Ossicular chain reconstruction in chronic otitis media: hearing results and analysis of prognostic factors / Reconstrução da cadeia ossicular na otite média crônica: resultados auditivos e análise de fatores prognósticos

Abstract Introduction The goal of ossiculoplasty is to improve hearing and the success of this procedure depends on several factors. Objective Analyze the hearing results in patients with chronic otitis media undergoing ossicular chain reconstruction, as well as predictive factors for successful surgery. Methods Charts of patients undergoing ossiculoplasty between 2006 and 2016 were reviewed. Sixty-eight patients were included, totaling 72 ears. The following data was analyzed: gender, age, smoking status, laterality, pathology, audiometric exams, type of surgery, previous surgery, characteristics of the middle ear, otorrhea and ossicular chain status. Patients were also classified according to two indices: middle ear risk index and ossiculoplasty outcome parameter staging. The results were evaluated by comparing the air-bone gap before and after surgery. The success of reconstruction was defined as air-bone gap ≤20 dB and the improvement of speech reception Thresholds, calculated through the mean frequencies 0.5, 1, 2 and 3 kHz. Results Reconstruction success rate was 61%. The mean preoperative air bone gap was 34.63 dB and decreased to 17.26 dB after surgery. There was a correlation between low risk in middle ear risk index and ossiculoplasty outcome parameter staging indices with postoperative success. The most frequently eroded ossicle was the incus and the type of prosthesis most used was tragal cartilage. In the patients without incus, we achieved success in 74.2% of the surgeries. In the absence of the stapes, the success rate decreased to 63.3%. In the absence of the malleus, 85% of the patients had and air bone gap ≤20 dB. Conclusion We achieved good audiometric outcomes in ossiculoplasty and the results are comparable to other centers. Ossicle status influenced postoperative results, especially in the presence of stapes. We also concluded that the indexes analyzed may help to predict the success of the surgery.

Resumo Introdução A ossiculoplastia tem como objetivo a melhoria da audição e o sucesso desse procedimento depende de diversos fatores. Objetivo Analisar os resultados auditivos em pacientes com otite média crônica submetidos a reconstrução da cadeia ossicular, bem como os fatores preditivos de sucesso cirúrgico. Método Prontuários de pacientes submetidos a ossiculoplastia entre 2006 e 2016 foram revistos. Sessenta e oito pacientes foram incluídos, total de 72 orelhas. Os seguintes dados foram analisados: sexo, idade, tabagismo, lateralidade, doença, exames audiométricos, tipo de cirurgia, cirurgia prévia, características da orelha média, otorreia e estado da cadeia ossicular. Os pacientes também foram classificados de acordo com dois índices: índice de risco da orelha média e estadiamento do parâmetro de desfecho da ossiculoplastia. Os resultados foram avaliados comparando o gap aéreo-ósseo antes e após a cirurgia. O sucesso da reconstrução foi definido como gap aéreo-ósseo ≤ 20 dB e a melhoria dos limiares de recepção de fala, calculados pelas frequências médias de 0,5, 1, 2 e 3 kHz. Resultados A taxa de sucesso da reconstrução foi de 61%. O gap aéreo-ósseo pré-operatório médio foi de 34,63 dB e diminuiu para 17,26 dB após a cirurgia. Houve correlação entre baixo risco no índice de risco para orelha média e os índices de estadiamento do parâmetro de desfecho da ossiculoplastia com sucesso pós-operatório. O ossículo com erosão mais frequente foi a bigorna e o tipo de prótese mais utilizada foi a cartilagem tragal. Nos pacientes sem bigorna o sucesso foi alcançado em 74,2% das cirurgias. Na ausência do estribo, a taxa de sucesso diminuiu para 63,3%. Na ausência do martelo, 85% dos pacientes apresentaram gap aéreo-ósseo ≤ 20 dB. Conclusão Melhora significativa da audição foi observada em pacientes submetidos à ossiculoplastia, os resultados foram comparáveis aos de outros centros. O "status" dos ossículos influenciou os resultados pós-operatórios, principalmente a presença do estribo. Também concluímos que os índices analisados podem ajudar a prever o sucesso da cirurgia.

Effect of Incudostapedial Reconstruction Using Conchal Cartilage Interposition Graft on Hearing Outcome

Abstract Introduction Chronic otitis media is a widely prevalent condition in developing countries and is a cause of correctable hearing loss. The most frequent ossicular chain defect found during surgery for chronic otitis media has been a discontinuity of the incudostapedial joint. This study observes the effect of incudostapedial reconstruction using conchal cartilage on the hearing of the patient. Objectives To evaluate improvement in hearing by incudostapedial reconstruction using conchal cartilage interposition graft in tympanoplasty and to identify the independent factors associated with erosion of the long process of incus among patients with chronic suppurative otitis media tubotympanic type. Methods This study was conducted in the department of ear, nose and throat (ENT) amongst 22 patients with tubotympanic-type chronic suppurative otitis media who were found to have erosion of the long process during tympanoplasty. These patients underwent incudostapedial reconstruction using conchal cartilage. Their hearing was again reassessed at 12 weeks postsurgery, and the changes were observed. Results A statistically significant improvement in air conduction by 15.14 dB was found after undergoing incudostapedial reconstruction using conchal cartilage (p < 0.001). There was no statistically significant change in bone conduction (p value > 0.05). A total of 59.1% of patients in the study had an improvement in hearing ranging from11 to 20 dB. It was also found that 50% of the patients had a postoperative hearing of 10 to 20 dB. Conclusion Conchal cartilage interposition graft effectively improved hearing when used for the reconstruction of the incudostapedial joint during tympanoplasty in patients of chronic suppurative otitis media.

