Experimental cholesteatoma: a comparison between spontaneous and induced models.

OBJECTIVE: To compare the incidence and the histopathological aspect of spontaneous and two induced Mongolian gerbils' models of cholesteatoma: External Auditory Canal (EAC) obliteration model and the Auditory Tube (AT) cauterization model. METHODS: Fifty-four ears of 27 animals were divided into EAC obliteration, AT cauterization, and control groups and histologically assessed for cholesteatoma incidence and classification at intervals of 2, 4, 8, and 16 weeks. RESULTS: Cholesteatoma was diagnosed in 30 of the 53 ears evaluated with a significantly higher incidence in groups that received some type of intervention (p<0.0001). It was not possible to histologically distinguish cholesteatomas of the same stage between the study groups. CONCLUSION: Although we observed a significant increase in cholesteatoma incidence with the two methods used when compared to the control group, all developed cholesteatomas were apparently identical from a histological point of view.

Experimental cholesteatoma: a comparison between spontaneous and induced models

Abstract Objective: To compare the incidence and the histopathological aspect of spontaneous and two induced Mongolian gerbils' models of cholesteatoma: External Auditory Canal (EAC) obliteration model and the Auditory Tube (AT) cauterization model. Methods: Fifty-four ears of 27 animals were divided into EAC obliteration, AT cauterization, and control groups and histologically assessed for cholesteatoma incidence and classification at intervals of 2, 4, 8, and 16 weeks. Results: Cholesteatoma was diagnosed in 30 of the 53 ears evaluated with a significantly higher incidence in groups that received some type of intervention (p < 0.0001). It was not possible to histologically distinguish cholesteatomas of the same stage between the study groups. Conclusion: Although we observed a significant increase in cholesteatoma incidence with the two methods used when compared to the control group, all developed cholesteatomas were apparently identical from a histological point of view.

Endoscopic-Assisted Canal Wall-up Tympanomastoidectomy for Reduction of Residual Cholesteatoma

Abstract Introduction The treatment of cholesteatoma is generally surgical, and the major obstacle is the high prevalence of recidivism. The endoscopic ear surgery technique is proposed to minimize this problem. Objectives To utilize endoscopes to visualize and manipulate cholesteatoma residues after microscopic removal Methods Cross-sectional study. Thirty-two patients with cholesteatoma underwent microscopic wall-up mastoidectomy combined with the endoscopic approach. The subjects were assessed for the presence and location of covert disease. Results Of the 32 cases, 17 (53.12%) had residual cholesteatoma in the endoscopic phase. Minimal disease was found, usually fragments of the cholesteatoma matrix. Pars tensa cholesteatomas had more covert disease than pars flaccida cholesteatomas (62.50% vs 43.75%). Posterior recesses (47.05%) and tegmen tympani (41.17%) were the locations with more covert disease (p< 0.05). Conclusion Cholesteatomas of the pars tensa presented more residual disease and were significantly more common in the posterior recesses and tegmen tympani.

Endoscopic-Assisted Canal Wall-up Tympanomastoidectomy for Reduction of Residual Cholesteatoma.

Introduction The treatment of cholesteatoma is generally surgical, and the major obstacle is the high prevalence of recidivism. The endoscopic ear surgery technique is proposed to minimize this problem. Objectives To utilize endoscopes to visualize and manipulate cholesteatoma residues after microscopic removal Methods Cross-sectional study. Thirty-two patients with cholesteatoma underwent microscopic wall-up mastoidectomy combined with the endoscopic approach. The subjects were assessed for the presence and location of covert disease. Results Of the 32 cases, 17 (53.12%) had residual cholesteatoma in the endoscopic phase. Minimal disease was found, usually fragments of the cholesteatoma matrix. Pars tensa cholesteatomas had more covert disease than pars flaccida cholesteatomas (62.50% vs 43.75%). Posterior recesses (47.05%) and tegmen tympani (41.17%) were the locations with more covert disease ( p < 0.05). Conclusion Cholesteatomas of the pars tensa presented more residual disease and were significantly more common in the posterior recesses and tegmen tympani.

Tympanic membrane perforations: a critical analysis of 1003 ears and proposal of a new classification based on pathogenesis.

