade mastoidea, presença de colesteatoma residual ou recorrente, resultados audiológicos, complicações pós-operatórias, tais como infecção e extrusão do enxerto, e qualidade de vida após o procedimento medida com a escala de resultados de Glasgow (ERG). Resultados: O tempo médio de seguimento foi de 28 meses. Sete pacientes apresentaram o ouvido seco, em média, 8 semanas após a cirurgia. Três pacientes desenvolveram exposição do enxerto ósseo seguido de infecção e extrusão do material de preenchimento. A densidade média do enxerto ósseo no local da obliteração foi de 755.35 unidades Hounsfield medida na tomografia realizada após um tempo médio pós-operatório de 31 meses. A porcentagem do volume mastoideo obliterado foi de 75 a 100% em 6 casos e de 50 a 75% em 1 caso. Nos 7 pacientes, houve um aumento na densidade óssea durante o período de seguimento. Um paciente apresentou colesteatoma epitimpânico recorrente (0,5cm) identificado na ressonância magnética 1 ano após a cirurgia, embora este não estivesse na área de obliteração. A audição foi preservada em 80% dos pacientes 12 meses após o procedimento. A qualidade de vida melhorou em todos os pacientes, com média do escore ERG de 52, em escala que varia de -100 a +100...

Assess the control of suppuration after revision surgery with mastoid obliteration for chronic otitis media (COM) with cholesteatoma using particulated frozen allograft bone (PFAB). Study Design: Exploratory, prospective, case series. Patients: Ten adults were selected from among patients who had undergone canal wall down or canal wall up mastoidectomy for COM with cholesteatoma, and had an indication for revision surgery. Intervention(s): Revision mastoidectomy with obliteration of the open cavity was performed with PFAB, a low-cost filler material obtained from a tissue bank. Main Outcome Measure(s): The main outcome measure was the control of suppuration. Secondary outcome measures included PFAB integration in the mastoid cavity, presence of recurrent or residual cholesteatoma, hearing outcomes, postoperative complications as infection and bone graft extrusion and quality of life after the procedure using the Glasgow benefit inventory (GBI) survey. Results: Mean follow-up was 28 months. Seven patients achieved a dry ear at a mean of 8 weeks postoperatively. Three patients developed bone graft exposure followed by infection and extrusion of the filler material. Mean bone density was 755.35 Hounsfield units at the obliteration site measured at computed tomography performed after a mean of 31 months postoperatively. Percentage of mastoid volume obliterated was between 75% and 100% in 6 cases and between 50% and 75% in 1 case. In all 7 patients, there was an increase in bone density postoperatively. One patient presented with recurrent epitympanic cholesteatoma (0.5 cm) at 1 year postoperatively, but it was not in the obliteration area. At 12 months postoperatively, 80% of patients had preserved hearing. All patients had an improvement of quality of life after mastoid obliteration, the average score on the GBI was 52 in a scale from -100 to +100. Conclusions: This study demonstrated that PFAB may be used to achieve a dry mastoid cavity with...

Surgical management of middle ear cholesteatoma and reconstruction at the same time / Manejo quirúrgico del colesteatoma del oído medio y reconstrucción en un solo tiempo

Introduction: In the surgical management of cholesteatoma, one can opt for a closed technique (simple mastoidectomy) or open surgery (radical mastoidectomy). Open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery combines the advantages of both techniques, namely, adequate surgical exposure, eradication of cholesteatoma, and anatomical reconstruction of the middle ear structures. Objective: To evaluate the surgical results in the management of cholesteatoma through the technique of open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery. Methods: Prospective analytical observational study conducted between 2009 and 2012 with patients undergoing this surgical technique in the Hospital Universitario del Valle [University Hospital of Valle], performing preoperative clinical monitoring and quarterly postoperative tomography with previous assessments of hearing and pre- and postoperative audiometry. Results: Forty-five patients were studied. Mean postoperative follow-up was 28 months. Surgical success was achieved in 93.3% of patients, as measured by clinical and radiological follow-up. Hearing preservation was found after reconstruction of the hearing mechanism, based on measured audiometry, i.e., pure-tone average (PTA), using the statistical test for paired samples between preoperative and postoperative PTA. (95%CI -1.47-12.15). Residual cholesteatoma was present in 6.6% of cases; three to four times lower than the rate reported in the literature. Conclusions: This type of surgery can be considered a successful technique in the treatment of cholesteatoma in selected cases.

