Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea

Objectives@#. Endoscopic tympanoplasty (ET) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility for the treatment of tympanic membrane (TM) perforations. However, the literature on surgical outcomes for large TM perforations is lacking and limited to small series. This study aimed to evaluate the clinical benefits of ET for large TM perforations. @*Methods@#. This retrospective cohort study was conducted at nine tertiary referral hospitals in South Korea, where 252 patients who underwent ET as primary surgery from September 2019 to August 2021 were included. The outcome measures included the graft success rate and pre- and postoperative audiometric data. @*Results@#. In 239 patients, the graft success rate of ET for large or subtotal perforations was 86.2% (206 patients), while the graft failure rate was 13.8% (33 patients). The graft failure rate was directly correlated with surgical techniques, including overlay and medial or lateral underlay tympanoplasty (P=0.027). Lateral underlay tympanoplasty showed the most favorable results. Sex, laterality, etiology, site and size of perforation, operation time, and graft materials did not vary significantly between the graft success and failure groups (P>0.05). The mean air-bone gap (ABG) improved significantly in both groups (graft success group: 10.0±0.6 dB and graft failure group: 7.7±0.3 dB; P<0.001). However, the ABG improvement did not significantly differ between the groups. Analysis of covariance revealed that the postoperative 500-Hz bone conduction threshold improved after successful ET (adjusted coefficient, –11.351; 95% confidence interval, –21.491 to –1.212; P=0.028). @*Conclusion@#. This study involved the largest population to date of large TM perforations treated by ET. The study findings suggest that ET is feasible and effective in treating large TM perforations.

Results of Active Middle Ear Implantation in Patients With Mixed Hearing Loss After Middle Ear Surgery: A Prospective Multicenter Study (the ROMEO Study)

Objectives@#. This study was conducted to evaluate the user satisfaction, efficacy, and safety of round window (RW) vibroplasty using the Vibrant Soundbridge (VSB) in patients with persistent mixed hearing loss after mastoidectomy. @*Methods@#. The study included 27 patients (mean age, 58.7 years; age range, 28–76 years; 11 men and 16 women) with mixed hearing loss after mastoidectomy from 15 tertiary referral centers in Korea. The VSB was implanted at the RW. The Korean translation of the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire and the Korean version of the International Outcome Inventory for Hearing Aids (K-IOI-HA) questionnaire were used to evaluate user satisfaction as the primary outcome. The secondary outcome measures were audiological test results and complication rates. @*Results@#. The mean scores for ease of communication (61.3% to 29.7% to 30.2%), reverberation (62.1% to 43.1% to 37.4%), and background noise (63.3% to 37.7% to 34.3%) subscales of the APHAB questionnaire significantly decreased after VSB surgery. The mean K-IOI-HA scores at 3 and 6 months after surgery were significantly higher than the mean preoperative score (18.6 to 27.2 to 28.1). The postoperative VSB-aided thresholds were significantly lower than the preoperative unaided and hearing aid (HA)-aided thresholds. There was no significant difference between preoperative unaided, preoperative HA-aided, and postoperative VSB-aided maximum phonetically balanced word-recognition scores. None of the 27 patients experienced a change in postoperative bone conduction pure tone average. One patient developed temporary facial palsy and two developed surgical wound infections. @*Conclusion@#. RW vibroplasty resulted in improved satisfaction and audiological test results in patients with mixed hearing loss after mastoidectomy, and the complication rate was tolerable.

Modified Canal Wall Down Mastoidectomy Without Meatoplasty / 대한이비인후과학회지

It is important to decide which procedure to employ between canal wall up mastoidectomy and canal wall down mastoidectomy (CWDM) as each procedure has its own advantages and disadvantages. To combine the advantages and compensate the disadvantages of each procedure, various methods and approaches have been devised. Mastoid and epitympanic obliteration, which minimizes the dead space in the mastoid cavity, was previously known to prevent the occurrence of retraction pockets. We performed mastoid and epitympanic obliteration also to prevent the occurrence of cavity problems without meatoplasty. Here we describe the surgical procedures for modified CWDM without meatoplasty and mastoid obliteration using autologous materials.

