External auditory canal: Inferior, posterior-inferior, and anterior canal wall overhangs.

OBJECTIVES: To characterize anatomic variants of the external ear canal (EAC), specifically canal wall overhangs. EAC overhangs are problematic since they obstruct the view of the tympanic membrane (TM) and middle ear, possibly creating diagnostic and surgical difficulties. METHODS: We reviewed pre-operative temporal bone CTs from children with cholesteatoma, and no history of EAC erosion or surgery. We measured the anterior canal wall overhang (ACOH), inferior (ICOH), and posterior-inferior (PICOH). A smaller angle means more EAC overhang. Angles >180° counted as 180° since they are non-obstructing. Analysis was performed between angular measurements and clinical and demographic data. RESULTS: 86 patients (88 ears total) were studied. Mean age was 8.3 years. Only obstructing angles were analyzed statistically (<180°). The ICOH was most severe and occurred in 72/88 (81.8%) ears with a mean of 145.9 ±â€¯12.8SD° (range 102-171°). ACOH occurred in 60/88 (68.2%) ears with a mean of 148.3 ±â€¯10.9SD° (range 120-169°). PICOH occurred in 59/88 (67%) ears with a mean of 150.4 ±â€¯9.2SD° (range 124-169°). Overall, ICOH was significantly more severe than PICOH (P = 0.026). ICOH had more Severe (142-102°) overhangs (27/88, 30.7%) than ACOH (17/88, 19.3%) or PICOH (11/88, 12.5%), but these were not significantly different. Analysis of clinical data showed that as the ICOH overhang became more severe, there was a history of significantly more (p = 0.039, r = -0.209) tympanostomy tubes placed. CONCLUSIONS: The greatest prevalence and severity of EAC overhang was the ICOH with a mean angle of 145.9°, compared with 148.3° and 150.4° for the ACOH and PICOH, respectively. This anatomic study demonstrates that ICOH and PICOH are prevalent anatomic variants and may possibly cause similar difficulties in otoscopic diagnosis and surgical TM and middle ear exposure as the well-known ACOH.

Paravertebral Nerve Block for Donor Site Pain in Stage I Microtia Reconstruction: A Pilot Study.

Acute Interventional Perioperative Pain Service consultants have routinely placed paravertebral nerve block (PVB) catheters for the continuous release of ropivacaine following stage I microtia reconstruction with costal cartilage graft at our institution since 2010. A retrospective chart review from July 2006 was performed to compare the length of hospital stay, median pain score (0-10 scale), and opioid use of patients receiving PVB with those of historical controls. Statistical analysis included t, Mann-Whitney U, and Fisher's exact tests. A total of 15 stage I microtia surgeries were included, 10 with PVB and 5 without. Patients with and without PVB had high peak pain scores (8.4 vs 7.8), remained in the hospital for 3.5 and 3.8 days, and consumed 0.69 and 0.36 mg/kg morphine equivalents, respectively. These findings highlight the feasibility of PVB, but larger studies are needed to optimize pain relief in this population.

The role of tympanostomy tubes in surgery for acquired retraction pocket cholesteatoma.

OBJECTIVE: 1. To determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) can decrease recurrence of ARPC and retraction pockets (RP). 2. To determine the need for subsequent TT in children that did not initially receive TT. STUDY DESIGN: Retrospective review of children who underwent primary surgery for ARPC. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Audiometry, operative reports, office findings, and recurrence of ARPC and RP were analyzed. Univariate analysis with Fisher's exact test, Wilcoxon rank-sum and t test, as well as multivariate analysis with logistical regression, were used for statistical analyses. RESULTS: 21 patients had TT at initial surgery and 34 patients did not. The recurrence of ARPC was 24% for the TT Group versus 44% for the no TT group (p=0.09). The incidence of RP was 33% in the TT group versus 41% in the no TT groups (p=0.35). 35% of the no TT group subsequently required TT. Audiometric outcomes were not different between groups. TT placement did not significantly affect the odds of recurrent ARPC and RP (95% CI 0.12-1.83, p=0.28 for ARPC and 95% CI 0.30-4.60, p=0.82 for RP). However, the odds of recurrent ARPC and RP were significantly increased in children with stapes and malleus erosion by cholesteatoma. Children with stapes and malleus involvement had 5.28 and 11.8 times higher odds of recurrent ARPC compared to those without ossicular erosion (95% CI 1.09-25.6, p=0.04 stapes and 95% CI 1.58-88.3, p=0.02 malleus). Similarly, children with malleus involvement had an 18.6 times higher odds of recurrent RP (95% CI 1.62-214, p=0.02) compared to those who did not. Incus erosion was not a significant predictor for recurrent ARPC and RP. CONCLUSION: There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT versus those who did not during initial surgery for ARPC. However malleus and stapes erosion were significantly associated with recurrent ARPC and RP. These findings suggest that TT at initial ARPC surgery did not play a role in preventing recurrence, but malleus and incus erosion, was predictive of recurrent disease. A larger, prospective study of TT at initial surgery for ARPC is needed.

