How I do it: modified Todd's meatoplasty.

BACKGROUND: Chronic otorrhoea after canal wall down mastoidectomy can be a clinical challenge. Basic principles for canal wall down surgery include establishing a large meatus. Several meatoplasty techniques have been reported. This paper describes this new indication for Todd's meatoplasty with surgical improvements. STUDY DESIGN: Retrospective review. SETTING: Academic tertiary referral centre. METHODS: Modifications of transposition postauricular flap meatoplasty are reported. This technique was applied in a series of patients with chronic otorrhoea after a canal wall down mastoidectomy. RESULTS: In general, a dry radical cavity was successfully created within six weeks and follow-up visits at the out-patient clinic were reduced. Only minor complications occurred, which are all reported. CONCLUSION: The postauricular flap meatoplasty is a valuable tool in the management of chronic otorrhoea after an open cavity approach for cholesteatoma.

Comparison of two cochlear implantation techniques and their effects on the preservation of residual hearing. Is the surgical approach of any importance?

The goal of this work was to review the pre-and postsurgical auditory thresholds of two surgical implantation techniques, namely the mastoidectomy with posterior tympanotomy approach (MPTA) and suprameatal approach (SMA), to determine whether there is a difference in the degree of preservation of residual hearing. In a series of 430 consecutive implanted patients 227 patients had measurable pre-operative hearing thresholds at 250, 500, and 1,000 Hz. These patients were divided into two groups according to the surgical technique that was used for implantation. The SMA approach was followed for 84 patients in Amsterdam, whereas the MPTA technique was adhered to 143 patients in Maastricht. The outcome variables of interest were alteration of pre-and postoperative auditory thresholds after cochlear implantation. Complete or partial preservation of residual hearing was obtained in 21.4 and 21.7% in the SMA and MPTA group, respectively. No statistical differences could be found between the SMA and MPTA group (p = 0.96; Chi-square test). The SMA technique is correlated with a similar degree of hearing loss after cochlear implantation compared to the MPTA technique. However, both techniques were not able to conserve a measurable amount of hearing in patients with a substantial degree of residual hearing. Therefore, both surgical techniques need to be refined for patients in which residual acoustical hearing is pursued.

What to do with the other ear after cochlear implantation.

Unilateral cochlear implantation has become a widely accepted surgical intervention for both deaf children and adults. It is a reliable and effective method to rehabilitate profound deafness. Recently the benefits of the use of a contralateral hearing aid (bimodal stimulation) with a cochlear implant became clear. Bilateral cochlear implantation benefits bilateral input into the auditory system for adults and children. To provide the binaural advantages experienced by normal hearing subjects bilateral cochlear implantation or bimodal stimulation is probably indicated. Whether to choose between both possibilities depends on many factors. Cortical auditory evoked potential (CAEP) measurements can be an important tool to decide bilateral implantation in young children. Enough residual hearing in the non-implanted ear might benefit from bimodal stimulation. New protocols are needed for the audiological management for recipients of cochlear implants.

Audiometric patterns in ototoxicity of intra-arterial Cisplatin chemoradiation in patients with locally advanced head and neck cancer.

This study describes audiometric patterns of ototoxicity in a consecutive series of patients uniformly treated with intra-arterial high-dose cisplatin chemoirradiation for advanced cancer of the head and neck. Air conduction thresholds were measured from 0.125 to 16 kHz and bone conduction thresholds were measured from 0.5 to 4 kHz. The overall audiometric pattern was characterized by maximum threshold shifts after the 2nd cisplatin infusion and a maximum total threshold shift at 8 kHz, irrespective of gender, age, pretreatment sensorineural hearing loss (SNHL) or subjective complaints during therapy. A hearing deterioration gradient was observed from (ultra-) high to low frequencies, worse with increasing pre-existent SNHL and with increasing cumulative dose of cisplatin chemoradiation. Cisplatin chemoradiation-induced hearing loss seemed to reach a plateau at higher levels (75-80 dB HL) for frequencies above 8 kHz compared to frequencies up to 8 kHz (45-60 dB HL). Recovery of SNHL was found after therapy in 27 ears characterized by extensive hearing loss at frequencies 1, 2 and 4 kHz.

