Techniques of the Tympanomastoidectomy with Reconstruction of the Posterior Bone Wall of the External Auditory Canal.

A combined tympanoplasty method, the mobile-bridge tympanoplasty, has been applied at the Clinic for Ear, Nose and Throat Diseases in Novi Sad since 1998. Mobile-bridge tympanoplasty is performed at our Clinic by applying Feldmann's procedure utilizing a microsurgical oscillating saw. It is a combination of closed and open techniques for surgical treatment of middle ear diseases. In addition to this technique, a method for reconstruction of the posterior bone wall of the external auditory canal was introduced. This procedure is applied in cases of damage or impairment of the bony ear canal wall using mastoid cortical temporal bone graft or modeled cartilage of the concha. Maintenance of general anatomical relations in the middle ear enables good ventilation of pneumatic spaces of the middle ear and Eustachian tube permeability, thus providing good conditions for ossicular chain reconstruction. The incidence of recurrent cholesteatoma in combined mobile-bridge tympanoplasty and tympanoplasty with reconstruction of the posterior bone wall was 6% in total. The incidence values for the recurrent cholesteatoma in closed tympanoplasty and in cases of open techniques were 10%. Mobile-bridge tympanoplasty and reconstruction of the posterior bone wall of external auditory canal are methods of choice in surgical treatment of middle ear cholesteatoma that progressed to the attic space, sinus tympani and facial recess.

Complications in Cochlear Implantation at the Clinical Center of Vojvodina.

INTRODUCTION: The first modern cochlear implantation in Serbia was performed on November 26, 2002 at the Center for Cochlear Implantation of the Clinic for Ear, Nose and Throat Diseases, Clinical Center of Vojvodina. OBJECTIVE: The aim of the paper is the analysis of intraoperative and postoperative complications. Major complications include those resulting in the necessity for revision surgery, explantation, reimplantation, severe disease or even lethal outcomes. Minor complications resolve spontaneously or can be managed by conservative therapy and do not require any prolonged hospitalization of the patient. METHODS: In the 2002-2013 period, 99 patients underwent surgical procedures and 100 cochlear implants were placed. Both intraoperative and postoperative complications were analyzed in the investigated patient population. RESULTS: The analysis encompassed 99 patients, the youngest and the oldest ones being one year old and 61 years old, respectively. The complications were noticed in 11 patients, i.e. in 10.5% of 105 surgical procedures. The majority of procedures (89.5%) were not accompanied by any post-surgical complications. Unsuccessful implantation in a single-step procedure (4.04%) and transient facial nerve paralysis can be considered most frequent among our patients, whereas cochlear ossification (1.01%) and transient ataxia (2.02%) occurred rarely. Stimulation of the facial nerve (1.01%), intraoperative perilymph liquid gusher (1.01%), device failure and late infections (1.01%) were recorded extremely rarely. CONCLUSION: Complications such as electrode extrusion, skin necrosis over the implant or meningitis, which is considered the most severe postoperative complication, have not been recorded at our Center since the very beginning. Absence of postoperative meningitis in patients treated at the Center can be attributed to timely pneumococcal vaccination of children.

Congenital cholesteatoma of mastoid origin--a multicenter case series.

BACKGROUND/AIM: The mastoid is the rarest site for the onset of congenital cholesteatoma (CC). The symptoms are atypical and minimal. The aim of this multicenter retrospective descriptive study was to define this extremely rare condition and its clinical presentation, diagnosis and management. METHODS: We analyzed data files for a 15-year period in 4 tertiary otology centers and discovered 6 patients with the diagnosis of CC of the mastoid. RESULTS: The clinical presentation of CC varied from incidental findings in patient to patient with otogenic meningitis. The most common findings during surgical procedures were mastoid cortex erosion, sigmoid plate dehiscence, dural exposure and external canal wall destruction. CONCLUSION: CC of mastoid origin tends to occur in adult patients probably because of minimal symptoms and the delayed diagnosis. It can exist for years in a nonaggressive state and develop to giant sizes. In children it is almost incidentally diagnosed. Early imaging is necessary in order to prevent serious complication.

Functional hearing results in patients with otosclerosis before and after stapedotomy.