Influencia auditiva de la pared posterosuperior del conducto auditivo externo, en la hipoacusia de conducción postimpanomastoidectomía / Hearing influence of the posterior ear canal wall, in the conductive hearing loss after tympanomastoidectomy

RESUMEN Introducción: El tratamiento de la otitis media crónica (OMC) colesteatomatosa es quirúrgico, cuyo objetivo es erradicar la enfermedad, evitar complicaciones y prevenir recurrencias. El gold standard es la timpanomastoidectomía con canal wall down (TCWD). Estudios en cadáver han definido que TCWD disminuye la audición 1-5 dB en frecuencias <1.000 Hz y 0-10 dB entre 1.000 y 3.000 Hz. De aquí nuestro interés por definir la influencia acústica de la pared posterosuperior del conducto auditivo externo (CAE). Objetivo: Determinar en cuantos decibeles se corrige la audición al reconstituir pared posterior del CAE pos-TCWD. Material y método: Trabajo experimental. A pacientes pos-TCWD se reconstituye de manera transitoria la pared posterior del CAE, realizándose audiometría pre y posprocedimiento. Resultados: 23 pacientes (25 oídos), promedio 48,8 años (18-72 años). En 96% existió una diferencia favorable al reconstruir la pared posterior, presentando una mejoría auditiva entre 1,2 y 10,6 dB (4,2 ± 2,8 dB). En frecuencias <1.000 Hz la mejoría fue de 6,0 dB (p <0,001), entre 1.000-3.000 Hz fue 2,6 dB (p <0,001) y >3.000 Hz no hubo diferencia. Considerando PTP de vía aérea la mejoría fue 4,6 dB (p <0,001). Conclusión: Nuestro estudio demuestra que existe mejoría auditiva en la gran mayoría de oídos evaluados al reconstituir la pared posterosuperior del CAE, alcanzando 6 dB en frecuencias <1.000 Hz y 2,6 dB en frecuencias medias. Si consideramos los PTP de vía aérea la mejoría es de 4,6 dB en presencia de pared posterior.

ABSTRACT Introduction: Cholesteatomas treatment is surgical and the goals are complete resection of it, to prevent complications and recurrences. The gold standard operative technique is canal wall down tympanomastoidectomy (CWDT), which reduces the recurrence rate lower than 2%. Studies on human temporal bones have defined that CWDT causes a decrease of 1 to 5 dB at frequencies below 1000 Hz and 0 to 10 dB between 1000 and 3000 Hz. Aim: To determine how many decibels the hearing is improved by reconstituting the posterior wall of the ear canal (EC) in patients after CWDT. Material and method: Experimental study. In patients after CWDT, the posterior wall of EC was reconstructed temporarily. Audiometry was performed before and after the procedure. Results: 23 patients were enrolled (25 ears evaluated). Average age 48.8 years (range 18 to 72 years). In 96% of the ears there was a difference after the procedure with a hearing improvement of 4.2 ± 2.8dB. In frequencies below 1000 Hz, hearing improvement was 6.0 dB (p<0.001), between 1000-3000 Hz, the improvement was 2.6 dB (p<0.001) and >3000 Hz there was no difference. When considering the airway-conduction pure tone average (PTA), the difference was a 4.6 dB improvement (p<0.001). Conclusions: Our study shows that there is a hearing improvement in the vast majority of ears that were evaluated by reconstituting the posterior wall of the EC, reaching a gain of 6 dB at frequencies <1000 Hz and 2,6 dB at mid frequencies. Considering the airway PTA, the improvement is 4.6 dB in the presence of posterior canal wall.

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.

Role of preoperative air-bone gap in tinnitus outcome after tympanoplasty for chronic otitis media with tinnitus / Papel do gap aéreo-ósseo pré-operatório no desfecho do zumbido após timpanoplastia para otite média crônica com zumbido

Abstract Introduction Previous reports indicated that middle ear surgery might partially improve tinnitus after surgery. However, until now, no influencing factor has been determined for tinnitus outcome after middle ear surgery. Objective The purpose of this study was to investigate the association between preoperative air-bone gap and tinnitus outcome after tympanoplasty type I. Methods Seventy-five patients with tinnitus who had more than 6 months of symptoms of chronic otitis media on the ipsilateral side that were refractory to medical treatment were included in this study. All patients were evaluated through otoendoscopy, pure tone/speech audiometer, questionnaire survey using the visual analog scale and the tinnitus handicap inventory for tinnitus symptoms before and 6 months after tympanoplasty. The influence of preoperative bone conduction, preoperative air-bone-gap, and postoperative air-bone-gap on tinnitus outcome after the operation was investigated. Results and conclusion The patients were divided into two groups based on preoperative bone conduction of less than 25 dB (n = 50) or more than 25 dB (n = 25). The postoperative improvement of tinnitus in both groups showed statistical significance. Patients whose preoperative air-bone-gap was less than 15 dB showed no improvement in postoperative tinnitus using the visual analog scale (p = 0.889) and the tinnitus handicap inventory (p = 0.802). However, patients whose preoperative air-bone-gap was more than 15 dB showed statistically significant improvement in postoperative tinnitus using the visual analog scale (p < 0.01) and the tinnitus handicap inventory (p = 0.016). Postoperative change in tinnitus showed significance compared with preoperative tinnitus using visual analog scale (p = 0.006). However, the correlation between reduction in the visual analog scale score and air-bone-gap (p = 0.202) or between reduction in tinnitus handicap inventory score and air-bone-gap (p = 0.290) was not significant. We suggest that the preoperative air-bone-gap can be a predictor of tinnitus outcome after tympanoplasty in chronic otitis media with tinnitus.