Intracochlear misdirected implantation of a cochlear implant.

This paper discusses a rare complication of an intracochlear misdirection of the electrode of a cochlear implant in a 55-year-old male. The patient received a cochlear implant using the mastoid-saving surgical approach. Intraoperative measurements showed impedance and NRT reactions suggesting a reasonable function of the inner ear and the implant. Postoperatively our patient suffered from passing vertigo. Postoperative CT scans revealed a misdirection implantation of the cochlear implant into the vestibular part of the inner ear. A deformed implant was removed and a reimplantation was successfully performed after enlarging and reshaping the cochleostomy. Our patient now enjoys all the benefits of an optimal functioning cochlear implant. Intracochlear misdirection of the electrode can occur even when intraoperative measurements seem to be normal. When a patient suffers from unexplained vertigo after cochlear implantation with a poor function of the implant a misdirection of the active electrode must be considered. New high resolution peroperative three-dimensional imaging techniques can probably help to avoid such insertion failures.

First experience with a new stapes clip piston in stapedotomy.

OBJECTIVE: Hearing results after 23 implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated. This new type of stapes piston was designed to avoid the crimping onto the incus in stapedotomy. This one clip fits all designs and enables solid fixation by clicking the prosthesis onto the long process of the incus without crimping. STUDY DESIGN: A retrospective pilot study was carried out by microcomputer of the preoperative and postoperative audiological results of patients in whom the titanium-clip stapes piston prosthesis was implanted. SETTING: Ear, nose and throat department of Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. PATIENTS: 23 Patients underwent a stapedotomy for hearing improvement suffering from otosclerosis. implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated. INTERVENTION(S): The stapedotomy was performed with the àWengen Clip Piston prosthesis. MAIN OUTCOME MEASURE(S): Pre and postoperative audiograms were used to evaluate the hearing gain improvement with the new stapes piston. Especially we looked at the airbone gap closure and the sensorineural hearing after the surgical procedure and compared these with the ones before surgery. RESULTS: The hearing results showed a closure of the pure-tone average air-bone gap to within 10 dB in 56.6% of cases (10 of 23 implantations) and to within 20 dB in 100% (23 of 23 implantations). A residual air-bone gap of greater than 20 dB was seen in the present pilot study. Postoperative overclosure of bone-conduction thresholds was discovered only for the frequency of 2 kHz. Sensorineural hearing loss greater than 10% did not occur, and there was no decline in the speech discrimination. CONCLUSIONS: The use of a newly designed titanium-clip stapes piston prosthesis with a diameter of 0.4 mm gives good results in cases of stapedotomy for otosclerosis. The titanium-clip design is a new development in the evolution of stapes piston prostheses. Surgical introduction, placement, and fixation are not always easy, depending on the anatomy of the middle ear and the thickness of the fixation area on the long process of the incus.

Retrospective analysis of early postoperative hearing results obtained after stapedotomy with implantation of a new titanium stapes prosthesis.

OBJECTIVE: To evaluate the early postoperative hearing results of a new titanium stapes prosthesis (K-Piston) implanted in patients with otosclerosis. STUDY DESIGN: A retrospective analysis of preoperative and early postoperative hearing thresholds. SETTING: One tertiary referral and teaching hospital. PATIENTS: Eighteen men and 40 women, mean age 47 years, with otosclerosis. INTERVENTION: Primary stapedotomy. MAIN OUTCOME MEASURE: Main outcome measures were the mean gains in bone-conduction and air-conduction pure-tone thresholds, and pure-tone averages for different frequency combinations. Success and failure of the individual cases were presented using Amsterdam Hearing Evaluation Plots. RESULTS: The overall postoperative air-bone gap for the frequency combination 0.5-1-2-4 kHz was 8.4 (standard deviation: 5.2) dB. In 79% of the patients the postoperative air-bone gap was less than 10 dB. Air-conduction improved even in higher frequencies, while the Carhart effect was not seen in most cases. In three patients a deterioration of bone-conduction was observed ranging from 11 to 16 dB sound pressure level (SPL), and in four patients the gain in air-conduction was insufficient (3-29 dB SPL) to close the preoperative air-bone gap to within 20 dB. CONCLUSION: The new low-weight, full-titanium stapes prosthesis with its slight rough surface and its good mechanical stability and biocompatibility can safely and successfully restore the function of the middle ear when implanted in patients with otosclerosis.