Surgical treatment of otosclerosis with stapedotomy leads to the improvement of subjective and objective problems in patients with otosclerosis. A prospective study included patients who had been treated surgically at the Department for Ear, Nose and Throat in Novi Sad in the period from September 2006 to September 2007. On the basis of the appropriate diagnostic procedures, 33 patients were diagnosed with otosclerosis. Functional hearing was assessed before and after surgery by means of pure tone audiometry. The comparison of functional results before and after surgery revealed no changes in pure tone average of bone conduction threshold (average hearing threshold for hearing range), whereas pure tone average of air conduction and pure tone average of the gap showed statistically significant improvement. The results of this study demonstrated the applicability of stapedotomy as a method for successful management of otosclerosis. This way of examination offers a new perspective on patients' health, which should be defined as a physical, psychosocial and social well-being, and not only the absence of a disease itself.

[Otitis media in children--a parallelism between the state-of-the-art knowledge and the context of real clinical practice].

INTRODUCTION: Inflammation of the middle ear is the most common illness among children. It is commonly recurrent by its nature, causing transient or long-term hearing reduction. From the clinical aspect, the problem of recrudescence and chronicity of childhood otitis media is enormous. There are controversies and nonuniformities in defining the cause, conservative and surgical treatment, prevention, mostly due to morphofunctional specificities and dynamic developmental features of the tubotympanomastoid complex. Some open questions are as follows: is recurrent otitis media in childhood really recurrent, or we are dealing with clinical manifestations of exacerbation of the chronic process (chronic from the very beginning), which are the factors predisposing and/or reflecting inflammatory processes in the middle ear, which are the potentials of real clinical practice, which are the modalities of prevention of inflammatory processes in the middle ear in children, is there a parallelism between the real clinical, therapeutic practice and current knowledge of the etiopathogenesis of otitis media in children? DISCUSSION: This study reviews current knowledge and identifies potential etiopathogenetic factors in the development of inflammatory processes of the tubotympanomastoid complex. Special attention was given to external predisposing factors, as well as internal factors which include genetic, immunobiochemical, factors of increased adherence of pathogens and Eustachian tube dysfunction. The study also deals with the potentials of diagnostic morphofunctional procedures, as well as modalities of the real clinical practice. CONCLUSION: An open question remains with regard to the parallelism between real clinical therapeutic potentials and state-of-the-art knowledge, as well as the role of preventive procedures in the field of inflammatory processes of the tubotympanic complex in children.

[Techniques end results of surgical treatment cholesteatoma of middle ear].

INTRODUCTION: Basic surgical techniques in the treatment of middle ear cholesteatoma include the intact-canal-wall and canal-wall-down tympanoplasty and combined method, i.e. the "mobile-bridge" tympanoplasty. The techniques including reconstruction of the posterior bone wall of the external auditory canal are combination of formerly mentioned methods. These tympanoplasty procedures involve a partial or complete removal of the posterior bone wall of the meatus. Subsequently, after the elimination of pathological process, the reconstruction of the middle ear is performed. MATERIAL AND METHODS: 200 patients with middle ear cholesteatoma, who had undergone various microsurgical procedures, were monitored and evaluated in the period 1998-2006. The aim of this study was to present the main principles of tympanoplasty and outcomes of middle ear cholesteatoma surgery through a comparative analysis of the applied tympanoplasty techniques. The closed ICW and open CWD tympanoplasty were compared with the combined mobile-bridge technique with the reconstruction of the posterior bone wall of the external auditory canal. RESULTS: The incidence values for the recurrent cholesteatoma in closed tympanoplasty and in cases of open techniques with radical trepanation of the temporal bone were 6% and 10%, respectively. In cases of combined mobile-bridge tympanoplasty with the reconstruction of the posterior bone wall of the auditory canal the incidence of residual cholesteatoma was 2%. The postoperative rejection of the replanted bone was observed in 2% of. the patients. CONCLUSION: The selection of the appropriate surgical procedure is determined by the type and extent of pathological process, anatomic features of the pneumatic space of the middle ear, available microsurgical equipment and otosurgical skills of the surgeon.

[Analysis of reasons for late diagnosis of hearing impairment in children].