Resumo Introdução Relatos anteriores indicaram que a cirurgia no ouvido médio pode melhorar parcialmente o zumbido após a cirurgia. No entanto, até agora, nenhum fator influenciador foi determinado para o resultado do zumbido após cirurgia de ouvido médio. Objetivo O objetivo deste estudo foi investigar a associação entre o gap aéreo-ósseo pré-operatório e o desfecho do zumbido após timpanoplastia do tipo I. Método Setenta e cinco pacientes com zumbido, com mais de 6 meses de sintomas de otite média crônica no lado ipsilateral que eram refratários ao tratamento médico foram incluídos nesse estudo. Todos os pacientes foram avaliados através de otoendoscopia, audiometria tonal/vocal, questionário utilizando a escala visual analógica e o questionário tinnitus handicap inventory para sintomas de zumbido antes e 6 meses após a timpanoplastia. A influência da condução óssea pré-operatória, gap aéreo-ósseo pré-operatório e pós-operatório sobre o desfecho do zumbido após a operação foi analisada. Resultados e conclusão Os pacientes foram divididos em dois grupos com base na condução óssea pré-operatória de menos de 25 dB (n = 50) ou mais de 25 dB (n = 25). A melhora do zumbido pós-operatória em ambos os grupos mostrou significância estatística. Pacientes com gap aéreo-ósseo pré-operatório inferior a 15 dB não apresentaram melhora no zumbido pós-operatório utilizando a escala visual analógica (p = 0,889) e o tinnitus handicap inventory (p = 0,802). Entretanto, pacientes com gap aéreo-ósseo pré-operatório maior do que 15 dB apresentaram melhoria estatisticamente significante no zumbido pós-operatório com a escala visual analógica (p < 0,01) e o tinnitus handicap inventory (p = 0,016). A mudança pós-operatória no zumbido mostrou significância em comparação com o zumbido pré-operatório usando a escala visual analógica (p = 0,006). No entanto, a correlação entre a redução no escore da escala visual analógica e gap aéreo-ósseo (p = 0,202) ou entre a redução no escore do tinnitus handicap inventory e gapaéreo-ósseo (p = 0,290) não foi significativa. Sugerimos que o gapaéreo-ósseo pré-operatório possa ser um preditor de desfecho do zumbido após timpanoplastia em otite média crônica com zumbido.

Timpanoplastía endoscópica: experiencia en el Hospital del Salvador / Endoscopic tympanoplasty: experience in Hospital del Salvador

RESUMEN Introducción: La técnica endoscópica para la cirugía de oído ha presentado un gran avance en los últimos años, debido al avance de las ópticas de alta resolución e instrumental quirúrgico. El uso de endoscopio en timpanoplastías facilita la visualización de zonas de difícil acceso, como es el caso de pacientes con pared anterior del conducto auditivo externo prominente y perforaciones timpánicas anteriores, además permite la revisión de la caja timpánica y de las vías de ventilación del oído medio. Objetivo: Mostrar la timpanoplastía endoscópica (TE) como alternativa en pacientes con otitis media crónica y analizar el éxito anatómico y funcional. Material y método: Revisión de fichas clínicas de pacientes sometidos a TE en el Hospital del Salvador. Resultados: Catorce pacientes fueron operados entre octubre de 2015 y agosto de 2016. La edad promedio fue de 45 años. Todos fueron sometidos a TE unilateral. Once de 14 perforaciones comprometía alguno de los cuadrantes anteriores. De éstas, en el 82% el borde anterior de la perforación no era visible con otomicroscopía. Se realizó otoendoscopía y audiometría 2 meses poscirugía, logrando un éxito anatómico de 92,8%, y mejoría en el PTP posoperatorio en todos los pacientes. Conclusión: Los resultados obtenidos son similares a los descritos utilizando microscopio. La TE permite mejor visualización convirtiendo esta técnica en una alternativa quirúrgica y de docencia atractiva. Es necesario realizar seguimiento a estos pacientes y aumentar el número de pacientes en el futuro.

ABSTRACT Introduction: The endoscopic ear surgery technique has been a great advance in the last years due to the developments in high resolution optics and surgical instruments. The use of an endoscope provides the visualization of difficult access zones in the middle ear, such as patients with prominent anterior wall of the external auditory canal and anterior tympanic perforations. Aim: To describe the endoscopic tympanoplasty (ET) as an alternative treatment for patients who suffer from chronic otitis media, and to analyze the functional and anatomic outcome. Material and method: Clinical record review of patients submitted to a ET in Hospital del Salvador. Results: 14 patients were operated during October 2015 and August 2016. The average age was 45 years. All of them where submitted to a unilateral ET. 11 of 14 perforations compromised some of the anterior quadrants. In 82% of the latter the anterior edge of the perforation was not visible with otomicroscopy. An otomicroscopy and audiometry were performed 2 months after surgery, anatomic outcome success was of 92,8%, and PTA improved after surgery in all patients. Conclusion: The obtained results are similar to those described using microscope. ET allows improved visualization making this technique an attractive surgery and teaching choice. It is necessary to evaluate these results with a higher number of patients.