Acetaminophen plus ibuprofen versus opioids for treatment of post-tonsillectomy pain in children.

OBJECTIVE: To determine the efficacy and safety of acetaminophen plus ibuprofen in treatment of post-tonsillectomy pain compared to acetaminophen plus opioids in children. STUDY DESIGN: Retrospective medical record review. SETTING: Tertiary-care children's hospital between September 2012 and March 2013. SUBJECTS AND METHODS: All children undergoing total tonsillectomy (n=1065). Analysis included descriptive analysis, chi-square testing, and logistic regression controlling for age, diagnosis, trainee involvement, concurrent surgical procedures, and Coblator use for differences of outcomes: (1) post-operative bleeding, (2) emergency department (ED) visits for pain, dehydration, or bleeding, and (3) nurse phone calls from families. RESULTS: All patients received acetaminophen. Seventy-four percent received ibuprofen (n=783) and 26.5% did not receive ibuprofen (n=282). In the ibuprofen group, 32.2% received opioids (n=252). Over eight percent of children had post-operative hemorrhage of any amount reported (n=89). Forty-eight percent of these required operative intervention (n=43). Ibuprofen prescription did not impact post-operative bleeding; operative intervention for bleeding, ED visits, or nurse phone calls either on chi-squared or logistic regression testing. Increasing age was found to increase bleeding risk as well as the likelihood of visiting the ED or calling the clinic nurses. All patients with multiple bleeding episodes were in the ibuprofen group. CONCLUSION: Prescription of ibuprofen did not increase the risk of bleeding and did not increase the likelihood of a post-operative ED visit or nurse phone call. Ibuprofen prescription may possibly increase the risk of multiple bleeding episodes, but further prospective studies are needed. Increased age increases the risk of bleeding, ED visits, and nurse phone calls.

Coexistence of dermal sinus tract, dermoid cyst, and encephalocele in a patient presenting with nasal cellulitis.

Dermoid cysts, encephaloceles, and dermal sinus tracts represent abnormalities that develop during the process of embryogenesis. The elucidation of the precise timing of formation for these malformations has remained elusive at the molecular level of study. Yet, clinical experience has demonstrated that these malformations do not all occur in the same patient, suggesting a shared pathway that goes awry at distinct points for different patients, resulting in 1 of the 3 malformations. Herein the authors describe a case in which all 3 malformations were present in a single patient. This is the first description in the English literature of a sincipital encephalocele occurring with a dermoid cyst and a dermal sinus tract.

Anatomic variants on computed tomography in congenital aural atresia.

OBJECTIVE: To report the prevalence of anatomic variants on computed tomography (CT) in congenital aural atresia (CAA) and external auditory canal stenosis (EACS). Anatomic variants included inferiorly displaced/obstructing tegmen mastoideum, malleus-incus complex (MIC) directly lateral to stapes, facial nerve obstruction of oval window (OW) or middle ear, and incudostapedial joint (ISJ) angle. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: An anatomic analysis of 130 CT scans (98 children, 32 bilateral) of CAA/EACS, performed by a blinded neuroradiologist. Both Jahrsdoerfer's and new/modified anatomic considerations were graded in 32 atresiaplasty and 66 nonsurgical patients. Surgical data were analyzed for anatomic correlations related to surgical findings. RESULTS: Prevalence of anatomic variants was as follows: 13% of the ears had mild inferior displacement of tegmen, 4% had a significantly obstructing tegmen, and 24% had MIC directly lateral to stapes. The facial nerve obstructed access to OW in 41% and middle ear in 21%. Six atresiaplasty patients were reported to have a large MIC obstructing stapes access with increased intraoperative difficulty in viewing and assessing the integrity and mobility of the ISJ and stapes. Five of these 6 (83%) were noted on CT scan. The mean ISJ angle was 101° (range, 51°-155°). CONCLUSION: A large obstructing MIC increases difficulty of atresiaplasty. Awareness of the presence of these anatomic variants is an aid in teaching temporal bone anatomy and may possibly influence the decision regarding atresiaplasty.

Congenital cholesteatoma: predictors for residual disease and hearing outcomes.