INTRODUCTION: Hearing loss in children will cause cognitive deficits in the central areas which are dependent upon hearing and is therefore responsible for delay in the speech development, poor language skills and disorders in psychological and mental behavior. An early identification of educationally significant hearing loss in infants and young children is an essential prerequisite for effective aural rehabilitation and educational intervention. Maturation of the auditory path takes place within the first 18 months of life and is dependant on the adequate acoustic stimulation. To ensure the optimal therapy a definite diagnosis of the hearing impairment should be made until the sixth month of life. Current health care standards recommend the confirmation of the neonatal hearing loss before the age of three months and the appropriate intervention before the age of six months. MATERIAL AND METHODS: The study consisted of the prospective analysis of data collected for 70 children with suspected hearing loss. According to the hearing level determined by the objective diagnostic methods (Brainstem Evoked Response Audiometry) the whole group was divided into three subgroups. We analyzed the average age when the hearing loss was detected, the reasons for the late identification of the hearing loss, as well as the risk-factors for hearing difficulties. RESULTS AND DISCUSSION: Of 70 children with suspected hearing loss, we found normal hearing or mild hearing loss in 17 cases (group 1), 16 children were suffering from moderate and severe hearing loss (group II), and 37% children were suffering from profound hearing loss (group III). Until the age of 2, the diagnosis was made in 40% of 70 children, most in the group III 58.8%, 25% in the group II and 17.64% of children in the group I. The average age when the hearing loss was suspected was 1.62, 2.38 and 1.41 in the groups I, II and III respectively, whereas the average age when the hearing was examined was 2.83, 3.32 and 2.32 in the groups I, II and III respectively. In 22 children (21.5%) no cause of hearing impairment could be determined Nineteen children (15.7%) had the history of familial hearing loss, 37 (52.8%) children suffered from acquired hearing loss. Risk- factors: the presence of the hearing impaired in the family as well as risk-factors was not the reason for parents to check the hearing status of their child. CONCLUSION: The mean age of children diagnosed to have the hearing impairment is still over 2 years in our region. However, the introduction of a universal screening programme would result in significantly earlier detection of the hearing impairment in children.

[Cochlear implantation--risk and complications].

As any other medical procedure cochlear implantation could be risky and there are possibilities for the development of complications. Serious and adequate diagnostic as well as preoperative preparation is necessary for cochlear implantation. Omissions in the audiological, radiological or psychological diagnostic procedures could provoke far reaching consequences in rehabilitation process. The commonest intraoperative complications may be divided into major and minor complications. Minor complications are those that resolve without surgical intervention: flap infection, change in taste, transitory balance problems, transitory facial palsy, non excessive intraoperative bleeding and other. Major complications required revision surgery because of flap problems, device extrusion or migration and device failure. CSF leak, meningitis as well as facial palsy. Adequate flap design should insure prevention of the flap necrosis, which is a very unpleasant complication. Principles of prevention, management, and sequelae of complications are given in this paper. Data presented in this paper indicate that cochlear implant surgery in children is a reliable and safe procedure with a low percentage of severe complications. Problems related to ear surgery can occur and should be manageable with standard procedures.

[Psychogenic hearing impairment in differential diagnosis of sudden hearing loss].

INTRODUCTION: Acute hearing impairment or deafhess may manifest as unilateral or bilateral. The etiopathogenetic substrate may be organic, functional and of unknown origin, the so-called idiopathic. The functional causes of impaired hearing and deafness also include psychogenic factors, where the essential dysfunction exists between the conscious simulation of hearing impairment and deafness for benefits versus psychogenic hearing impairment in conversion disorders where physical symptoms result as a symbolic expression of long-term psychological problems or conflicts. Acute hearing impairment, pseudohypacusis, as a symptom of conversion disorder, where hearing impairment is without evidence of organic cause, is a rare pseudosensory form of this disease. Numerous literature data indicate that these disorders are most common among children, whereas in adults only individual cases are reported. In otorhinolaryngological practice, other symptoms of conversion disorders are much more common (psychogenic aphonia and dysphonia, globus pharyngeus, sensation disorder in the head and neck region). CASE REPORT: The paper includes a detailed presentation of the diagnostic procedure, clinical course, differential diagnostic dilemmas and therapeutic procedure in cases of acute bilateral psychogenic hearing impairment in adolescents. CONCLUSION: Acute hearing impairment caused by organic substrate is irreversible in most cases, whereas in psychogenic hearing impairment the prognosis is excellent, particularly among children and adolescents. Identification of the etiologic factors of reversible hearing loss, including psychogenic ones, by the otorhinolaryngologist is of utmost importance in order to provide early differential diagnosis and timely inclusion of a psychiatrist and a clinical psychologist into the diagnostic-therapeutic.