Tumor Growth and Hearing Changes in the Natural Progress of Vestibular Schwannoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#Vestibular schwannoma is a benign neoplasm originating from the vestibular nerve, and the most common symptom caused by the tumor is unilateral hearing loss. This study is aimed to review the clinical outcomes of tumor growth and hearing changes in the natural progress of vestibular schwannoma.SUBJECTS AND METHOD: We retrospectively reviewed 28 patients who were diagnosed with vestibular schwannoma and treated with the ‘wait and scan’ modality for more than a year. We analyzed the patients' audiological changes and tumor growth by reviewing the temporal bone MR images. Patients were classified into an intrameatal group and extrameatal group according to the involvement of the cerebropontine angle.@*RESULTS@#The overall mean follow-up was 45.6±25.8 months. Among the 28 patients, 6 (21.4%) showed tumor growth after ‘wait and scan.’ Hearing thresholds and speech discrimination scores showed deterioration after ‘wait and scan’ in both groups. Among the 12 patients with serviceable hearing at initial diagnosis, 9 (75.0%) preserved serviceable hearing after ‘wait and scan.’ When the pure tone average and speech discrimination scores were applied to the scattergram, most values were positioned near the center of the scattergram, which implied slight changes after ‘wait and scan.’@*CONCLUSION@#The percentage of patients showing tumor growth after the ‘wait and scan’ policy was low. Patients with serviceable hearing at diagnosis would most likely preserve their hearing after ‘wait and scan.’ Considering the limited tumor growth and minimal hearing changes, rather than microsurgery or radiation surgery, the conservative ‘wait and scan’ policy can be an alternative treatment modality in patients with small-sized, non-growing vestibular schwannomas.

Comparison of Intratympanic, Systemic, and Combined Steroid Therapies for Sudden Sensorineural Hearing Loss in Patients with Diabetes Mellitus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#We investigated whether the intratympanic steroid injections might be an effective initial treatment for sudden sensorineural hearing loss (SSNHL) in patients with diabetes mellitus (DM).SUBJECTS AND METHOD: We assessed a total of 167 patients with DM and SSNHL who visited a tertiary referral otolaryngology department between January 2010 and April 2018. Forty-two patients with DM and SSNHL received intratympanic steroid injections; 48 patients with DM and SSNHL received systemic steroid treatment; and 77 patients with DM and SSNHL received a combination of systemic and intratympanic treatment. Initial and post treatment hearing levels and fasting blood sugar (FBS) were assessed, and correlations between hearing gain and the duration of DM, HbA1c, FBS were investigated.@*RESULTS@#After steroid treatment, hearing levels were 38.87±25.35 dB in the intratympanic injection group, 41.09±28.49 dB in the systemic steroid treatment group, and 47.81±27.12 dB in the combined treatment group. Final hearing levels and hearing gain in the three groups did not differ significantly. FBS after treatment in the systemic steroid treatment and combined steroid treatment group worsened relative to the intratympanic injection group (202.00±9.40 mg/dL to 326.63±7.85 mg/dL). FBS, duration of DM, and HbA1c levels did not affect the hearing gain in patients with DM and SSNHL.@*CONCLUSION@#Intratympanic steroid injections are comparable to the systemic steroid treatment modality for SSNHL in patients with DM. Thus, intratympanic steroid injections may serve as an effective initial treatment modality for SSNHL in patients with DM.

