Over-under cartilage tympanoplasty: technique, results and a call for improved reporting.

OBJECTIVE: This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications. METHOD: This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained. RESULTS: Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring. CONCLUSION: Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Do central vestibular findings predict abnormal findings on magnetic resonance imaging?

OBJECTIVE: To determine whether central findings from vestibular tests predict abnormal findings on magnetic resonance imaging. METHOD: This study was a retrospective case series at a tertiary referral centre. The main outcome measure of this diagnostic intervention study was the positive predictive value of central vestibular findings in relation to magnetic resonance imaging abnormalities. RESULTS: Central vestibular findings had a 50.9 per cent positive predictive value for magnetic resonance imaging abnormalities across all age groups although they varied according to age group. Optokinetic nystagmus (p < 0.05) and abnormal findings on videonystagmography tests (p < 0.05) were the main predictors of magnetic resonance imaging abnormalities. White matter lesions constituted the bulk of the central lesions on magnetic resonance imaging followed by cortical and cerebellar atrophy. CONCLUSION: Central vestibular findings had a 50.9 per cent positive predictive value for magnetic resonance imaging abnormalities across all age groups. Magnetic resonance imaging is medically justified to further evaluate patients with central findings on vestibular studies. Therefore, it is reasonable to request magnetic resonance imaging in these patients.

Ultrasonic bone aspirator use in endoscopic ear surgery: feasibility and safety assessed using cadaveric temporal bones.

OBJECTIVES: To describe the feasibility and assess the safety of using an ultrasonic bone aspirator in endoscopic ear surgery. METHODS: Five temporal bones were dissected via endoscopic ear surgery using a Sonopet ultrasonic bone aspirator. Atticoantrostomy was undertaken. Another four bones were dissected using routine endoscopic equipment and standard bone curettes in a similar manner. Feasibility and safety were assessed in terms of: dissection time, atticoantrostomy adequacy, tympanomeatal flap damage, chorda tympani nerve injury, ossicular injury, ossicular chain disruption, facial nerve exposure and dural injury. RESULTS: The time taken to perform atticoantrostomy was significantly less with the use of the ultrasonic bone aspirator as compared to conventional bone curettes. CONCLUSION: The ultrasonic bone aspirator is a feasible option in endoscopic ear surgery. It enables easy bone removal, with no additional complications and greater efficacy than traditional bone curettes. It should be a part of the armamentarium for transcanal endoscopic ear surgery.

Middle-ear endoscopy and trans-tympanic drug delivery using an interventional sialendoscope: feasibility study in human cadaveric temporal bones.

OBJECTIVE: This study aimed to assess the feasibility of using a 1.3 mm, semi-rigid, interventional salivary endoscope for middle-ear endoscopy, and as a trans-tympanic route for delivery of medication, in human cadaveric temporal bones. STUDY DESIGN: Human cadaveric study. METHODS: Five temporal bones harvested from human cadavers were examined. A 1.3 mm, interventional sialendoscope was used to make endoscopy-assisted myringotomy incisions in the postero-inferior quadrant (n = 5) and the antero-inferior quadrant (n = 3). RESULTS: Middle-ear examination was successful in all specimens (n = 5). Access to the round window niche and adequate visualisation of the round window were achieved in all five temporal bones (100 per cent). A guide wire could be navigated to the round window niche without difficulty. Other structures identified in all specimens included the incudostapedial joint, stapedius tendon, pyramidal eminence and facial nerve via an extended myringotomy incision. The anterior middle-ear space was also successfully examined through an endoscope-guided anterior myringotomy. The opening to the eustachian tube was visualised and cannulated with a guide wire in all preparations in which this was attempted (n = 3). CONCLUSIONS: The 1.3 mm, interventional sialendoscope allowed adequate visualisation of the eustachian tube, middle-ear space and round window niche, with interventional capabilities, in a cadaveric model. Our result validates the feasibility of its use for trans-tympanic drug delivery.

Facial function in hearing preservation acoustic neuroma surgery.

OBJECTIVE: To determine if facial function is worse after hearing preservation acoustic neuroma surgery (retrosigmoid and middle fossa) than in translabyrinthine surgery. DESIGN: Retrospective medical record review. SETTING: Private neuro-otology subspecialty practice of patients operated on in a tertiary care hospital. PATIENTS: This study evaluated 315 consecutive acoustic neuroma surgical procedures between April 1989 and July 1998. A total of 209 translabyrinthine procedures and 106 hearing preservation surgical procedures were performed. The hearing preservation procedures were equally divided between retrosigmoid (n = 48) and middle fossa (n = 58) procedures. METHODS: Medical records were reviewed and tabulated for tumor size, surgical approach, and House-Brackmann facial function grade at short-, intermediate-, and long-term intervals. RESULTS: Postoperative facial function in hearing preservation surgical procedures at short- and long-term follow-up was not worse than facial function after translabyrinthine surgical procedures in comparably sized tumors. CONCLUSION: Concern about postoperative facial function should not be the deciding factor in selecting hearing preservation vs nonhearing preservation acoustic neuroma surgery.

Hearing results of intratympanic steroid treatment of endolymphatic hydrops.