Introducción: El manejo del colesteatoma es quirúrgico. Se puede optar por una técnica cerrada (mastoidectomía simple) o técnica abierta (mastoidectomía radical). La mastoidectomía abierta con reconstrucción de la pared posterosuperior y reconstrucción del oído medio en un solo tiempo quirúrgico reúne las bondades de ambas técnicas: una adecuada exposición quirúrgica, erradicación del colesteatoma y reconstrucción anatómica de las estructuras del oído medio. Objetivo: Evaluar los resultados quirúrgicos en el manejo del colesteatoma con la técnica de mastoidectomía abierta con reconstrucción de la pared posterosuperior y el oído medio en un solo tiempo quirúrgico. Métodos: Estudio analítico observacional prospectivo realizado entre 2009-2012 con pacientes sometidos a esta técnica quirúrgica en el Hospital Universitario del Valle, realizándose un seguimiento clínico preoperatorio y postoperatorio trimestral, y evaluaciones previas con tomografía de oído y audiometría pre y postoperatoria. Resultados: Se estudiaron 45 pacientes. La media de seguimiento postoperatorio fue de 28 meses. Se alcanzó éxito quirúrgico en el 93.3% de los pacientes medidos por el seguimiento clínico y radiológico. Se encontró preservación de la audición después de la reconstrucción del mecanismo auditivo, medido con audiometría basada en el promedio tonal auditivo, mediante la prueba estadística para muestras pareadas entre la PTA preoperatoria y postoperatoria (IC95% -1.47-12.15). Se presentó colesteatoma residual en el 6.6%, tres a cuatro veces menor al reportado en la literatura. Conclusion: Este tipo de cirugía se puede considerar una técnica exitosa en el tratamiento de colesteatoma en casos seleccionados.

Hidrocéfalo ótico secundario a trombosis del seno lateral en niños: reporte de un caso clínico y revisión de la literatura / Otitic hydrocephalus secondary to lateral sinus thrombosis in children: a case report and literature review

La trombosis del seno lateral es una complicación potencialmente mortal de la otitis media aguda, aunque infrecuente en la actualidad debido al amplio uso de antibióticos. Sus manifestaciones clínicas son habitualmente fiebre, cefalea y otalgia, agregándose vómitos, edema de papila y compromiso del estado general. El examen diagnóstico de elección es la resonancia magnética en fase venosa y el manejo incluye terapia antibiótica endovenosa, miringotomía con instalación de tubo de ventilación y mastoidectomía, asociado o no a anticoagulación. Se reporta el caso de un escolar de 9 años derivado al Hospital Carlos Van Buren con un hidrocéfalo ótico secundario a una trombosis del seno lateral, manejado con terapia antibiótica endovenosa, mastoidectomía simple, miringotomía con instalación de tubos de ventilación y anticoagulación, evolucionando favorablemente con regresión de la sintomatología y recanalización del seno en el control imagenológico. Se realiza una revisión bibliográfica sobre la presentación clínica, diagnóstico y manejo de la trombosis del seno lateral en niños como complicación de la otitis media aguda.

Lateral sinus thrombosis (LST) is a potentially life threatening complication of acute otitis media. However, report rates have been decreasing since the spreaded use of antibiotic prescription. Patient developing LST usually complain about fever, headache and ear pain. Consequently, they may develop vomiting, papilledema and unhealthy-ness. Magnetic resonance venography (MRV) is considered the gold standard for LST diagnosis. Management procedures include parenteral antibiotics, myringotomy with tympanostomy tube and mastoidectomy, associated or not with anticoagulant therapy. The present study reports the case of a 9-year-old male referred to the Hospital Carlos Van Buren diagnosed with an otitic hydrocephalus secondary to lateral sinus thrombosis, managed with intravenous antibiotic therapy, simple mastoidectomy, myringotomy with tympanostomy tube placement and anticoagulation. Favorable clinical and imagenologic outcomes were obtained. We provide a brief summary about clinical features, diagnosis and management of the LST in children as a complication of acute otitis media.