Microscopic versus Endoscopic Inlay Butterfly Cartilage Tympanoplasty

BACKGROUND AND OBJECTIVES: Inlay butterfly cartilage tympanoplasty makes the graft easy, and reduces operating time. The present study aimed to investigate the outcomes of microscopic versus endoscopic inlay butterfly cartilage tympanoplasty. SUBJECTS AND METHODS: In this retrospective study, the outcomes of 63 patients who underwent inlay butterfly cartilage tympanoplasty with small to medium chronic tympanic membrane perforation were evaluated. Twenty-four patients underwent conventional microscopic tympanoplasty and 39 underwent endoscopic tympanoplasty. The outcomes were analyzed in terms of the hearing gain and graft success rate. RESULTS: The surgical success rate was 95.8% in the patients who underwent conventional microscopic tympanoplasty and 92.3% in those who underwent endoscopic tympanoplasty. In both groups of patients, the postoperative air-bone gap (ABG) was significantly lower than the preoperative ABG. There were no significant differences between the preoperative and postoperative ABG values in either group. CONCLUSIONS: Endoscopic inlay tympanoplasty using the butterfly cartilage technique appears to be an effective alternative to microscopic tympanoplasty and results in excellent hearing.

Outcomes of Modified Canal Wall Down Mastoidectomy and Mastoid Obliteration Using Autologous Materials

OBJECTIVES: The traditional canal wall down mastoidectomy (CWDM) procedure commonly has potential problems of altering the anatomy and physiology of the middle ear and mastoid. This study evaluated outcomes in patients who underwent modified canal wall down mastoidectomy (mCWDM) and mastoid obliteration using autologous materials. METHODS: Our study included 76 patients with chronic otitis media, cholesteatoma, and adhesive otitis who underwent mCWDM and mastoid obliteration using autologous materials between 2010 and 2015. Postoperative hearing air-bone gap and complications were evaluated. RESULTS: During the average follow-up of 64 months (range, 20 to 89 months), there was no recurrent or residual cholesteatoma or chronic otitis media. No patient had a cavity problem and anatomic integrity of the posterior canal wall was obtained. There was a significant improvement in hearing with respect to the postoperative air-bone gap (P<0.05). A retroauricular skin depression was a common complication of this technique. CONCLUSION: The present study suggests that our technique can prevent various complications of the classical CWDM technique using autologous tissues for mastoid cavity obliteration. It is also an appropriate method to obtain adequate volume for safe obliteration.

Comparison of Intratympanic, Systemic, and Combined Steroid Therapies for Sudden Sensorineural Hearing Loss in Patients with Diabetes Mellitus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: We investigated whether the intratympanic steroid injections might be an effective initial treatment for sudden sensorineural hearing loss (SSNHL) in patients with diabetes mellitus (DM). SUBJECTS AND METHOD: We assessed a total of 167 patients with DM and SSNHL who visited a tertiary referral otolaryngology department between January 2010 and April 2018. Forty-two patients with DM and SSNHL received intratympanic steroid injections; 48 patients with DM and SSNHL received systemic steroid treatment; and 77 patients with DM and SSNHL received a combination of systemic and intratympanic treatment. Initial and post treatment hearing levels and fasting blood sugar (FBS) were assessed, and correlations between hearing gain and the duration of DM, HbA1c, FBS were investigated. RESULTS: After steroid treatment, hearing levels were 38.87±25.35 dB in the intratympanic injection group, 41.09±28.49 dB in the systemic steroid treatment group, and 47.81±27.12 dB in the combined treatment group. Final hearing levels and hearing gain in the three groups did not differ significantly. FBS after treatment in the systemic steroid treatment and combined steroid treatment group worsened relative to the intratympanic injection group (202.00±9.40 mg/dL to 326.63±7.85 mg/dL). FBS, duration of DM, and HbA1c levels did not affect the hearing gain in patients with DM and SSNHL. CONCLUSION: Intratympanic steroid injections are comparable to the systemic steroid treatment modality for SSNHL in patients with DM. Thus, intratympanic steroid injections may serve as an effective initial treatment modality for SSNHL in patients with DM.