PURPOSE: To present a large series ears with tympanic membrane perforations (TMP), to describe their characteristics, and to propose a new classification system based on the pathogenesis of TMP. METHODS: This cross-sectional study was conducted at a tertiary university hospital with 1003 ears (792 consecutive patients with TMP in at least 1 ear). Otoendoscopy and audiometry were performed. Perforation measurements and their locations were digitally assessed. TMP with no suggestive signs of previous retraction were classified as Group 1, and those with possible previous retraction were classified as Group 2. Signs of retraction previous to the TMP, symptom length, perforation size and location, status of the contralateral ear, and hearing status were compared. RESULTS: Group 1 comprised 63.5% of the included ears. Compared to Group 2, Group 1 presented a higher rate of central perforations (99% vs. 53%), a shorter duration of symptoms, smaller perforations (mean area: 18.5% vs. 41.4%), a higher rate of perforations in the anterior quadrants, better hearing levels (mean tritonal gap: 23.9 dB vs. 29.2 dB), and a lower rate of abnormal contralateral ears (28% vs. 66%). CONCLUSION: The classification of TMP into two groups based on signs of previous retractions is feasible and indicates two different levels of disease severity. While the group without previous signs of retraction comprises ears with more limited disease, membranes with previous retraction seem to show more severe disease and, consequently, a less functional middle ear.

Central versus marginal tympanic membrane perforations: does it matter? An analysis of 792 patients.

BACKGROUND: There is a lack of studies concerning chronic otitis media without cholesteatoma. OBJECTIVES: To perform an analysis of tympanic membrane perforations (TMP), compare the parameters of central and marginal TMP, combining both the traditional and more recent technologies available. MATERIAL AND METHODS: 792 consecutive patients. The TMP subgroups were divided by central and marginal locations and compared based on signs suggestive of previous tympanic retraction, namely, medialized malleus, tympanic remnants over the promontory, tympanic remnants over the ossicular chain, and incus/stapes erosion. Analysis of the status of the contralateral ear (CLE). RESULTS: Central TMP was diagnosed in 79.8%. Compared with the central group, the marginal group had more reported hearing loss (95.6%), greater conductive hearing loss (pure tone average for air-conduction 43.3 dB and average air-bone gap of 28.7 dB), a larger perforated area (46.45%), more posteroinferior quadrant involvement, a greater number retraction signs prior to the TMP, and more changes in the CLE (71%). CONCLUSION: The differences between TMP subgroups are highlighted when we use all technologies available to compare them. Marginal TMPs have more altered parameters than central TMPs. SIGNIFICANCE: There is a great possibility to enhance the knowledge of TMPs and to improve the pathogenesis-based treatment.

The Role of Tympanic Membrane Retractions in Cholesteatoma Pathogenesis.

OBJECTIVE: To analyze the contralateral ear (CLE) of patients with cholesteatoma and to correlate the cholesteatoma growth pattern in the affected ear with the findings in the CLE. METHODS: Videotoscopy of both ears in 432 patients with cholesteatomas classified as posterior epitympanic (PEC), posterior mesotympanic (PMC), two routes, or undetermined. Tympanic membrane (TM) retractions were classified by location and severity and TM perforations according to signs of previous TM retraction. RESULTS: TM retraction was the most prevalent alteration in the CLE (42.6%). Cholesteatoma was observed in 17.4%. In patients with PEC, the retraction in the CLE was more frequent in the PF (66.7%) than in the PT (1.4%), and in those with two-route cholesteatoma, the retraction in the CLE most frequently involved both the PT and PF (65.6%; p < 0.0001). CONCLUSION: Our results confirm the essential role of TM retraction at least in the earlier phases of cholesteatoma pathogenesis.