Long-term Outcome of Cochlear Implant in Patients with Chronic Otitis Media: One-stage Surgery Is Equivalent to Two-stage Surgery

This study compared long-term speech performance after cochlear implantation (CI) between surgical strategies in patients with chronic otitis media (COM). Thirty patients with available open-set sentence scores measured more than 2 yr postoperatively were included: 17 who received one-stage surgeries (One-stage group), and the other 13 underwent two-stage surgeries (Two-stage group). Preoperative inflammatory status, intraoperative procedures, postoperative outcomes were compared. Among 17 patients in One-stage group, 12 underwent CI accompanied with the eradication of inflammation; CI without eradicating inflammation was performed on 3 patients; 2 underwent CIs via the transcanal approach. Thirteen patients in Two-stage group received the complete eradication of inflammation as first-stage surgery, and CI was performed as second-stage surgery after a mean interval of 8.2 months. Additional control of inflammation was performed in 2 patients at second-stage surgery for cavity problem and cholesteatoma, respectively. There were 2 cases of electrode exposure as postoperative complication in the two-stage group; new electrode arrays were inserted and covered by local flaps. The open-set sentence scores of Two-stage group were not significantly higher than those of One-stage group at 1, 2, 3, and 5 yr postoperatively. Postoperative long-term speech performance is equivalent when either of two surgical strategies is used to treat appropriately selected candidates.

Preparation and placement of cartilage island graft in tympanoplasty / Preparação e colocação de enxertos de cartilagem “em ilha" em timpanoplastia

Introduction: Cartilage graft tympanoplasty has a better success rate in the treatment of chronic otitis media if regularly prepared and placed. Objective: To prepare cartilage island material and evaluate its effect on the success rate of tympanoplasty. Methods: The medical records of 87 patients (48 males and 39 females; mean age, 27.3 ±11.2 years; range, 14–43 years) with chronic otitis media without cholesteatoma who underwent intact canal-wall-up tympanoplasty and revision surgery between December of 2007 and October of 2011 were retrospectively evaluated. Surgery was performed under general anesthesia via a retroauricular approach. Results: The overall success rate of this technique was 93% in terms of perforation closure. No graft lateralization or displacement into the middle ear occurred. The overall average preoperative air bone gap was 37.27 ± 12.35 dB, and the postoperative air bone gap was 27.58 ± 9.84 dB. The mean postoperative follow-up period was 15.3 months (range: 7–21 months). Conclusion: If cartilage graft is properly prepared and placed, cartilage graft tympanoplasty appears to provide better success rates and hearing results. .

Introducão: A timpanoplastia de enxerto de cartilagem tem uma melhor taxa de sucesso no tratamento de otite média crónica se for preparada e colocada de forma sistemática. Objetivo: Preparar o material de enxerto de cartilagem “em ilha" e avaliar o seu impacto na taxa de sucesso da timpanoplastia. Método: Os registos médicos de 87 pacientes (48 do sexo masculino e 39 do sexo feminino; idade média 27.3 ±11.2 anos; intervalo 14–43 anos) com otite média crónica sem colesteatoma que foram submetidos a timpanoplastia de levantamento de parede do canal intacto e cirurgia de revisão entre Dezembro 2007 e Outubro 2011 foram avaliados em retrospetiva. A cirurgia foi realizada sob anestesia geral através de uma abordagem retro auricular. Resultados: A taxa de sucesso global da nossa técnica foi de 93% em termos de sutura da perfuração. Não ocorreu lateralização do enxerto nem deslocação para o ouvido médio. O intervalo aéreo-ósseo pré-operatório médio global (ABG) era de 37.27 ±12.35 dB e o ABG pós-operatório era de 27.58±9.84dB. O período médio de seguimento pós-operatório era de 15.3 meses (intervalo 7-21 meses). Conclusão: Se o enxerto de cartilagem for devidamente preparado e colocado, a Timpanoplastia de enxerto de cartilagem apresenta melhores taxas de sucesso e resultados ao nível da audição. .

(Central) Auditory Processing: the impact of otitis media

OBJECTIVE: To analyze auditory processing test results in children suffering from otitis media in their first five years of age, considering their age. Furthermore, to classify central auditory processing test findings regarding the hearing skills evaluated. METHODS: A total of 109 students between 8 and 12 years old were divided into three groups. The control group consisted of 40 students from public school without a history of otitis media. Experimental group I consisted of 39 students from public schools and experimental group II consisted of 30 students from private schools; students in both groups suffered from secretory otitis media in their first five years of age and underwent surgery for placement of bilateral ventilation tubes. The individuals underwent complete audiological evaluation and assessment by Auditory Processing tests. RESULTS: The left ear showed significantly worse performance when compared to the right ear in the dichotic digits test and pitch pattern sequence test. The students from the experimental groups showed worse performance when compared to the control group in the dichotic digits test and gaps-in-noise. Children from experimental group I had significantly lower results on the dichotic digits and gaps-in-noise tests compared with experimental group II. The hearing skills that were altered were temporal resolution and figure-ground perception. CONCLUSION: Children who suffered from secretory otitis media in their first five years and who underwent surgery for placement of bilateral ventilation tubes showed worse performance in auditory abilities, and children from public schools had worse results on auditory processing tests compared with students from private schools. .

Acquired cholesteatoma of the ear; comparative analysis of histopathological findings in adults, children and recurrent cases

To compare the histopathological characteristics of acquired cholesteatoma in adults, children and recurrent cases. A retrospective analysis of 60 histopathological specimens for 60 patients aged 9 to 63 years who underwent otologic surgery for chronic otitis media with cholesteatoma was carried out at King Hussein Medical Centre between January 2006 till July 2010. Patients were divided into three groups as follows; group A patients aged > 16 years with no history of previous ear surgery, group B patients aged > 16 years and had history of previous otologic surgery for cholesteatoma and group C patients aged

Timpanoplastía: revisión y experiencia de 4 años en el Hospital Clínico de la Universidad Católica de Chile / Tympanoplasty: review and experience of 4 years at the Hospital Clínico de la Universidad Católica de Chile