The aetiology of otosclerosis: a review of the literature.

During the last century, hundreds of studies have been performed to identify factors that are involved in the aetiology of otosclerosis. These studies include a variety of aetiological factors and, although many theories have been postulated, the process of the development of the disease remains unclear. A historical overview and analysis of the literature dealing with the aetiology of otosclerosis is presented. The role of collagen disorders, genetic linkage studies, associations with the HLA system and measles virus infection as causal factors is discussed. From an epidemiological point of view, the disease has an autosomal dominant mode of inheritance. Therefore, since the introduction of new genetic research techniques over the last decades, more studies have been performed to find evidence of a genetic factor that initiates the development of otosclerosis. In this review, we tried to categorize the most prominent studies in sections according to their subjects within the diversity of aetiological factors that have been studied.

Efficacy of evaluation of audiometric results after stapes surgery in otosclerosis. I. The effects of using different audiologic parameters and criteria on success rates.

The Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery proposed guidelines to provide more uniformity in reporting hearing results after middle ear surgery. One of the proposals was to include the hearing thresholds at 0.5, 1, 2, and 3 kHz in a 4-frequency pure-tone average (PTA) and to use post-operative bone-conduction (BC) levels rather than preoperative BC levels in describing postoperative air-bone gaps (ABGs). The hearing results of 451 stapes operations were evaluated to analyze to what extent the choice of different audiologic criteria affects success rates. It appeared that choice of PTA significantly affects postoperative gain in air-conduction thresholds and ABG levels. If one takes the improvements in speech-reception thresholds as the gold standard, the gain in air-conduction correlates best with a gain in speech-reception threshold if a higher frequency, such as 3 or 4 kHz, is included in a 4-frequency PTA. Also, choice of preoperative or postoperative BC in computing postoperative ABGs had a significant effect on the mean postoperative ABG levels, showing more favorable results with the use of preoperative BC thresholds.

Efficacy of evaluation of audiometric results after stapes surgery in otosclerosis. II. A method for reporting results from individual cases.

To standardize the reporting of hearing results after middle ear surgery, the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery proposed 2 levels of guidelines: level 1 for reporting summary data and level 2 for reporting raw data. The Committee encourages the reporting of raw data from each individual case. However, in studies in which the examined population is too large, this can yield difficulties. With respect to this point, we designed a method for a simple visual presentation of hearing results in an attempt to provide data from each individually operated ear in a patient group. In this method the relation between the preoperative and postoperative bone-conduction levels is evaluated to assess overclosure and iatrogenic cochlear damage, and the relation between postoperative gain in air conduction and the preoperative air-bone gap is evaluated as a measure of technical success rate. This results in 2 plots, which we called the Amsterdam Hearing Evaluation Plots. Audiometric data from 451 stapes operations were used to demonstrate the use of the Amsterdam Hearing Evaluation Plots.

Ionomeric cement in the human middle ear cavity: long-term results of 23 cases.

OBJECTIVES: The long-term results of the implantation of glass ionomer cement in the human mastoid and middle ear were studied. STUDY DESIGN: A prospective study of the survival of bone cement in the middle ear. METHODS: Ionocem (IONOS, Medizinische Produkte Gmbh & Co., Seefeld/Obb, Germany), a two-compound bone material that forms a stable, water-proof junction with bone, was implanted in 23 middle ears of 23 patients (13 male and 10 female patients). Closure of the dehiscence of the tegmen was performed in 7 cases, obliteration of the mastoid cavity in 10 cases, and ossicular chain reconstruction in 6 cases. RESULTS: The follow-up period was 5.1 years. Complications attributable to operation were not seen, but adverse tissue reaction with severe middle ear infection and abundant otorrhea occurred in six cases after 12 months, requiring repeat operation. In three more cases, a spontaneous extrusion of the bone cement was seen after 4 years. The bone cement was totally extruded in nine cases. The mean survival time was 28 months. CONCLUSIONS: The use of Ionocem for obliteration of the mastoid cavity or for the closure of dehiscence of the tegmen has a high risk of extrusion. Therefore, it is not the first-choice material to use for obliteration or tegmen defect closure in the middle ear.