Characteristics of 419 patients with acquired middle ear cholesteatoma / Características de 419 pacientes com colesteatoma adquirido de orelha média

Abstract Introduction: Cholesteatoma is a destructive lesion that can result in life-threatening complications. Typically, it presents with hypoacusis and continuous otorrhea as symptoms. Because it is a rare disease, there are few studies in Brazil describing the characteristics of patients with the disease. Objective: This study aimed to determine the prevalence of cholesteatoma in patients with chronic otitis media and describe clinical, audiological and surgical characteristics of patients with acquired middle ear cholesteatoma treated at a referral hospital in the public health system. Methods: Cross-sectional and prospective cohort study, including 1710 patients with chronic otitis media, treated between August 2000 and June 2015, without prior surgery. Detailed clinical history, videotoscopy, and audiometry were performed, in addition to review of medical records to search for surgical data. Cholesteatomas were classified according to their route of formation. Results: Of the patients with chronic otitis media, 419 (24.5%) had cholesteatoma; mean age of 34.49 years; 53.5% female and 63.8% adults. Bilateral cholesteatoma was observed in 17.1%. Anterior epitympanic cholesteatoma corresponded to 1.9%; posterior epitympanic, 32.9%; posterior mesotympanic, 33.7%; two routes, 14.8%; and indeterminate, 16.7%. The mean air-bone gap was 29.84 dB and did not differ between routes of formation. There were no correlations between gap size and patient age or duration of symptoms. Of the surgical cases, 16.8% underwent closed tympanomastoidectomy and 75.2% open tympanomastoidectomy. Conclusion: The prevalence of cholesteatoma in patients with chronic otitis media was 24.5% and it was more common in adults than in children. Posterior mesotympanic cholesteatoma was more frequent, with no difference in mean air-bone gap between the different routes of formation. In patients undergoing surgery, open tympanomastoidectomy was the procedure most frequently chosen.

Resumo Introdução: Colesteatoma é uma lesão destrutiva que pode levar a complicações potencialmente letais. Tipicamente, apresenta hipoacusia e otorreia contínua como sintomas. Por ser uma doença rara, existem poucos estudos no Brasil que descrevam as características destes pacientes. Objetivo: O presente estudo teve como objetivos determinar a prevalência de colesteatoma entre os pacientes com otite média crônica (OMC) e descrever as características clínicas, audiológicas e cirúrgicas dos pacientes com colesteatoma adquirido de orelha média atendidos em um hospital de referência do sistema público de saúde. Método: Estudo transversal e de coorte prospectivo, incluindo 1.710 pacientes com OMC, atendidos entre agosto de 2000 e junho de 2015, sem tratamento cirúrgico prévio. Foram feitas anamnese detalhada, videotoscopia e audiometria, além de revisão de prontuários para busca de dados cirúrgicos. Os colesteatomas foram classificados conforme sua via de formação. Resultados: Dos pacientes com otite média crônica, 419 (24,5%) apresentavam colesteatoma. Média de 34,49 anos; 53,5% do sexo feminino e 63,8% adultos. Colesteatoma foi observado bilateralmente em 17,1%. Os epitimpânicos anteriores corresponderam a 1,9%; os epitimpânicos posteriores a 32,9%; os mesotimpânicos posteriores a 33,7%; duas vias a 14,8% e indeterminados a 16,7%. A média tritonal dos gaps aeroósseos foi de 29,84 dB e não diferiu entre os grupos segundo as vias de formação. Não foram observadas correlações entre tamanho do gap e idade do paciente ou duração dos sintomas. Dos pacientes operados, 16,8% foram submetidos a timpanomastoidectomia fechada e 75,2% a timpanomastoidectomia aberta. Conclusão: A prevalência de colesteatoma em pacientes com otite média crônica foi de 24,5% e foi mais frequente em adultos do que em crianças. Os mesotimpânicos posteriores foram mais frequentes, não foi observada diferença na média dos gaps aeroósseos entre diferentes vias de formação. Nos pacientes submetidos a cirurgia, a timpanomastoidectomia aberta foi o procedimento escolhido.

Characteristics of 419 patients with acquired middle ear cholesteatoma.