Enxertos e anastomoses do nervo facial na orelha média: caixa do tímpano e mastoide / Facial nerve grafting and end-to-end anastomosis in the middle ear: tympanic cavity and mastoid

O nervo facial, quando seccionado, pode ser reparado em seu tronco por enxerto ou anastomose. OBJETIVO: Discutir as técnicas em questão e mostrar o que podemos esperar das mesmas. MÉTODO: Foram operados sete pacientes com secção do nervo facial. As cirurgias foram quatro enxertos e três anastomoses. Cinco paralisias foram iatrogênicas e duas por projéteis de arma de fogo. A avaliação da recuperação motora foi feita pela tabela de Janssen. RESULTADOS: Obtivemos 72,5% em média de recuperação motora nos casos de enxerto e 73,3% nos casos de anastomose. CONCLUSÃO: 1. Enxertos e anastomoses são soluções adequadas para reparar o nervo facial seccionado, mas nunca permitem uma recuperação facial completa, podendo ocorrer sincinesias. 2. Em princípio, o nosso objetivo é fazer a anastomose, mas quando existe tração mínima nos cotos do facial, preferimos os enxertos. 3. Em ambas as técnicas, conseguimos acima de 70% de recuperação motora em média (72,5% nos enxertos e 73,3% nas anastomoses).

Sectioned facial nerves can be repaired with grafting or end-to-end anastomosis. OBJECTIVE: To discuss these repair procedures and what can be expected of them. METHOD: Seven patients with sectioned facial nerves were included in the study. Four underwent grafting and three were offered end-to-end anastomosis. Facial nerve palsy was iatrogenic in five patients and was caused by bullet wounds in two. Assessment of motor function recovery was based on Janssen's scale. RESULTS: Mean motor recovery was rated at 72.5% for subjects offered grafting and 73.3% for patients submitted to anastomosis. CONCLUSION: 1. Grafting and anastomosis are proper solutions to repair sectioned facial nerves; complete recovery is never attained; synkinesis may occur. 2. In principle anastomosis is the procedure of choice, but when there is minimal traction in the facial nerve stump grafting is preferred. 3. Both procedures yielded mean motor recovery rates above 70% (72.5% for grafting and 73.3% for anastomosis).

Estimulação calórica a ar em mastoidectomias abertas unilaterais / Air caloric test in canal wall down mastoidectomy

Poucos trabalhos desde a década de 70 foram realizados a fim de elucidar a prova calórica em alterações da orelha média, apesar de inúmeras controvérsias que este exame pode trazer em estruturas anatômicas tão distintas. Na mastoidectomia radical, estes estudos são mais escassos. OBJETIVO: Este estudo teve como objetivo analisar os achados da estimulação calórica a ar em indivíduos com mastoidectomia radical unilateral sem queixas de tontura. MATERIAL E MÉTODO: Estudo prospectivo, realização da estimulação calórica a ar em 36 indivíduos sem queixas vestibulares, sendo 21 com cirurgia de mastoidectomia aberta unilateral e 15 sem nenhuma alteração na orelha média ou externa. RESULTADOS: 80,95% dos indivíduos apresentaram respostas assimétricas na prova calórica frias, sendo as respostas maiores do lado da mastoidectomia aberta. Em 72,73%, o mesmo efeito ocorreu com a prova calórica quente. Na análise das quatro estimulações, encontrou-se assimetria das provas quente e frias em 81,82% dos casos. Em 47,61%, foi encontrada estimulação paradoxal da prova calórica quente. CONCLUSÃO:As respostas nistágmicas do lado da mastoidectomia aberta foram maiores se comparadas com o lado saudável. A estimulação paradoxal da prova calórica quente foi um achado frequente. Não foram encontradas respostas hipofuncionantes.

Since the 1970s, few studies have been conducted to elucidate the use of caloric tests on middle ear disorders, despite the many controversies that this test may produce in anatomical structures that are so distinct. In cases of mastoidectomy, such studies are even rarer. OBJECTIVE: This study aims to analyze the findings from air caloric stimulation done in individuals submitted to unilateral radical mastoidectomy without complaints of dizziness. MATERIALS AND METHOD: Thirty-six individuals without vestibular complaints were enrolled in this prospective study. Air caloric stimulation was offered to all subjects. Twenty-one individuals had undergone unilateral open mastoidectomy and 15 did not present any middle or outer ear abnormalities. RESULTS: 80.95% of the individuals presented asymmetrical responses in the cold caloric test, with greater response on the side of the open mastectomy. In 72.73% of the subjects the same effect was observed in the hot caloric test. The four stimulation modes revealed asymmetries in both hot and cold tests in 81.82% of the cases. Paradoxical stimulation was observed in 47.61% of hot caloric tests. CONCLUSION: Nystagmic responses on the side of the open mastoidectomy were greater than on the healthy side. Paradoxical stimulation in caloric tests was a frequent finding. No hypofunctioning responses were found.