Computed Tomography and Magnetic Resonance Imaging Evaluation in Pediatric Unilateral Sensorineural Hearing Loss / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#Children with unilateral sensorineural hearing loss (USNHL) are not actively evaluated by physicians. The diagnostic tool for evaluation of USNHL is also controversial, and no strategy for diagnosing USNHL through imaging studies has been established. We examined the results of temporal bone computed tomography (TBCT) imaging and magnetic resonance imaging (MRI) studies on children with USNHL.SUBJECTS AND METHOD: Eighty-nine patients with USNHL were reviewed. Of these patients, 21 underwent both TBCT and MRI, 51 underwent temporal MRI only, and 17 underwent TBCT only.@*RESULTS@#The etiology of USNHL were determined through imaging studies in 20 patients. The most common abnormal finding (65%) was a narrow internal auditory canal identified on TBCT and cochlear nerve aplasia on temporal MRI. Incomplete partition (20%), common cavity (10%), and labyrinthitis ossificans (5%) were also observed in imaging studies. The hearing threshold was lower in USNHL patients with normal findings (76.1±28.7 dB) than in USNHL patients with abnormal findings on TBCT or temporal MRI (100.1±22.3 dB).@*CONCLUSION@#Cochlear and cochlear nerve abnormalities can be detected through imaging studies in approximately 25% of patients with USNHL. Therefore, we suggest that children should undergo TBCT when USNHL is confirmed through audiologic evaluation.

The Comparison of Short-Term Therapeutic Effects of Acute Low-Tone Sensorineural Hearing Loss according to Steroid Capacity / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Acute low-tone sensorineural hearing loss refers to a condition wherein thresholds increase only at low frequencies in pure-tone audiometry. Systemic steroid treatment is commonly used for acute low-tone sensorineural hearing loss without vertigo, but there has been no established treatment in most clinical researches. The purpose of this study is to compare and analyze the short-term effects of high- and half-dose oral steroid therapy on patients suffering from acute low-tone sensorineural hearing loss without vertigo. SUBJECTS AND METHOD: Forty-six patients diagnosed with acute low-tone sensorineural hearing loss were divided into two groups and treated with high-dose (24 patients) and half-dose (22 patients) steroids, respectively. A retrospective analysis was conducted on their medical records. RESULTS: There were no significant differences between the two groups in any of the following: age, sex ratio, duration of symptoms before treatment, pure-tone hearing thresholds, low frequency hearing thresholds and speech intelligibility. However, both groups showed significant differences in hearing thresholds before and after treatment. In addition, no significant difference was noted in the recovery and recurrence rate between the two groups. CONCLUSION: According to the results of this study, there is no difference in treatment effect between the high- and half-dose groups. Therefore, half-dose steroids may be used as a treatment option for acute low tone sensorineural hearing loss.

Vestibular Function and Prognosis of Sudden Sensorineural Hearing Loss with Vertigo / 대한평형의학회지

OBJECTIVES: Vertigo combined with sudden sensorineural hearing loss (SSNHL) is known as a poor prognostic factor. We investigated clinical findings and vestibular function tests in patients of SSNHL with vertigo to find the prognostic factors. METHODS: We retrospectively evaluated data on the patients diagnosed with SSNHL with vertigo at Bucheon Soonchunhyang University Hospital from March 2009 to February 2018. We reviewed medical records and the results of vestibular function tests and audiometry. RESULTS: Of the 68 patients, 30 (44.1%) showed profound hearing loss and 53 (77.9%) showed poor recovery. Age and the degree of initial hearing loss showed negative prognostic factor in hearing recovery. Abnormal results of cervical vestibular evoked myogenic potentials (cVEMP) also showed significantly differences between good and poor recovery groups. CONCLUSIONS: In this study, most of the patients of SSNHL with vertigo showed poor recovery. Age, degree of initial hearing loss, and the abnormal result of the cVEMP have a negative effect on the prognosis of hearing recovery.