INTRODUCTION: Cholesteatoma is a destructive lesion that can result in life-threatening complications. Typically, it presents with hypoacusis and continuous otorrhea as symptoms. Because it is a rare disease, there are few studies in Brazil describing the characteristics of patients with the disease. OBJECTIVE: This study aimed to determine the prevalence of cholesteatoma in patients with chronic otitis media and describe clinical, audiological and surgical characteristics of patients with acquired middle ear cholesteatoma treated at a referral hospital in the public health system. METHODS: Cross-sectional and prospective cohort study, including 1710 patients with chronic otitis media, treated between August 2000 and June 2015, without prior surgery. Detailed clinical history, videotoscopy, and audiometry were performed, in addition to review of medical records to search for surgical data. Cholesteatomas were classified according to their route of formation. RESULTS: Of the patients with chronic otitis media, 419 (24.5%) had cholesteatoma; mean age of 34.49 years; 53.5% female and 63.8% adults. Bilateral cholesteatoma was observed in 17.1%. Anterior epitympanic cholesteatoma corresponded to 1.9%; posterior epitympanic, 32.9%; posterior mesotympanic, 33.7%; two routes, 14.8%; and indeterminate, 16.7%. The mean air-bone gap was 29.84dB and did not differ between routes of formation. There were no correlations between gap size and patient age or duration of symptoms. Of the surgical cases, 16.8% underwent closed tympanomastoidectomy and 75.2% open tympanomastoidectomy. CONCLUSION: The prevalence of cholesteatoma in patients with chronic otitis media was 24.5% and it was more common in adults than in children. Posterior mesotympanic cholesteatoma was more frequent, with no difference in mean air-bone gap between the different routes of formation. In patients undergoing surgery, open tympanomastoidectomy was the procedure most frequently chosen.

Cholesteatoma growth patterns: are there audiometric differences between posterior epitympanic and posterior mesotympanic cholesteatoma?

The objective of this is to verify whether the hearing impairment caused by posterior epitympanic differed from that caused by posterior mesotympanic cholesteatomas by a cross-sectional study. We evaluated 264 ears of patients with cholesteatoma, who had not been subjected to ear surgery. Otoendoscopy and pure-tone audiometry were performed. Analyzed route involved in cholesteatoma formation: posterior epitympanic or posterior mesotympanic, air-bone gaps at 512-4000 Hz and pure-tone averages. The mean age of the patients enrolled in this study was 33.8 years, and 51.8 % of them was male. Posterior epitympanic cholesteatoma was found in 50.4 % of the study population. When the air-bone gaps were compared, the mesotympanic group had greater thresholds at 500, 2000 Hz, and a greater pure-tone average (P = 0.003, P = 0.03, and P = 0.02, respectively). Posterior mesotympanic cholesteatoma showed greater air-bone gaps thresholds at the speech frequencies than posterior epitympanic cholesteatoma did. Moreover, the two growth patterns were very similar with regard to all other audiometric parameters analyzed in this study.

Tomographic evaluation of the contralateral ear in patients with severe chronic otitis media.

UNLABELLED: Some studies indicate a bilateral tendency of chronic otitis media. It is believed that the contralateral ear can provide evidences of the route of formation of ear disease in the most affected, be a parameter of Eustachian tube function and predict successful treatment. The CT scan is an excellent test to evaluate the structures of the temporal bone and the changes resulting from otitis media. OBJECTIVE: To evaluate Temporal Bone Computed Tomography of patients with chronic otitis media and describe abnormalities in the contralateral ear. METHOD: Cross-sectional study. Evaluation of CT scans of 75 patients with chronic otitis media from a tertiary referral hospital in Brazil by a neuroradiologist. RESULTS: Population was consisted of 50.6% males with a mean age of 36 years. We found 54.7% of changes in contralateral ear clearly associated with chronic otitis media. CONCLUSION: The prevalence of radiographic changes in the contralateral ears of patients with chronic otitis media corroborates with clinical, histopathological and functional resources developed by the same group that this disease has a bilateral feature.

Avaliação tomográfica das orelhas contralaterais de pacientes com otite média crônica grave / Tomographic evaluation of the contralateral ear in patients with severe chronic otitis media

Alguns estudos indicam uma tendência à bilateralidade da otite média crônica. Acredita-se que a orelha contralateral possa fornecer evidências da via de formação da doença da orelha mais afetada, ser um parâmetro da função da tuba auditiva e predizer o sucesso do tratamento. A tomografia computadorizada é um excelente teste para avaliar as estruturas do osso temporal e as alterações decorrentes da da otite média. OBJETIVO: Avaliar tomografias computadorizadas (TC) de osso temporal de pacientes com otite média crônica e descrever anormalidades na orelha contralateral. MÉTODO: Estudo de Prevalências (transversal). Avaliação das TC de 75 pacientes com otite média crônica de um hospital terciário de referência no Brasil por um neurorradiologista. RESULTADOS: A população foi constituída por 50,6% do sexo masculino, com idade média de 36 anos. Encontramos 54,7% de alterações na orelha contralateral claramente relacionadas com otite média crônica. DISCUSSÃO: A prevalência de alterações radiográficas nas orelhas contralaterais de pacientes com otite média crônica corrobora com estudos clínicos, histopatológicos e funcionais desenvolvidos pelo mesmo grupo de pesquisa e sugere que esta doença tem uma característica bilateral.