Mastoidectomia: parâmetros anatômicos x dificuldade cirúrgica / Mastoidectomy: anatomical parameters x surgical difficulty

INTRODUÇÃO: A meninge temporal rebaixada e o/ou seio sigmoide anteriorizado são condições que podem determinar dificuldades cirúrgicas na realização da mastoidectomia. OBJETIVO: Correlacionar a medida do prolapso do seio sigmoide e da meninge temporal na tomografia com a dificuldade cirúrgica na mastoidectomia. MÉTODO: As medidas tomográficas de prolapso sigmóideo e da meninge temporal foram correlacionadas com presença ou não de dificuldade cirúrgica observados durante o procedimento mastoidectomia de pacientes com otomastoidite crônica (n=30). FORMA DE ESTUDO: Coorte contemporânea com corte transversa. RESULTADOS: Em 10 pacientes, observou-se dificuldade cirúrgica assim distribuída: devido ao prolapso do seio sigmoide (n = 2) ou prolapso da meninge temporal (n = 7) ou ambos (n = 1). Nos pacientes cuja dificuldade cirúrgica foi devido ao prolapso do seio sigmoide, a distância na tomografia da borda anterior do seio sigmoide à parede posterior do canal auditivo externo foi menor que 9 mm. Nos pacientes cuja dificuldade cirúrgica foi devido ao prolapso da meninge temporal, a distância tomográfica desta ao plano superior do osso petroso foi 7 mm. CONCLUSÃO: A distância na tomografia computadorizada entre a meninge temporal e o plano superior do osso petroso 7 mm e uma distância do bordo anterior do seio sigmoide à parede posterior do canal auditivo externo inferior a 9 mm são preditivos de dificuldades cirúrgicas durante a mastoidectomia.

INTRODUCTION: The lowered temporal meninges and/ or anterior sigmoid sinus are contiditions that can determine surgical difficulties in performing mastoidectomy. OBJECTIVE: To correlate in the tomography the extent of the prolapse of the sigmoid sinus and of temporal meninges with the surgical difficulty in the mastoidectomy. METHOD: The tomographic measurements of prolapse sigmoid and of temporal meninges were correlated with the presence or non-presence of the surgical difficulty observed during the mastoidectomy procedure in patients with ostomatoiditis chronic (n=30). FORM OF STUDY: Contemporary cohort transverse. RESULTS: In 10 patients were observed surgical difficulty distributed as: due to prolapse of the sigmoid sinus (n = 2) or temporal meninges prolapse (n = 7) or both (n = 1). In patients in which the surgical difficulty was due to sigmoid sinus prolapse, the tomography distance of the anterior border of the sigmoid sinus to posterior wall of external auditory canal was lower than 9 mm. In patients in which surgical difficulty was due to temporal meninges prolapse, the tomographic distance to the upper plane of the petrous bone was 7 mm. CONCLUSION: The computerized tomography distance between the temporal meninges and the upper plane of the petrous bone 7 mm and the distance of the anterior border of the sigmoid sinus to posterior wall of external auditory canal was lower than 9 mm are predictive to the surgical difficulties to perform mastoidectomy.

Hydroxyapatite granules used in the obliteration of mastoid cavities in rats / Utilização de hidroxiapatita de cálcio no preenchimento de defeitos ósseos criados em mastoides de ratos

Prospective Experimental study in which we created a bony defect in the mastoids of rats and filled it up with hydroxyapatite to evaluate bone regeneration, to solve the problems of open cavities after mastoidectomies that frequently present with otorrhea, infection, granulation tissue and hearing loss. OBJECTIVE: The aim was to evaluate bone regeneration in defects created in the mastoids of rats, using hydroxyapatite, to see how much of the cavity we could reduce. MATERIAL AND METHODS: Twelve rats Wistar-Furth were used. A 0.5 x 0.5 cm bone defect was created in both temporal bones of the rats, and filled with 15 micrograms of hydroxyapatite. The left side was used as control. The animals were slaughtered 40 days afterwards and histology analyses were carried out. RESULTS: In the hydroxyapatite group, the new bone growth involved an area of 68.53 percent of the total; and in the control group it was only of 15.97 percent. DISCUSSION AND CONCLUSIOn: It was observed a very good hydroxyapatite integration to the temporal bone in this experimental model. The microscopic results were superior with the use of hydroxyapatite when compared to the control group. It is a safe method and easy to apply to solve the problems of open cavities with chronic discharge and difficult to clean.