OBJECTIVE: To determine predictive factors for residual disease and hearing outcomes of surgery for congenital cholesteatoma (CC). DESIGN: Retrospective record review of surgery for CC from January 1, 1998, through December 31, 2010. The initial extent of CC was staged using the system as defined by Potsic et al. SETTING: Tertiary care children's hospital. PATIENTS: Eighty-one children (82 ears) underwent a total of 230 operations for CC. The mean (SD) age was 5.3 (2.9) years, and the mean follow-up was 4.3 years. INTERVENTION: Initial and subsequent operations for CC and audiologic evaluations. MAIN OUTCOME MEASURES: Statistical analyses were performed to determine factors associated with increased residual disease for CC and poorer hearing outcomes. RESULTS: Higher initial stage of disease, erosion of ossicles, and removal of ossicles were significantly associated with increased likelihood of residual CC (46%, 50%, and 51%, respectively; P < .001). More extensive disease at initial surgery was associated with poorer final hearing outcomes (P < .05). Other significant findings included CC medial to the malleus (41.5%) or incus (54.3%), abutting the incus (51.3%) or stapes (63%), or enveloping the stapes (50%); all patients had increased residual disease (all P < .05). Excellent audiometric results (air-bone gap of ≤20 decibel hearing level) were obtained in 63 (77%) of the 82 ears. CONCLUSIONS: More extensive initial disease, ossicular erosion, and the need for ossicular removal were associated with residual disease. On the basis of our data, the best chance for completely removing CC at initial surgery involves removing involved ossicles if they are eroded, if the CC is abutting or enveloping the incus or stapes, if the CC is medial to the malleus or incus, or if the matrix of the CC is violated. These results may help guide surgeons to achieve the best results for their patients.

Persistent alternobaric vertigo at ground level.

We recently encountered a 15-year-old female with bilateral tympanostomy tubes who manifested persistent severe vertigo, at ground level, secondary to a unilateral middle-ear pressure of +200 mm H(2)O elicited by an obstructed tympanostomy tube in the presence of chronic nasal obstruction. We believe this is a previously unreported scenario in which closed-nose swallowing insufflated air into her middle ears, resulting in sustained positive middle-ear pressure in the ear with the obstructed tube. Swallowing, when the nose is obstructed, can result in abnormal negative or positive pressures in the middle ear, which has been termed the Toynbee phenomenon. In patients who have vertigo, the possibility that nasal obstruction and the Toynbee phenomenon are involved should be considered.

Prospective blinded study of computed tomography in congenital aural atresia.

OBJECTIVE: To report a preliminary descriptive study of new and refined anatomic considerations for computed tomography (CT) in congenital aural atresia (CAA). DESIGN/PATIENTS: Thirty-two temporal bone CT scans from 26 patients (6 bilateral cases) with CAA were graded in a prospective blinded manner with both Jahrsdoerfer's system and the new/refined anatomic considerations. In addition to Jahrsdoerfer's grading, new and refined considerations graded included the presence or absence of: (1) inferiorly displaced tegmen mastoideum, (2) malleus/incus complex directly lateral versus anterolateral to stapes, which may make surgical stapes access much more difficult, and (3) possible facial nerve obstruction of surgical access at two sites: oval window and middle ear. SETTING: Tertiary-care children's hospital. RESULTS: Inferiorly displaced tegmen mastoideum occurred in 5 ears (16%), the malleus/incus complex was directly lateral to the stapes in 12 ears (38%), the facial nerve possibly obstructed access to the oval window in 17 ears (53%), and it possibly obstructed access to the middle ear in 5 ears (16%). CONCLUSION: New and refined anatomic/radiographic considerations for CT in CAA are reported for a series of temporal bones. The presence of these anatomic variants may influence the decision against atresiaplasty since these anatomic factors may possibly make atresiaplasty more difficult or impossible. Precise determination of atresiaplasty candidacy is important since Bone Anchored Hearing Aid is also a valuable option.

Congenital external auditory canal stenosis and partial atretic plate.