Computed Tomography and Magnetic Resonance Imaging Evaluation in Pediatric Unilateral Sensorineural Hearing Loss / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Children with unilateral sensorineural hearing loss (USNHL) are not actively evaluated by physicians. The diagnostic tool for evaluation of USNHL is also controversial, and no strategy for diagnosing USNHL through imaging studies has been established. We examined the results of temporal bone computed tomography (TBCT) imaging and magnetic resonance imaging (MRI) studies on children with USNHL. SUBJECTS AND METHOD: Eighty-nine patients with USNHL were reviewed. Of these patients, 21 underwent both TBCT and MRI, 51 underwent temporal MRI only, and 17 underwent TBCT only. RESULTS: The etiology of USNHL were determined through imaging studies in 20 patients. The most common abnormal finding (65%) was a narrow internal auditory canal identified on TBCT and cochlear nerve aplasia on temporal MRI. Incomplete partition (20%), common cavity (10%), and labyrinthitis ossificans (5%) were also observed in imaging studies. The hearing threshold was lower in USNHL patients with normal findings (76.1±28.7 dB) than in USNHL patients with abnormal findings on TBCT or temporal MRI (100.1±22.3 dB). CONCLUSION: Cochlear and cochlear nerve abnormalities can be detected through imaging studies in approximately 25% of patients with USNHL. Therefore, we suggest that children should undergo TBCT when USNHL is confirmed through audiologic evaluation.

Analysis of Prognostic Factors in Malignant External Otitis

OBJECTIVES: Malignant external otitis (MEO) is a potentially fatal infection of the external auditory canal, temporal bone, and skull base. Despite treatment with modern antibiotics, MEO can lead to skull base osteomyelitis. Until now, there have been few studies on the prognostic factors of MEO. METHODS: We performed a retrospective study to identify prognostic factors of MEO, and a meta-analysis of other articles investigating MEO. On the basis of disease progression the 28 patients in our study were divided into ‘controlled’ and ‘uncontrolled’ groups, consisting of 12 and 16 patients, respectively. We identified three categories of prognostic factors: those related to patient, disease, and treatment. We compared these prognostic factors between the controlled and uncontrolled groups. RESULTS: In our study, the duration of diabetes mellitus (DM), presence of inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), and computed tomography or magnetic resonance imaging findings influenced the prognosis of MEO. In contrast, prognosis was unrelated to age, gender, mean glucose level, hemoglobin A1c level, pathogen, comorbidity, or cranial nerve involvement. No factor related to treatment modality was correlated with prognosis, such as surgery, steroid therapy, or interval to the first appropriate treatment. Cranial nerve involvement has been proven to be associated with disease progression, but the relationship between cranial nerve involvement and the prognosis of MEO remains controversial. As a part of this study, we conducted a meta-analysis of cranial nerve involvement as a prognostic factor of MEO. We found that cranial nerve involvement has a statistically significant influence on the prognosis of MEO. CONCLUSION: We found that glycemic control in diabetes mellitus, cranial nerve involvement, and the extent of disease determined from various imaging modalities influence the prognosis of MEO. We suggest that significant prognostic factors should be monitored to determine the prognosis of patients with MEO.

A Case of Recurrent Vertigo in Vestibular Schwannoma Treated with Chemical Labyrinthectomy / 대한평형의학회지

Vestibular schwannoma (VS) can have various symptoms and almost half of the patients have balance problems. Some patients with VS can suffer from recurrent vertigo mimicking Meniere's disease. We present the case of a 61-year-old male patient who was suffering from recurrent vertigo due to VS while symptoms improved by chemical labyrinthectomy with gentamicin. We consider that chemical labyrinthectomy can be an option in the treatment of patients with recurrent vertigo for VS.

A Case of Extramedullary Relapsed Acute Promyelocytic Leukemia Presenting as a Mass in the External Auditory Canal / 대한이비인후과학회지

Acute promyelocytic leukemia (APL) is a unique subtype of acute myelogenous leukemia for which complete remission is induced by using anticancer drugs with all-trans retinoic acid (ATRA). Extramedullary involvement at relapse is occasionally observed in patients with APL, and is said to be more common after treatment with ATRA. We describe a 35-year-old man who had a relapse due to a mass that developed in the external auditory canal after treatment with ATRA. He was successfully treated with arsenic trioxide and radiotherapy.