Introducción: Desde la introducción de esta técnica quirúrgica en la segunda mitad del siglo XIX ha habido múltiples publicaciones sobre diversas experiencias y nuevas técnicas a nivel nacional e internacional. En nuestro hospital esta cirugía es parte de la práctica clínica habitual. Objetivo: El objetivo general es revisar la experiencia en timpanoplastías en el Hospital Clínico de la Universidad Católica de Chile en los últimos 4 años. Los objetivos específicos son revisar la epidemiología de los pacientes intervenidos, las técnicas quirúrgicas utilizadas y los resultados anatómicos y audiológicos conseguidos. Material y método: Estudio retrospectivo y descriptivo. Se revisó la totalidad de las fichas y audiometrías de los pacientes sometidos a timpanoplastías que cumplieron criterios de inclusión y exclusión bien definidos. Se incluyeron sólo pacientes cuya cirugía fue realizada entre enero de 2007 y diciembre de 2010. Resultados: Se obtuvo éxito anatómico en 82,4 por ciento de nuestros pacientes, con una tasa de complicaciones de 17,57 por ciento. Con respecto a los resultados auditivos, se observó un éxito auditivo total de 87,08 por ciento, y sólo en 13 por ciento de los pacientes empeoró su audición. Conclusiones: Los resultados anatómicos y auditivos obtenidos son comparables a lo publicado en la literatura nacional en la última década. Nuestra experiencia muestra un buen rendimiento con las técnicas e injertos utilizados, así como un buen resultado en las cirugías realizadas por médicos residentes, similares a los obtenidos por médicos staff.

Introduction: Since the introduction of this surgical technique in the second half of the nineteenth century, there have been many national and international publications on various experiences and new techniques. In our hospital this surgery is part of the routine clinical practice, so we decided to conduct this study to review our experience over the last 4 years. Aim: The general objective is to review the experience of tympanoplasty in the Hospital Clínico de la Universidad Católica de Chile in the last 4 years. The specific objectives are to review the epidemiology of patients undergoing this surgery, the surgical techniques used and the anatomical and audiological results achieved. Material and method: Descriptive and retrospective study. We reviewed all the clinical records and hearing tests in patients undergoing tympanplasty who met inclusion and exclusion criteria clearly defined. We only included patients whose surgery was performed between January 2007 and December 2010. Results: Anatomical success was archieved in 82.4 percent of our patients, with a complication rate of 17.57 percent. With regard to hearing results, there was a total audiological success of 87.08 percent and only 13 percent of our patients experienced worsening of their audition. Conclusions: The anatomical and audiological results obtained are comparable to those published in the national literature in the last decade. Our experience shows a good performance with the techniques and grafts used, and good results in surgeries performed by residents, similar to those obtained by staffs.

Evaluation of the organic and functional results of tympanoplasties through a retro-auricular approach at a medical residency unit / Avaliação dos resultados organofuncionais de timpanoplastias por via retroauricular em serviço de residência médica

Tympanoplasty aims at rebuilding the tympanic membrane with or without middle ear functional recovery. AIM: To evaluate the surgical results of tympanoplasties with a retro-auricular surgical approach at a medical residency unit. MATERIALS AND METHODS: Thirty-nine patients with diagnosis of simple chronic otitis media were evaluated; these patients underwent tymplanoplasty by a retro-auricular approach (underlay technique) at a medical residency unit. Patients were included in a prospective medical and audiologic investigation protocol that consisted of a clinical, otomicroscopic and audiometric evaluation. All procedures were supervised by training specialists otorrinolaringology. RESULTS: The rate of surgical success - full integration of the graft - was 95 percent of cases. Improvement of hearing, as demonstrated in audiometry, occurred in 72 percent of cases. Improvement in tinnitus was demonstrated subjectively on a visual analog scale in 69 percent of cases. CONCLUSION: Tympanoplasty through a retro-auricular approach is easy to perform. Full graft integration occurred in 95 percent of cases and was independent of factors deemed by many authors as relevant. The results - improvement of the quality of hearing and tinnitus - were significant.

Atimpanoplastia tem por objetivo a reconstrução da membrana timpânica com ou sem reconstrução funcional da orelha média. OBJETIVO: Avaliar os resultados cirúrgicos das timpanoplastias com o acesso cirúrgico retroauricular realizadas em serviço de residência médica. MATERIAL E MÉTODO: Foram avaliados 39 pacientes com diagnóstico de otite média crônica simples submetidos à timpanoplastia por via retroauricular (técnica "underlay") em um serviço de residência médica. Os pacientes foram incluídos em um protocolo de investigação médica e audiológica prospectivo que consistiu em avaliação clínica, otomicroscópica e audiométrica. Todos os procedimentos foram supervisionados por preceptores especialistas em otorrinolaringologia. RESULTADOS: A taxa de sucesso cirúrgico representado pela integração total do enxerto ocorreu em 95 por cento dos casos. A melhora da qualidade auditiva, comprovada pela audiometria, ocorreu em 72 por cento dos casos. Foi demonstrada a melhora subjetiva do zumbido, com a utilização da escala visual analógica, em 69 por cento dos casos. CONCLUSÃO: A timpanoplastia por via retroauricular é de fácil realização. A integração total do enxerto ocorreu em 95 por cento dos casos e foi independente de fatores considerados por muitos autores como relevantes. Os resultados quanto à melhora da qualidade auditiva e do zumbido foram significativos.