OBJECTIVES/HYPOTHESIS: This study evaluated the effectiveness of a single application of steroids to the open middle ear in improving short-term hearing in patients with Meniere's disease and cochlear hydrops. STUDY DESIGN: Retrospective study in which each patient's pretreatment hearing served as the control compared with posttreatment hearing. METHODS: Patients were treated with a single application of dexamethasone, 8 mg, in hyaluronan. Following tympanotomy and lysis of round window adhesions, steroids were placed in the round window niche with absorbable gelatin sponge and the remainder of the middle ear was then filled with the steroid solution. Systemic steroids were not administered. Audiograms were performed within 1 month before surgery and at least 1 month after surgery. RESULTS: Between September 1996 and July 1997, 21 ears in 19 patients underwent intratympanic steroid treatment. The criterion for hearing change was a 10-dB or greater change in pure-tone average (PTA), or a 15% change in speech discrimination score (SDS). Of the 15 ears meeting inclusion criteria for this study, five (33%) demonstrated hearing improvement and three (20%) demonstrated hearing deterioration. Maximum improvement was a 38-dB improvement in PTA and a 32% improvement in SDS. CONCLUSION: A single application of intratympanic dexamethasone/hyaluronan solution directly to the round window did not produce dramatic short-term hearing improvement in patients with endolymphatic hydrops. Although the theoretical basis for intratympanic steroid treatment of endolymphatic hydrops is appealing, we urge close evaluation of the results of specific protocols of intratympanic steroid administration before widespread utilization of this treatment. The choice of steroid, route of administration, frequency of application, and need for simultaneous systemic administration require standardization to adequately assess the efficacy of this treatment.

Educational outcomes of an otitis media workshop for primary care providers in Latin America.

Otitis media is a prevalent condition that can be diagnosed and treated by primary care providers skilled in otoscopy. Previous analysis demonstrated that brief, intensive instruction at one site in rural Mexico improved the test scores of health care providers and changed long-term practices (Eavey R, et al. Otolaryngol Head Neck Surg 1993; 109:895-8). We wanted to confirm these test score findings at other sites. A didactic course on otitis media with a practical otoscopy workshop was conducted at six Mexican locations and in one Venezuelan city by an interdisciplinary group of physicians. The same coded test was given immediately before and after the course. The Wilcoxon test for significance of intrasubject performance before and after intervention was used as a nonparametric assessment. At all seven sites (n = 190 subjects), test scores demonstrated statistically significant improvement (range = p < 0.001 to p < 0.0001). We conclude that this educational method consistently improved short-term knowledge of otitis media and that further teaching efforts and a longer term practice-impact study are warranted.

Technical refinements in retraction for middle fossa surgery.

OBJECTIVE: This report describes an alternative technique for exposure of the floor of the middle fossa. STUDY DESIGN: Descriptive review of alternative middle fossa retraction techniques on a retrospective case series. SETTING: Tertiary referral center. PATIENTS: Patients undergoing middle fossa or combined petrosal craniotomy were studied. INTERVENTIONS: Dural elevation was carried anteriorly past the middle meningeal artery to permit separation of the dura from connective tissue over the Gasserian ganglion. With the dural release, flexible spatula retractors (Fukushima) can be used. RESULTS: The advantages of this technique are 1) this system is "low profile," with the back of the retractor posing no obstruction to vision or angle of instrument manipulation; 2) the anterior dural release permits extensive exposure with less force than is necessary when dural attachments to the trigeminal nerve remain intact; and 3) anterior exposure of the clivus and petrous apex is achieved without the need for transection of V3 (3rd division fifth cranial nerve). CONCLUSIONS: The authors find these refinements of practical benefit for breadth of exposure, visibility, and room for instrumentation during middle fossa surgery.

Cytotoxicity of cytokeratin monoclonal antibody against keratinocytes: a possible therapeutic adjunct for cholesteatoma?

HYPOTHESIS: Monoclonal antibodies directed against cytokeratin subtypes in cholesteatoma produce growth inhibition of keratinocytes. BACKGROUND: Despite elegant surgical procedures for cholesteatoma, residual disease is an important clinical problem. Although gross cholesteatoma removal usually is feasible, microscopic foci of residual keratinocytes may develop into clinically significant disease. This study was designed to evaluate the keratinocyte cytotoxicity of monoclonal antibodies directed against a cytokeratin subtype relatively unique to cholesteatoma. METHODS: Keratinocytes and skin fibroblasts were trypsinized, counted, and seeded in multiwell plates. The cells were exposed to mouse monoclonal antibody to cytokeratin 10 at dilutions of 1:10, 1:25, 1:50, 1:100, and 1:200 with six replicates. After 24-, 48-, and 96-hour incubations, cells that had been pulsed with 3H-thymidine were harvested. Cellular DNA was processed for quantification of 3H-thymidine incorporation with a beta scintillation counter. Cells exposed to antibody are reported as percent inhibition relative to controls. RESULTS: Inhibition ranged from 88.9% for the 1:10 concentration to 26.9% for the 1:200 concentration after 24 hours of incubation. Similar effects were noted at the 48- and 96-hour intervals. Overall, the effect was significantly more pronounced on the keratinocytes than inhibition on skin fibroblasts. CONCLUSIONS: These results suggest that monoclonal antibodies have in vitro activity against keratinocytes. Additional investigation of a possible role for cytokeratin monoclonal antibodies should be pursued with a goal of developing a clinically useful biologic adjunct for cholesteatoma management.

Stapedectomy in military aircrew.

Stapedectomy in military aircrew is generally considered to be the end of an aviation career. Perilymphatic fistulae, prosthesis dislodgement, and perforation of the vestibule are recognized complications of stapedectomy. Consequently, barotrauma, G forces, and otherwise hostile conditions and their effects on the poststapedectomy ear are usually cited as reasons for grounding. Data supporting such a restrictive policy, however, are limited. This study examined the aeromedical outcome of 16 U.S. Air Force aircrew members who returned to flight duty after stapedectomy between 1965 and 1992. Selected patients were subjected to centrifuge and altitude chamber testing before they returned to flight duty. No episodes of sudden hearing loss or vestibulopathic conditions have occurred in the entire study group. Guidelines for surgical technique, reconstruction materials, and postoperative aeromedical testing are proposed for evaluating selected stapedectomy patients before their return to flight status.