Estudo experimental prospectivo utilizando ratos que foram submetidos à realização de defeito ósseo em mastoide para avaliar o grau de regeneração óssea após preenchimento com hidroxiapatita de cálcio sintética, para resolver o problema das cavidades abertas pós-mastoidectomia que frequentemente se apresentam com secreção, tecido de granulação, otorreia e perda de audição. OBJETIVO: Avaliar a regeneração óssea em defeitos criados em mastoides de ratos, utilizando hidroxiapatita cáustica, avaliando quanto a cavidade mastoidea criada pode ser diminuída, por meio de microscopia óptica. MATERIAL E MÉTODO: Foram utilizados 12 ratos Wistar. Foi criado um defeito ósseo de 0,5cm x 0,5cm no osso temporal de todos os animais bilateralmente com broca. Padronizou-se à direita o preenchimento do defeito com 15 microgramas de hidroxiapatita, e à esquerda o não preenchimento como controle. A eutanásia foi realizada no 40º pós-operatório e procedeu-se à análise histológica. RESULTADOS: No grupo hidroxiapatita, a neoformação óssea perfez uma área correspondente a 68,53 por cento, no grupo controle 15,97 por cento (p=0,0022). CONCLUSÃO: Observou-se a integração satisfatória da hidroxiapatita nesse modelo experimental. Pode ser um método de fácil aplicação para resolver o problema das cavidades abertas.

Unexpected postoperative seizure after mastoid surgery. A case report

Postoperative seizures [expected after neurosurgery] are rare events. When they do occur, they are usually attributable to an identifiable drug reaction, a metabolic or neurological event. We report a case of postoperative seizure in postanesthesia care unit. A 19-yr-old female, 48 kg, was admitted to a hospital for left middle-ear surgery. Her medical history, physical examination and laboratory evaluation were normal. Anesthesia was induced with fentanyl 1 micro g/kg, thiopental 5 mg/kg and rocuronium 0.5 mg/kg to produce neuromuscular blockade. Anesthesia was initially maintained with oxygen, nitrous oxide and sevoflurane. Mastoid surgery was completed in 195 minutes after induction. The patient was extubated, but approximately 10 minutes after arrival in recovery she started to generalized tonic clonic convulsion. Oxygen was administered by face mask and thiopental 100 mg was administered intravenously. Blood sugar, electrolytes and body temperature were normal. After ten minutes convulsion episode was repeated. Because of the continuing seizure activity in a patient at risk of pulmonary aspiration and security of air way, her trachea was intubated by using thiopental and succinylcholine and ventilation controlled artificially. The seizures were controlled with midazolam and phenytoin. Computerized tomography [CT] showed left temporal cortical suspected hipodensity [Fig. 1] and the patient was transferred to ICU

Meningites bacteriennes sur une otite moyenne chronique : des urgences particulieres

Urgence medico-chirurgicale; une meningite bacterienne sur otite moyenne chronique comporte; a part les caracteristiques semiologiques reconnues par tous; des quelques particularites interessantes. Trois cas vus avec un delai de 2 a 12 jours entre debut des symptomes et hospitalisation sont rapportes dans ce travail. Deux patients avaient pu beneficier d'une ponction lombaire et un patient d'une mastoidectomie en urgence. L'evolution etait defavorable pour les deux premiers patients. Le pronostic d'une meningite en relation avec une otite est tres severe d'ou l'interet de traiter au plus vite l'etiologie en parallele avec la prise en charge de l'atteinte infectieuse

Comparison of pre and post-operative hearing results in canal wall down mastoidectomy with type III tympanoplasty.

This study was done to compare the pre and post-operative hearing results in patients undergoing canal wall down mastoidectomy with classical type III tympanoplasty using temporalis fascia alone. Patients of >or=5 years age with the diagnosis of Chronic otitis media (squamous) with conductive or mixed hearing loss, needing canal wall down mastoidectomy and with intact and mobile stapes suprastructure at surgery who underwent classical type III tympanoplasty were included in the study. The pre and post-operative PTA was performed and evaluated. The post-operative hearing was assessed in terms of average ABG and size of ABG closure. Mean pre and post-operative air bone gap in classical type III tympanoplasty were 37.8 dB and 29.8 dB respectively and these differences were statistically significant. The postoperative PTA-ABG ranged from 15-61.2 dB. Hearing results after type III tympanoplasty varied widely showing statistically significant improvement in mean post-operative PTA-ABG but there was a great variation.