Patterns of cholesteatoma extension in chronic otitis media

To analyze the patterns of extension of cholesteatoma during surgery for chronic otitis media. A retrospective review was made of all cholesteatoma surgery in otology center within 6 years. Data included demographic data and the patterns of extension of cholesteatoma. One hundred sixty six patients, 86 [51.8%] males and 80 [48.2%] females, who were admitted with clinical diagnosis of chronic suppurative otitis media, with cholesteatoma. Analysis of the patterns of extension of cholesteatoma, showed that the tympanic cavity was involved in [91.6%], mastoid cavity in [74%] and Eustachian orifice in [42%] of our patients. In the Tympanic cavity, oval window [46%] and sinus tympani [40%] were involved. The most common patterns of extension included tympanic cavity. Attic and antrum involvement were greater than attic only. This study showed that despite decrease in chronic otitis media cases; still there is extensive extension of cholesteatoma in various part of temporal bone in different patients

Effect of ear surgery on bone conduction thresholds of patients with chronic middle ear disease

To determine the effects of surgical treatment on bone conduction thresholds in patients with chronic middle ear disease. This prospective quasi experimental study included 83 patients of chronic middle ear disease, which were surgically treated at the department of otolaryngology of a tertiary care teaching hospital in Rawalpindi, between May 2007 to May 2010. The preoperative and postoperative bone conduction thresholds were obtained one day before and six months after the surgical procedure and the data was analyzed in various ways to determine any statistical difference by applying paired t test. Statistical significance was accepted if p value is <0.05. Statistically significant deterioration in mean bone conduction thresholds was found only with radical mastoidectomy at 4000 Htz. There was no change in mean bone conduction thresholds in 68 [82%] of patients. A total of 7 [8.4%] patients showed improvement whereas 8 [9.6%] patients showed worsening of postoperative bone conduction thresholds. Mean improvement in bone conduction thresholds was 16.25 db [range 10 to 22.5 dB] whereas mean deterioration of 14.68 dB [range 10 to 30 dB] were noted. The surgical treatment of chronic middle ear disease does not affect bone conduction thresholds in majority of the patients

Timpanoplastías en adultos en el Complejo Asistencial Dr. Sótero del Río (CASR): revisión de 5 años / Tympanoplasty in adults at the Complejo Asistencial Dr. Sótero del Rio (CASR): review of 5 years experience

Introducción: En la residencia de tercer año de la beca de otorrinolaringología de la Pontificia Universidad Católica de Chile se realiza el "comité de oído" en el Hospital Clínico UC y el Complejo Asistencial Dr. Sótero del Rio (CASR) lo que nos ha permitido una experiencia. Quisimos revisar los resultados de las timpanoplastías realizadas en este último en un plazo de 5 años. Objetivo: Los objetivos de este estudio son identificar y describir las características epidemiológicas de los pacientes sometidos a timpanoplastía atendidos en el CASR, además evaluar la frecuencia de utilización de diferentes técnicas quirúrgicas y sus resultados anatómicos y auditivos. Material y método: Se realizó un estudio retrospectivo y descriptivo. Se revisaron 101 fichas de los pacientes mayores de 15 años con diagnóstico de OMC sometidos a timpanoplastía atendidos en el CASR entre enero de 2000 y diciembre de 2004. Resultados: Éxito anatómico en el 79 por ciento de los casos. En relación al resultado auditivo 62 por ciento de los pacientes mejoró más de 10 dB su audición y 30 por ciento> la mantuvo igual, lo que determina 92 por ciento de los pacientes con buen resultado auditivo. Conclusiones: Estos resultados corresponden al rendimiento de la timpanoplastía practicada en su mayoría por residentes de 3° año y otorrinos generales con distintos niveles de formación en otocirugía. Esto podría explicar la leve disminución en el éxito anatómico, comparado con series nacionales.

Introduction: In the third year of the residency of otolaryngology in the Pontificia Universidad Católica de Chile the residents forms part of the "ear committee" of the Hospital Clínico UC and the Complejo Asistencial Dr Sotero del Rio (CASR), is that why we want to review the timpanoplasty results with a follow up of 5 years. Aim: The aim of this study is identify and show the epidemiologic data of the patients who was operated of timpanoplasty in the CASR, also review the different surgical techniques and the anatomic and auditive results. Material and method: A retrospective, descriptive study was made. We review 101 records of all patients older than 15 years old, who presented chronic otitis media and underwent tympanoplasty, between January 200 and December 2004. Results: Anatomical success in 79 percent of all cases. 62 percent of all cases were better than 10 dB from base hearing, and 30 percent keep the same level of hearing, which determines 92 percent> of all the patients with a good hearing outcome. Conclusions: These results correspond to the performance of tympanoplasty practiced mostly by residents of 3rd year and general ENT with different levels of training in otologic surgery. This may explain the slight decrease in the anatomic success compared with national series.

Morphological aspects of tympanic bulla after ventral osteotomy in cats / Aspectos morfológicos da bulla tympanica de gatos após osteotomia ventral

PURPOSE: To evaluate tympanic bulla healing after experimental ventral osteotomy in cats. METHODS: Twenty adult cats were submitted to unilateral ventral bulla osteotomy and divided into two groups: cats of A1 group (n=10) were euthanized at 8 weeks and cats of A2 group (n=10), at 16 weeks postoperative. RESULTS: Signs of Horner's syndrome or damage to the inner ear were not found. Open-mouth radiographs taken in the immediate postoperative showed interruption in the contour of the larger compartment of the operated bulla. The result of Mcnemar'test was significant in A2 group (*p=0.0156). Macroscopic exams revealed that the operated bullae were similar to the normal ones, with preservation of the tympanic cavity. Connective tissue at the osteotomy site of the larger compartment was significantly found in the operated bullae in both groups (McNemar test: A1 p=0.0020*; A2 p=0.0078*). Histomorphometric analyses showed that the connective tissue length at the osteotomy site was shorter in A2 group than in the A1 group (Mann-Whitney test: p=0.0021*). CONCLUSIONS: Experimental ventral osteotomy did not alter significantly the tympanic bulla conformation and complete regeneration of tympanic bulla frequently did not occur before 16 weeks of postoperative period.