OBJECTIVES: To report outcomes of surgery for severe congenital external auditory canal (EAC) stenosis with or without partial atretic plate (PAP). DESIGN: Retrospective review. SUBJECTS: Thirteen patients (18 ears) had surgery for severe EAC stenosis with (n=10, 56%) or without PAP (n=8, 44%). Indications included severe stenosis with hearing loss, cerumen impactions, and/or canal cholesteatoma. Mean age=7.8 years (range 0.4-19.9 years). Mean follow up=5.2 years (range 0.4-10.0 years). SETTING: Tertiary care children's hospital. INTERVENTIONS: Nineteen endaural canaloplasties were performed in 17 ears (2 revisions). There was one post-auricular approach. Fifteen tympanoplasties were performed in 13 ears (2 revisions). PAP was reconstructed with drilling to enlarge the bony annulus and fascia grafting to enlarge the tympanic membrane in 10 (56%) ears. OUTCOME MEASURES: Patency of EACs; otologic findings; pure tone averages (PTA); complications. RESULTS: All (100%) EACs had improved patency (>or=4mm). Findings included canal cholesteatoma (2/18, 11%), ossicular fixation (4/18, 22%), stapes abnormality (2/18, 11%), and incudostapedial discontinuity from cholesteatoma (1/18, 6%). Mean preoperative PTA=38.7 dB HL (range 60-20 dB HL). Mean post-operative PTA=23.6 dB HL (range 50-6.7 dB HL). Audiologic results were significantly better for cases without PAP (p<.01) and without ossicular fixation (p<.01). There were seven minor and no major complications. CONCLUSIONS: Endaural canaloplasty is safe and effective for providing patent EACs and hearing improvement for severe congenital EAC stenosis. However, since hearing outcomes were worse for cases with PAP and ossicular fixation, alternatives such as hearing aids or BAHA may be considered.

Combined atresiaplasty and tragal reconstruction for microtia and congenital aural atresia: thesis for the American Laryngological, Rhinological, and Otological Society.

OBJECTIVE: To describe a new technique for combining atresiaplasty with tragal reconstruction by performing the tragal reconstruction with cartilage grafting at the same time as the atresiaplasty for patients with microtia and congenital aural atresia. Hearing and canaloplasty outcomes for this combined technique are reported. PATIENTS: Patients with aural atresia (n = 19) with (n = 16) or without (n = 3) microtia, and a Jahrsdoerfer grade of 6 or higher. Mean age was 8.3 years. Atresiaplasty was performed in 20 ears, with the new combined technique in 15 ears (75%). METHODS/INTERVENTIONS: During the meatoplasty portion of atresiaplasty, the tragus was reconstructed with a cartilage graft and an anteriorly pedicled skin flap. OUTCOME MEASURES: Hearing results, complications including canal stenosis, infections, sensorineural hearing loss, and facial nerve injuries. RESULTS: The mean postatresiaplasty pure tone average (PTA) and air bone gap (ABG) were 37.5 and 29.4 dB, respectively. Eleven (55%) of the ears had an ABG of < or =30 dB, and 10 (50%) had speech reception thresholds (SRT) of < or =30 dB. Six ears (30%) had postoperative infections. Revision surgery was performed in four ears (20%) for canal/meatal stenosis, and in six (30%) for conductive hearing loss. Bone Anchored Hearing Aid was performed in six patients (30%). There was no sensorineural hearing loss or facial nerve injury. CONCLUSIONS: The new combined tragal reconstruction and atresiaplasty technique yielded satisfactory hearing, canal/meatal patency, and cosmetic results, with acceptable rates of complications. This combined tragal reconstruction and atresiaplasty technique is a valuable option in the armamentarium of microtia and atresia surgeons.

Outcomes studies of epiglottic and base of tongue prolapse in children.

OBJECTIVES: The purpose of this study was to compare previously reported flexible fiberoptic laryngoscopy (FFL) findings of a grading system for children with epiglottic and base of tongue (EBT) prolapse with findings at follow-up FFL. Surgical outcomes and tracheotomy decannulation are also reported. STUDY DESIGN: : Retrospective medical record review. METHODS: Fourteen children with EBT prolapse had transnasal FFL in the supine position on at least two occasions. Findings were graded for initial versus most recent FFL. The previously published EBT prolapse grading system was reapplied. Mean age was 8.7 years at the last evaluation. Mean interval between initial and most recent FFL was 1.9 years. RESULTS: At follow-up FFL, six (43%) children had the same grade of EBT prolapse, five (36%) had a milder grade, and three (21%) had a more severe grade. Five (36%) children were decannulated, and nine (64%) children remain tracheotomy dependant. Of nine children who had surgery, four (44%) were decannulated. Eight (89%) of nine children who were not decannulated have a history of developmental delay (P < .03). Twelve (86%) children had gastroesophageal reflux disease, and six (43%) had abnormal swallowing function. CONCLUSIONS: The grading system was successfully reapplied to compare initial with follow-up findings in a cohort of children with EBT prolapse. Gastroesophageal reflux disease and swallowing dysfunction are common in this population. Judicious surgery may have some efficacy for EBT prolapse in selected patients. Many children with EBT prolapse still require tracheotomy, especially those with developmental delay.