Aplicação da ressonância magnética no acompanhamento da cirurgia do colesteatoma / The role of magnetic resonance imaging in the postoperative management of cholesteatomas

A tomografia computadorizada e ressonância magnética (RM) com seqüências convencionais têm baixa especificidade para a diferenciação entre tecido de granulação e recidiva de colesteatoma. OBJETIVO: Avaliar a aplicação da RM com sequência de difusão e pós-contraste T1 tardio na detecção de recidiva de colesteatoma. MATERIAL E MÉTODO: Realizado estudo transversal prospectivo de dezessete pacientes estudados no pós-operatório de colesteatoma utilizando RM de 1.5 T com seqüência difusão, T1, T2 e pós-contraste T1 tardio nos planos coronal e axial. Dois radiologistas avaliaram e decidiram em consenso a presença de foco de hipersinal na difusão e T2, iso/hipossinal em T1 e ausência de impregnação pelo contraste como suspeitos de recidiva de colesteatoma. Os achados da revisão cirúrgica foram comparados com o resultado da RM. RESULTADOS: Onze dos doze casos de recidiva de colesteatoma apresentaram hipersinal na difusão. Todos os pacientes com tecido de granulação na cavidade cirúrgica não apresentaram alteração de sinal na difusão. Um paciente com abscesso no conduto auditivo interno também apresentou hipersinal na difusão. A sensibilidade, especificidade, valor preditivo positivo e negativo foram respectivamente 91,6 por cento, 60 por cento, 84,6 por cento e 75 por cento. CONCLUSÃO: A seqüência de difusão combinada com pós-contraste tardio pode ser útil na diferenciação entre tecido de granulação e recidiva de colesteatoma.

Conventional CT and MRI scans have low specificity when it comes to differentiating granulation tissue from relapsing cholesteatoma. AIM: this paper aims to analyze the use of DWI and delayed post-contrast T1-weighed imaging in the detection of recurring cholesteatomas. MATERIALS AND METHOD: this is a cross-sectional prospective study that looked at 17 cholesteatoma patients postoperatively. All patients underwent diffusion magnetic resonance imaging at 1.5T, T1, T2, and delayed post-contrast T1 and images were produced from both coronal and axial planes. Two radiologists assessed the images and decided consensually that the presence of hyperintensive signal in DWI on T2, iso/hypointensive signal on T1, and absence of contrast uptake were indicative of relapsing cholesteatoma. Surgical review findings were compared to DWI scans. RESULTS: eleven of the twelve cases of recurring cholesteatoma presented hyperintensive signal in the DWI scans. None of the patients with granulation tissue in the surgical wound presented hyperintensive signal in the DWI scans. A patient with an abscess in the internal acoustic meatus also presented a hyperintensive signal in the DWI scans. Sensibility, specificity, positive predictive value and negative predictive value were 91.6 percent, 60.0 percent, 84.6 percent, and 75.0 percent, respectively. CONCLUSION: DWI combined with delayed post-contrast T1 SE sequence proved to be useful in the differential diagnosis of granulation tissue and recurring cholesteatoma.

Carcinoma adenóide cístico de conduto auditivo externo / Adenoid cystic carcinoma of the external auditory canal

O carcinoma adenóide cístico é um raro tumor originado das glândulas salivares, principalmente quando se localiza no conduto auditivo externo. Apresenta alta taxa de invasão perineural e metástases, devendo ser tratado com combinação de cirurgia agressiva seguida de radioterapia. Relatamos um caso de carcinoma adenóide cístico de conduto auditivo externo em paciente de 77 anos com queixa de hipoacusia e otalgia. A mesma foi tratada com mastoidectomia radical e radioterapia.

Adenoid cystic carcinoma is a rare tumor originating from the salivary glands, especially when arise the external auditory canal. This tumor has high rate of perineural invasion and metastasis, then must be treated with aggressive surgery combined with postoperative radiation. We report a case of an adenoid cystic carcinoma arising the external auditory canal of 77 years old female patient, who complained hypoacusis and pain. She was treated by radical mastoidectomy and radiotherapy.