The prevalence of allergy in young children with an acquired cholesteatoma.

STUDY OBJECTIVE: To determine whether allergic sensitisation occurs more frequently in young children with an acquired cholesteatoma in comparison with young children without ear diseases. DESIGN: In this retrospective case-control study the allergic sensitisation of 43 children (age 0-10 years) who were operated for an acquired cholesteatoma was compared with the allergic sensitisation of children without ear pathology. SETTING: Otology department of the ORL clinic of the Academic Medical Centre of University of Amsterdam in the Netherlands. MEASUREMENTS: From all subjects a complete history examination was performed and stored in a database. To assess for the presence of allergic sensitisation in patients who underwent radical ear surgery because of an acquired cholesteatoma, and the control group a multiantgen radioallergosorbent test (RAST) was performed. The GraphPad Prism v 2.0. statistical software was used to perform the analyses. RESULTS: Eighteen subjects (41.8%) demonstrated sensitivity to allergens and this is statistically significant (P < 0.0047) higher than the control group and expected for the general paediatric population. 80% of the patients with a positive multiantgen radioallergosorbent test were boys. In all positive cases an allergy for the house dust mite was determined. CONCLUSION: Allergy is statistically frequently present in paediatric patients with an acquired cholesteatoma. The house dust mite seems to be the most important allergen when allergy is involved with an acquired cholesteatoma. Cholesteatoma with an positive allergy test occurs much more often in boys than girls. This could mean that young boys with a series of inflammatory middle ear diseases and allergic sensitisation are probably more at risk to develop an acquired cholesteatoma in childhood.

Comparison of stapes prostheses: a retrospective analysis of individual audiometric results obtained after stapedotomy by implantation of a gold and a teflon piston.

PURPOSE: Evaluation of hearing results after implantation of a Teflon piston (type Causse; Xomed Surgical Products, Jacksonville, FL) and of a pure gold piston (K-piston; Heinz Kurz GmbH Medizintechnik, Dusslingen, Germany), both with a shaft diameter of 0.4 mm in cases of otosclerosis requiring stapedotomy. An important difference between both prostheses is the difference in mass: the gold piston is three times heavier than the Teflon piston. METHODS: Retrospective analyses were carried out of the presurgery and postsurgery audiologic results obtained after primary stapedotomy by implantation of 62 Teflon pistons and 66 gold pistons. The results were compared according to mean values of several audiometric parameters. Furthermore, individual audiometric results have been evaluated with the "Amsterdam Hearing Evaluation Plots" (AHEPs) as a method for visual presentation of hearing results from each operated ear. With this method, "unsuccessfully" and "successfully" inserted prostheses can be recognized easily and a more realistic comparison between prostheses is possible. RESULTS: It was found that in the overall group the heavier gold prosthesis gives a significantly larger gain in air-conductive hearing at 2 kHz (p < 0.05) and in the speech frequency range 0.5 to 2 kHz (p < 0.05). There were no significant intergroup differences with regard to change in bone-conduction and air-bone gaps. Analysis of the hearing results of the subgroup that included only the "successfully" implanted prostheses according to the criteria of the AHEPs had mainly consequences for improvement of air-conduction thresholds: none of the intergroup differences were statistically significant. CONCLUSIONS: For a fair comparison between prostheses, it is necessary to take only the prostheses into account that are inserted properly and that are functioning under normal conditions with regard to transmission of sound vibrations. After analysis of the hearing results of these "successfully" implanted prostheses, a trend was noticed that the heavier gold piston gives more gain in the low- and mid-frequency range and the light-weighted Teflon piston gives more gain in the high-frequency range, although none of the differences were significant.

Long-term effect of hyperbaric oxygenation treatment on chronic distressing tinnitus.