The Difference of Clinical Symptoms and Audiovestibular Function between Intrameatal and Extrameatal Acoustic Neuroma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Various hearing tests and vestibular function tests are used to diagnose acoustic neuroma. We analyzed the clinical characteristics and the results of audiovestibular function tests between patients of intrameatal and extrameatal acoustic neuroma. SUBJECTS AND METHOD: Reviewing the medical records for 64 patients with acoustic neuroma between March 2007 and February 2014, we divided the patients into two groups, intrameatal (31 patients) and extrameatal acoustic neuroma (33 patients) according to the involvement of cerebropontine angle. We compared the clinical characteristics, pure tone audiograms, speech audiometry, caloric test, and vestibular evoked myogenic potential (VEMP) between the two groups. RESULTS: While hearing loss was the most frequent presenting symptom in patients with intrameatal acoustic neuroma, dizziness was the most common symptom in patients with extrameatal acoustic neuroma. Hearing thresholds measured by pure tone audiometry and speech discrimination scores were significantly worse for patients with extrameatal acoustic neuroma. Abnormal unilateral canal paresis of caloric test was significantly higher for extrameatal acoustic neuroma than for intrameatal acoustic neuroma. Most patients with acoustic neuroma showed abnormal findings in the VEMP test, but the number of patients between intrameatal and extrameatal acoustic neuroma did not differ significantly. CONCLUSION: Clinical symptoms and the results of audiovestibular function tests differed according to the tumor size of acoustic neuroma. Physicians should counsel patients presenting with audiovestibular symptoms of the possibility of acoustic neuroma.

Persistent Postural-Perceptual Dizziness / 대한평형의학회지

Persistent postural-perceptual dizziness (PPPD) was derived from phobic postural vertigo and chronic subjective dizziness. Two key physical symptoms of PPPD are postural unsteadiness and visually induced dizziness. Although the underlying mechanism of PPPD is still enigmatic, the prognosis is good with adequate treatment. In this paper, diagnostic criteria, pathophysiology and treatment regarding PPPD will be reviewed.

Surgical Findings to Differentiate Between Facial Nerve Schwannoma and Vestibular Schwannoma

OBJECTIVES: Facial nerve schwannomas may be misdiagnosed as vestibular schwannomas (VSs) if the tumor is confined to the internal auditory canal (IAC) without involvement the geniculated ganglion or labyrinthine segment of facial nerve. Because facial nerve schwannomas may be misdiagnosed as VSs, we investigated the differences between the two. METHODS: The study included 187 patients with a preoperative diagnosis of VS. Of these, six were diagnosed with facial nerve schwannomas during surgery. We reviewed the preoperative evaluations and surgical findings of facial nerve schwannomas mimicking VSs. RESULTS: No useful preoperative predictors are available for facial nerve schwannomas mimicking VSs. Facial nerve schwannomas are usually confined to the IAC. After opening the dura of the IAC, a facial nerve schwannoma can be diagnosed after identifying a normal-appearing nerve located lateral to the tumor. When this was the case, we performed facial nerve preservation surgery or decompression. CONCLUSION: Facial nerve schwannomas can be differentiated from VSs by identifying specific findings during surgery.

A Case of Cerebellar Arteriovenous Malformation with Positional Down Beat Nystagmus / 대한평형의학회지

Brain arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system in the central nervous system. The first symptom of AVM is intracranial hemorrhage, followed by headache and seizure. However, dizziness as a symptom of AVM is very rare. We report a 16-year-old female patient who presented with disequilibrium. She showed down-beating nystamgus on Dix-Hallpike test and falling tendency on Romberg test with eyes open. Magnetic resonance image showed cerebellar AVM.

A Case of Arachnoid Cyst Presenting with Sudden Hearing Loss / 대한이비인후과학회지

Arachnoid cysts compose 1% of all intracranial tumors and are usually incidental findings in brain imaging. They may present with symptoms such as dizziness, tinnitus and hearing loss, although they may be usually asymptomatic. In particular, presentation with sudden deafness is very rare. We report a case of a 21-year-old male who presented with sudden hearing loss linked to a cerebellopontine angle (CPA) arachnoid cyst. In this case, the cystic lesion at the CPA was found by magnetic resonance imaging of the brain. The hearing loss of this patient was successfully treated with steroids.