Uso do cimento de osso alfa-tricálcio-fosfato no tratamento cirúrgico da cavidade mastóidea / Use of alpha-tricalcium phosphate bone cement in the surgical treatment of mastoid cavity

Introdução: A mastoidectomia cavidade aberta pode gerar algumas complicações e a obliteração da cavidade mastóidea é uma técnica descrita e estudada para a eliminação desta cavidade. Materiais aloplásticos têm sido estudados em cirurgias de obliteração da cavidade mastóidea. O cimento de osso alfa-tricálcio-fosfato é um material composto por cálcio e fosfato e apresenta composição bioquímica semelhante à fase mineral do osso. Objetivo: Estudar a biocompatibilidade do cimento de osso alfa-tricálcio-fosfato na obliteração da cavidade mastóidea em "guinea pigs". Método: Vinte "guinea pig" foram submetidos a procedimento cirúrgico. Em 10 cobaias (grupo cimento) a bula timpânica foi obliterada com o cimento de osso alfa-tricálcio-fosfato e em 10 cobaias (grupo controle) a cavidade foi deixada sem preenchimento. Os animais foram avaliados quanto à presença de sinais clínicos de rejeição ao material e outras complicações. Os ossos temporais foram removidos e avaliados quanto ao tipo e o grau de resposta inflamatória e o grau de ossificação. Resultados: Entre as cobaias que completaram o estudo não foram observados sinais de complicações em nenhum caso. Também não foi observado presença de reação inflamatória crônica tipo corpo estranho em nenhuma amostra de ambos os grupos. Quanto ao grau de ossificação, a média dos escores de ossificação no grupo controle (3,5) foi maior que o observado no grupo cimento (1,0). Conclusões: 1) O cimento de osso alfa-tricálcio-fosfato é biocompatível em osso temporal de cobaia. 2) O cimento de osso alfatricálcio- fosfato sofre remodelação óssea, porém não apresenta propriedade de osteocondução.

Introduction: Open cavity mastoidectomy can generate some complications and mastoid cavity obliteration is a technique described and studied for the elimination of this cavity. Alloplastic materials have been studied in mastoid cavity obliteration surgery. Alpha-tricalcium phosphate bone cement is a material composed by calcium and phosphate and presents biochemical characteristics similar to the bone mineral phase. Objective: This study is aimed at evaluating the biocompatibility of alpha-tricalcium phosphate bone cement in the obliteration of the mastoid cavity in guinea pigs. Methods: 20 guinea pigs were submitted to surgical procedure. In 10 cement study group animals, the tympanic bulla was obliterated with alpha-tricalcium phosphate bone cement and in 10 guinea pigs (control group), the cavity was left unfilled. The animals were evaluated for clinical signs of material rejection and other complications. The temporal bones were removed and analyzed as for the type and degree of inflammatory response, as well as the degree of ossification. Results: In the animals that completed the study, there were no complications. There were not either the presence of foreign body inflammatory reaction in none of the samples of both groups. As for the ossification degree, the average ossification scores in the control group (3.5) was greater than that shown by the cement group (1.0). Conclusions: 1) The alpha-tricalcium phosphate bone cement is biocompatible in guinea pig's temporal bone 2) The alphatricalcium phosphate bone cement undergoes bone remodeling, but it doesnït present osteoconductive properties.

Osso da mastóide como auto-enxerto para reconstrução do dorso nasal

Introdução: Vários enxertos e/ou implantes têm sido usados para reconstrução do dorso nasal. Em alguns casos, especialmente os narizes pós-cirurgia de câncer, traumático, acometidos por granulomatose e multioperados, a quantidade de aumento é maior que o normalmente disponível em auto-enxerto de septo e concha auricular. Objetivo: Avaliar a segurança e a eficácia do osso de mastóide como auto-enxerto para reconstrução do dorso nasal. Método: Um estudo de 20 pacientes consecutivos submetidos a reconstrução do dorso nasal com osso de mastóide, durante um período de 4 anos. O resultado foi avaliado principalmente por complicações e satisfação do paciente e cirurgião. Resultados: Os enxertos variaram de 5 a 12 mm em espessura. O período de seguimento variou de 6 meses a 4 anos. Dezessete (85%) pacientes apresentaram resultados satisfatórios para o cirurgião e o paciente. Um paciente mostrou aumento excessivo leve somente notado pelo cirurgião. Um paciente apresentou aumento deficiente, necessitando cirurgia revisional. Um paciente precisou de cirurgia de revisão devido a deslocamento do enxerto no primeiro mês de pós-operatório. Nenhum caso apresentou infecção ou absorção de enxerto. Conclusões: O osso de mastóide se apresentou como um material efetivo como auto-enxerto para reconstrução do dorso nasal. A taxa de complicação foi baixa. O seguimento a longo prazo mostrou que não ocorre absorção clinicamente significante.