OBJETIVO: Avaliar a morfologia da bulla tympanica de gatos após osteotomia ventral unilateral. MÉTODOS: Foram utilizados 20 gatos distribuídos em dois grupos de 10 animais cada, de acordo com o período de observação: A1 (8 semanas) e A2 (16 semanas). RESULTADOS: Nenhum animal apresentou síndrome de Horner ou lesão do ouvido interno. Nas radiografias em projeção com a boca aberta realizadas no pós-operatório imediato observou-se a interrupção do compartimento maior da bulla tympanica operada, resultado significante no grupo A2 (McNemar, p=0,0156*). Os exames macroscópicos revelaram que a bulla tympanica operada apresentava conformação semelhante a da bulla tympanica normal, com preservação da cavidade timpânica. Na maioria das bullae tympanicae operadas observou-se a presença de tecido conjuntivo na área de osteotomia. O resultado do teste de McNemar foi significante em ambos os grupos (A1, p=0,0020*; A2, p=0,0078*). Os exames histomorfométricos demonstraram que a extensão de tecido conjuntivo presente no local da osteotomia do compartimento maior era menor nas bullae tympanicae operadas do grupo A2 (Mann-Whitney, p=0,0021*). CONCLUSÕES: A osteotomia ventral não alterou de maneira significativa a conformação da bulla tympanica. A regeneração total da bulla tympanica geralmente não ocorreu antes de 16 semanas de pós-operatório.

Comparação audiometria em crianças com tubo de ventilação / Audiometric comparison in children with vent tub

Introdução: Otite média com efusão (OME) é uma das doenças mais comuns na infância. Manifestações clínicas variam do prejuízo na fala ao déficit no aprendizado. O diagnóstico deve ser feito, principalmente, pelo exame físico e timpanometria. O tratamento da OME pode ser clínico ou cirúrgico, inserindo-se um tubo de ventilação. Objetivo: Avaliar o seguimento de pacientes com OME submetidos à colocação de tubo de ventilação comparando-se os achados audiométricos pré e pós-operatórios. Método: Crianças com OME e falha no tratamento clínico foram submetidas à timpanostomia e colocação de tudo de ventilação. A audiometria obtida no pré-operatório foi comparada à solicitada durante o acompanhamento, entre seis e doze meses após a cirurgia, posteriormente à extrusão do tubo. Resultados: O Limiar de Reconhecimento de Fala passou de um valor médio de 28,75 dB para 13 dB. Conclusões: As crianças submetidas à colocação de tubo de ventilação apresentaram significativa melhora audiométrica após a cirurgia. Visto que os dados deste estudo foram obtidos de exames objetivos, acreditamos que esta seja uma excelente forma de avaliar os resultados cirúrgicos de pacientes submetidos à colocação de tubo de ventilação.

Introduction: Otitis media with effusion (OME) is one of the most common diseases in the childhood. Clinical manifestations vary from speech damage to learning deficit. The diagnosis must be made, mainly, through the physical exam and tympanometry. The treatment of OME may be clinical or surgical, with a vent tube. Objective: To evaluate the follow-up of patients with OME submitted to the placing of vent tube and compare the pre- and postoperative audiometric findings. Method: Children with OME and failure in the clinical treatment were submitted to tympanometry and placing of vent tube. The audiometry obtained in the postoperative period was compared with that requested during follow-up, between six and twelve months after surgery, subsequent to the tube extrusion. Results: The Speech Recognition Threshold exceeded an average value of 28.75 dB to 13 dB. Conclusions: The children submitted to the placement of the vent tube presented a significant audiometric improvement after the surgery. Since the data in this study were obtained from objective exams, we believe this is an excellent way to evaluate the surgical results of patients submitted to the placement of the vent tube.

Correlação entre timpanograma e fluído de miringotomia em crianças portadoras de otite média com efusão / Correlation between tympanogram and myringotomy fluid in pediatric patients with otitis media with effusion

A Otite Média com Efusão é uma das causas da impotência auditiva que pode ser tratada simplesmente com a miringotomia ou sem a inserção do tubo de ventilação. Objetivo: Este estudo tem o objetivo de avaliar os diferentes tipos de fluidos após a miringotomia em Otite Média com Efusão; avaliar o exame de timpanograma de pacientes que são submetidos à miringotomia; correlacionar o fluído de miringotomia e o timpanograma pré-operatório em crianças portadoras de Otite Média com Efusão. Método: Um estudo retrospectivo em crianças menores de 12 anos portadoras de Otite Média com Efusão foi realizado na seção de otorrinolaringologia na escola da T.U. em Katmandu entre outubro de 2005 e setembro de 2007. Todos os pacientes que foram submetidos à miringotomia foram avaliados pelo exame timpanométrico e este foi comparado com os tipos de fluidos durante a cirurgia. O resultado foi estatisticamente analisado através do teste Qui-Quadrado. Resultados: A faixa etária dos pacientes era entre cinco e oito anos. Cerca de 56,8% das crianças apresentavam fluido de miringotomia espesso com aspiração seca em 27,5%. O timpanograma evidenciou curva tipo B em 90,2% das crianças. Curva tipo B e fluido espesso foram encontrados em 63%, e 21% das crianças apresentavam aspiração seca. Entretanto, todos os pacientes com fluido expesso apresentaram curva tipo B no timpanograma. A sensibilidade da curva B para prever a presença de fluido foi de 97,3%, enquanto a especificidade para foi de 28,6%. Conclusão: A Curva tipo B é a curva comum no timpanograma em pacientes portadores de Otitie Média com Efusão, porém, nem sempre ela indica a presença de fluido na orelha média. O timpanograma é bastante útil para prever a origem do fluído de miringotomia