Some studies indicate a bilateral tendency of chronic otitis media. It is believed that the contralateral ear can provide evidences of the route of formation of ear disease in the most affected, be a parameter of Eustachian tube function and predict successful treatment. The CT scan is an excellent test to evaluate the structures of the temporal bone and the changes resulting from otitis media. OBJECTIVE: To evaluate Temporal Bone Computed Tomography of patients with chronic otitis media and describe abnormalities in the contralateral ear. METHOD: Cross-sectional study. Evaluation of CT scans of 75 patients with chronic otitis media from a tertiary referral hospital in Brazil by a neuroradiologist. RESULTS: Population was consisted of 50.6% males with a mean age of 36 years. We found 54.7% of changes in contralateral ear clearly associated with chronic otitis media. CONCLUSION: The prevalence of radiographic changes in the contralateral ears of patients with chronic otitis media corroborates with clinical, histopathological and functional resources developed by the same group that this disease has a bilateral feature.

Myringostapediopexy: is it a natural type III tympanoplasty?

INTRODUCTION: Natural myringostapediopexy is an infrequent abnormality, and studies about resulting hearing loss are scarce. In several cases, natural myringostapediopexy may function as a Type III tympanoplasty. OBJECTIVE: This study evaluated conductive hearing loss in myringostapediopexy. MATERIALS AND METHODS: This cross-sectional comparative study included a historical and current sample of 46 patients, one with bilateral myringostapediopexy, at a total of 47 ears. All underwent pure tone and speech audiometry and were divided according to age into a pediatric (younger than 18 yr) and an adult group. The Statistical Package for Social Science (SPSS) 10.0 was used for statistical analysis, and the level of significance was set at p lower than 0.05. RESULTS: Patient distribution according to sex was similar (53.2% male), and 57.4% were adults. Mean conductive hearing loss in ears with myringostapediopexy ranged from 14.13 to 21.28 dB according to the frequency assessed. Pure tone average was 18.46 dB. A conductive hearing loss equal to or lower than 25 dB at all frequencies was found in 53% of the patients. The 2,000 and 3,000 Hz frequencies had the greatest prevalence of clinically nonsignificant conductive hearing loss (87% and 91%). Sensorineural hearing loss was found in 14 patients (30%), all adults, and 43% of the cases were mild. The comparison according to age did not reveal any significant differences in conductive hearing loss at any of the frequencies. CONCLUSION: Most patients with natural myringostapediopexy included in the study had clinically irrelevant conductive hearing loss. There were no differences in conduction loss between children and adults. The reconstruction of the ossicular chain and tympanoplasty, for purely functional reasons, are not justified in these cases, particularly not for patients with mixed hearing loss.

Otite média aguda / Acute otitis media

A otite média é a mais comum das infecções infantis, a principal causa de consultas médicas e a razão mais frequente para a prescrição de antimicrobianos às crianças (Rovers, 2008). Trata-se, pois, de uma doença universal em lactentes e crianças, sendo que muitos destes podem manifestar múltiplos episódios durante os primeiros anos de vida (Pelton; Leibovitz, 2009). A incidência é maior até os primeiros 24 meses, sendo que dados apontam que quase 80% das crianças apresentarão ao menos um episódio de otite média aguda (OMA) ao final deste período (Paradise e cols, 1997). A evolução dos conceitos com referência à patogênese, à imunoprofilaxia (exemplo, introdução da vacina conjugada 7-valente no ano 2000) e à conduta na OMA forneceu melhores subsídios sobre o diagnóstico, a terapêutica medicamentosa e as estratégias de prevenção, otimizando os desfechos na OMA e limitando a emergência de bactérias resistentes (Pelton; Leibovitz, 2009).