Intracranial complications of chronic suppurative otitis media

To study the presentations of various intra cranial complications of chronic suppurative otitis media [SOM]. This prospective and descriptive study was conducted in the department of ENT, Lady Reading Hospital Peshawar from April 2006 to march 2007. All the cases with suspected intra cranial complications were admitted to the department and assessed clinically and radiologically. Audiological, and laboratory investigations were done as well. Out of 50 cases 36 were male and 14 female ranging from 10-40years in age. Complications like meningitis and brain abscesses were more common in males in the 2[nd] and 3[rd] decade of life [72%]. Most of the complications were from atticoantral diseases. The main presenting features were foul smelling otorrhea, headache, and fever, neck stiffness, chloestosteatoma and granulations in the ear. Meningitis [46%], temporal lobe abscess [36%] and extra dural abscess [14%] were the commonest complications. Burr hole aspiration, for intra cranial abscess and radical/modified radical mastoidecomy for SOM were the main surgical procedure carried out for these patients. Otogenic intra cranial complications like meningitis and brain abscesses are still common in spite of advances in the medical sciences. Complications are common in 2[nd] and 3[rd] decade of life. Meningitis is the commonest complication followed by brain abscess Burr whole aspiration with modified, radical mastoidectomy is the main stay of treatment along with parenteral antibiotics

Meatoplasty with intraoperative topical mitomycin C application: technique and outcome

The present study was designed to evaluate the outcome of meatoplasty using Z-shaped incision with application of mitomycin C as trial to enlarge the external auditory meatus of patients undergoing modified radical mastoidectomy in comparison to classic meatoplasty with application of mitomycin C. The study included 40 patients; 25 males and 15 females with mean age of 38.7 +/- 8.4 years. All patients underwent Jull history taking, complete otorhinolaryngological examination and CT scanning and then were randomly allocated into two equal groups [n=20] according to the procedure assigned: Classic meatoplasty [C group] and Z-shaped meatoplasty [Z group] using Z-shaped skin incision made along the posterior and inferior conchal borders and extended along the posterior ear canal meatus. In both groups, mitomycin C, 0.4 mg/ml solution was applied on a sponge to the edge of the remnants of conchal cartilage for 5 minutes. Patients were examined bi-weekly till the ear was fully healed. Meatoplasty was assessed as regards the feasibility of easy examination and debridement with the use of simple otologic tools and an operating microscope. Both groups were compared as regards age, sex, operative time and amount of intraoperative bleeding. All cases passed smooth intraoperative course with non-significantly longer operative time and non-significantly more bleeding during Z-meatoplasty compared to classic meatoplasty. All Z flaps healed completely with good take without sloughing or change in color and the meatus was so enlarged to allow inspection of mastoid cavity and easy debridement with simple tools and allowed frequent otoscopic examination for cavity inspection. Only one ear, in Z group, developed hypertrophic scar that did not impose significant narrowing of the meatus. On contrary; 3 ears had classic meatoplasty developed keloid formation and significant narrowing of the meatus that hampered cavity examination and debridement. Another ear, in C group, developed postoperative perichondritis that resolved with local care and oral antibiotics, but unfortunately developed meatal stenosis. Thus, Z-meatoplasty showed a success rate of 95% which is significantly higher compared to classic meatoplasty [80%]. It could be concluded that application of mitomycin C in conjunction with Z-meatoplasty is an effective modality for reduction of possibility for hypertrophic meatal scar with its subsequent problems. Also, classic meatoplasty with mitomycin C application provided acceptable frequency of hypertrophic meatal scar and is recommended wherever Z-meatoplasty was technically difficult

Myiasis infestation in postoperative mastoid cavity.

This is a case report of myiasis in modified radical mastoidectomy cavity in a 48 years old male presented in the Department of ENT and Head and Neck Surgery, T.U.Teaching Hospital, Katmandu, Nepal. Around 50 maggots were removed from his mastoid cavity. Patient was managed with turpentine oil and antibiotics which was given to prevent secondary infection. Literature search revealed only one case report of Myiasis infestation in a postoperative mastoid cavity.

Surgical emphysema and pneumomediastinum following mastoidectomy.

Surgical emphysema and pneumomediastinum are rare complications of mastoidectomy probably resulting from the use of a compressed air-powered mastoid drill. Early diagnosis and appropriate management according to the severity is vital.