Otitis Media with Effusion is a common cause of hearing disability that can be treated simply with myringotomy with or without ventilation tube insertion. Aim: The aims of this study are 1) to assess different types of fluid after myringotomy in Otitis Media with Effusion, 2) to assess the Pre Operative Tympanogram in Patients undergoing myringotomy 3)to correlate between myringotomy fluid and pre operative tympanogram in pediatric patients with Otitis Media with Effusion Method: A retrospective study in children (< 12 years) with Otitis media with effusion was carried out in ENT Department, T.U. Teaching Hospital, Kathmandu between October 2005 to September 2007. All patients undergoing myringotomy were assessed by tympanometry and compared with the types of fluid during surgery. Result was analyzed statistically using Chi -Square Test. Results: Most of the patients were in age group 5-8 years. Around 56.8 % of children had thick myringotomy fluid with dry tap in 27.5 %. Tympanogram showed B type curve in 90.2 % children. In patients with B type curve, thick fluid was found in 63.0%, while 21.0 % children had dry tap. But all patients with thick fluid had B type curve in Tympanogram. Sensitivity of B curve to predict fluid was 97.3% while Specificity was 28.6%. Conclusion: Common type of tympanogram curve in patients with Otitis Media with Effusion is B type, but it doesn?t always indicate to have fluid in middle ear. Tympanogram is useful in predicting the nature of the myringotomy fluid.

[Tympanoplasty without use of gelfoam in the middle ear]

In the conventional technique of tympanoplasty almost all of the ENT surgeons use gelfoam in the middle ear for supporting graft against margin of tympanic membrane perforation. In this study we didn't use gelfoam in the middle ear and compared the results of graft success rate with two techniques. In this clinical trial, during 2 years 181 patients with chronic otitis media [COM] underwent tympanoplasty with underlay grafting. In 83 patients gelfoam was used in the middle ear for tympanoplasty or tympanomastoidectomy [CCTM, OCTM]. In 98 patientswe did not use gelfoam in the middle ear. In the first group 59 and 24 patients underwent CCTM and OCTM respectively and in the second group 61 and 37 patients underwent CCTM and OCTM respectively. In the patients with using gelfoam, graft success rate was 91% for tympanoplasty and CCTM group and 83% for OCTM group. In patients without gelfoam, graft success rate was 89% in tympanoplasty and CCTM group and 84% in OCTM group. In this study, the graft success rate was similar in 2 groups. The advantage of this technique is rapid improvement of patients' hearing after removal of the external ear canal rosebud. In addition, the reaction of immune system is less than usual technique. We conclude that this technique could be routinely used in tympanoplasty and tympanomastoidectoy

Correlação da cadeia ossicular no transoperatório com achados histológicos de colesteatomas / Hystology findings' correlation between the ossicular chain in the transoperative and cholesteatomas

A Otite Média Crônica é definida pela presença de alterações teciduais inflamatórias irreversíveis na fenda auditiva. As lesões ossiculares são as mais prevalentes. OBJETIVO: Correlacionar o grau de comprometimento da cadeia ossicular, visualizada no transoperatório, com o grau histológico de inflamação e com a espessura da perimatriz de colesteatomas. TIPO DE ESTUDO: Estudo transversal. MÉTODOS: Descrições cirúrgicas de 71 pacientes foram revisadas. Colesteatomas coletados e fixados em formol 10 por cento e preparadas uma lâmina em Hematoxilina-Eosina e outra em Picrossírios. A leitura foi "cega", através de imagens digitais, no ImageProPlus. A análise estatística foi realizada através do coeficiente de Spearman, sendo considerados como estatisticamente significativos os valores de P≤0,05. RESULTADOS: Havia algum envolvimento da cadeia ossicular em 65 casos. O ossículo mais freqüentemente afetado era a bigorna, seguida pelo estribo e pelo martelo. Ao aplicarmos o coeficiente de Spearman entre o grau de comprometimento da cadeia ossicular com a idade do paciente à cirurgia, a espessura da perimatriz e o grau histológico de inflamação não foram detectadas correlações. CONCLUSÃO: Os nossos achados indicam que é praticamente universal o acometimento da cadeia ossicular na presença de colesteatoma. Não foi encontrada correção entre a erosão ossicular e os achados histológicos.

Chronic otitis media is hystopathologycaly defined as the presence of irreversible inflammatory tissue changes in the middle ear. Ossicular lesions represent the most prevalent change. AIM: to correlate the degree of ossicular chain changes seen during surgery with the inflammatory histological degree and the thickness of the cholesteatoma perimatrix. STUDY DESGN: Cross-sectional study. METHODS: Seventy-one descriptions of surgeries done in patients submitted to tympanomastoydectomy were reviewed. Cholesteatoma were collected and fixed in 10 percent formaldehyde. Two slides were made for each cholesteatoma, one stained with HE and another with picrossirius. Images were obtained from light microscopy and digitally processed and "blindly" analyzed using Image Pro-Plus Software. For statistical analysis we used Spearman's coefficient. Differences were considered statistically significant if P≤0.05. RESULTS: the ossicular chain was involved in 65 cases. The incus was the most frequently affected bone, followed by the stapes and the malleus. When the Spearman's coefficient was employed considering ossicular chain change degree with patient's age by the time of surgery, perimatrix thickness and histological degree of inflammation, correlations were not established. CONCLUSION: Our findings indicate that ossicular chain changes are practically universal when a cholesteatoma is present. We didn't find correlations related with bone erosion and cholesteatoma's histological findings.