Tinnitus is still a phenomenon with an unknown pathophysiology with few therapeutic measures. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus. In this study, we prescribed HBO to 20 patients who had had severe tinnitus for more than one year and who had already had other forms of tinnitus therapy with unsatisfactory results. Four patients could not cope with the pressure gradient. The effect of HBO was assessed using subjective evaluation and VAS scores before and after HBO. Follow-up continued until one year after treatment. Six patients had a reduction of tinnitus and accompanying symptoms, eight patients did not notice any change and two patients experienced an adverse effect. Any outcome persisted with minor changes until one year after treatment. HBO may contribute to the treatment of severe tinnitus, but the negative effect on tinnitus should be weighed carefully.

Evaluation of second-ear stapedotomy with the Glasgow benefit plot.

This study reports the evaluation of the results after 72 stapedotomies in patients with bilateral otosclerosis. All pre- and postoperative audiological data, together with all relevant information of the operations, were stored in a data base and analyzed retrospectively. The Glasgow benefit plot (GBP) is a useful method to evaluate the hearing results of each individual ear after stapes surgery in a more functional way rather than from a technical standpoint. Therefore, it has been used to assess the benefit obtained after second-ear stapedotomy. From the results it appears that a second operation on the contralateral side increases the chances of achieving at least one 'normal'-hearing ear, and it makes symmetrical 'normal' hearing possible in the majority of the cases.

Experience with a new pure gold piston in stapedotomy for cases of otosclerosis.

This study reports the evaluation of the hearing results after 62 implantations of a pure gold (99.9%) piston in cases of otosclerosis. A retrospective analysis of the pre- and postsurgery audiological results of these patients was carried out by microcomputer. This study shows that the use of a pure gold piston ((K-piston) with a diameter of 0.4 mm gives good results in cases of stapedotomy for otosclerosis. The hearing results show a closure of the pure-tone average (PTA) air-bone gap to within 10 dB was 70.9% (44/62) and to within 20 dB in 95.1% (59/62). A residual airbone-gap of > 20 dB was seen in three cases (4.8%). A postoperative overclosure of bone conduction thresholds was discovered for all frequencies measured. Sensorineural hearing loss (> 10%) did not occur and there was no decline in the speech discrimination. The future for this new generation of stapes pistons seems to be promising.

Quinine pharmacokinetics: ototoxic and cardiotoxic effects in healthy Caucasian subjects and in patients with falciparum malaria.

OBJECTIVE: To study the pharmacokinetic behaviour of quinine in Caucasians with and without malaria. METHOD: Quinine-dihydrochloride was administered intravenously as a single dose of 300 mg to 12 healthy subjects and as multiple doses of 600 mg in 4 h every 8 h in 10 patients with falciparum malaria. Plasma quinine concentrations were measured by high-performance liquid chromatography RESULTS: Quinine pharmacokinetics are time-dependent: the apparent elimination halftime is shorter in the accumulation phase than in the elimination phase; in malaria patients the maximal quinine concentration was reached in half the time calculated on the basis of the elimination phase after the last quinine infusion. Nevertheless a loading dose seemed advisable to reach adequate therapeutic levels quickly. In malaria patients the highest plasma concentrations during or at the end of the infusions were positively correlated with body weight. There was no correlation between body weight and the volume of distribution of quinine as calculated during the elimination phase. Hearing loss was audiometrically documented in 9 healthy subjects at a mean maximal plasma quinine concentration of only 2 mg/l. All malaria patients suffered serious cochlear hearing impairment. The ototoxic effects in both healthy subjects and patients appeared to be reversible. No electrographic changes were noted in the healthy subjects, whereas a clinically insignificant mean lengthening of the corrected QT interval was seen in the malaria patients. CONCLUSION: Intravenous quinine pharmacokinetics in healthy Caucasians were similar to those reported for Nigerian or Thai subjects. At effective doses quinine causes considerable but reversible cochlear hearing losses in both healthy persons and in patients. Our findings do support the need for a loading dose. The fact that in malaria patients there was no correlation between body weight and quinine VD as calculated during the elimination phase renders questionable the usefulness of dosing quinine according to body weight.