[Corrosive substance ingestions management].

Acute poisonings with corrosive substances make 15-20% of all acute poisonings in our country. They are on the second place, after drug poisonings, which are far more often. After the ingestion of corrosives, corrosive lesions of the gastrointestinal tract appear. The oesophagus has lesions mostly in cases of ingestion of alkali, and the stomach (gaster) is damaged when an acid is ingested The first steps in the management of the patients having ingested a corrosive substance are to stabilise all vital parameters of the patient (reanimation) and to dilute the substance. The dilution can be done within 60 minutes, with water or milk. After the stabilisation of all vital parameters, the further treatment should start, meaning diagnostics and therapeutic measures. The best diagnostic procedure to determine the presence and severity of corrosive oesophageal lesions is oesophagoscopy. Basic therapeutic principles in the management of patients after corrosive substance ingestion must be applied. According to these principles, it is contraindicated to induce vomiting, diarrhoea and do corrosive substance neutralisation or gastric lavage. Charcoal has no effect, and is not indicated. It is important to identify the kind and quantity of ingested substance, as well as to withhold all oral feedings, and to assess fluid and electrolyte balance carefully and to watch for development of complications. This paper presents the complete treatment protocol of ENT Clinic, Clinical Center of Vojvodina, Serbia. This protocol has been in use since the year 2000 and the results are excellent.

[Cochlear implantation at the Ear, Nose and Throat Clinic of the Clinical Center of Vojvodina].

INTRODUCTION: A cochlear implant is a small electronic device that can provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. Cochlear implants bypass the damaged hearing systems and directly stimulate the auditory nerve. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognizes the signals as sound. Hearing through a cochlear implant differs from normal hearing and takes time to learn or relearn. Cochlear implantations have been performed at the ENT Clinic in Novi Sad since 2002. The aim of this retrospective investigation was to evaluate performance of cochlear implanted patients in regard to the age of hearing loss identification, age at implantation, as well as complications. MATERIAL AND METHODS: During a 5-year period (2002-2007), 45 patients underwent cochlear implantation (46 implants) at the ENT Clinic in Novi Sad. Only four patients were postlingually deaf adults. Forty-one implanted patients were children with a mean age at implantation of 42.2 months (range: 2 to 8 years). Out of these patients, 28 (68.2%) had congenital deafness of unknown cause. The commonest known cause was meningitis, found in 4 (9.7%) patients, followed by use of ototoxic drugs and hereditary deafness. Etiological factors included: postnatal hypoxia, intracranial hemorrhage, pre term birth, cytomegalovirus infection during pregnancy, middle ear cholesteatoma, as well as sudden bilateral deafness. The time span between diagnosis of hearing loss and implantation was 34.6 months in 2002 and only 10 months in 2007. RESULTS: 6 (13%) patients presented with complications. There were 4 major, and two minor complications. The following complications were noted: ossified cochlea which required reoperation, unsuccessful operation in a patient with Down syndrome, facial tics, temporary facial weakness and ataxia. Five out of six complications were successfully resolved CONCLUSION: New, more sophisticated audiological evaluation is essential to shorten the time for diagnosing hearing impairment. The results of the investigation performed at the Cochlear Implantation Center of the ENT Clinic in Novi Sad show that cochlear implantation is an effective procedure which should be continued.

[Correlation between auditory threshold and transitory evoked otoacoustic emissions]. / Korelacija izmedju praga sluha i tranzitorno evociranih otoakustickih emisija.

The aim of this study was to compare transiently evoked otoacoustic emissions (TEOAE) and pure tone audiometry in normal hearing ears and ears with cochlear hearing loss (60 ears of 30 subjects), to obtain defined data on qualitative and quantitative correlations. We wanted to determine the reliability with which a clinical examiner could predict a typical, idealized audiometric configuration from TEOAE measurements. The results show that the presence of otoacoustic emissions drops as a function of hearing loss and that there is a highly statistically significant correlation between characteristics of otoacoustic emission (coefficient of correlation and strength of otoacoustic emissions) and hearing loss at 1000-3000 Hz frequency. Otoacoustic emissions are never found when hearing loss at 1000-3000 Hz exceeds 36 dBnHL. The main practical conclusion is that otoacoustic emission presence indicates middle frequency functional integrity of the outer hair cells of Corti's organ. Absence of otoacoustic emissions is harder to interpret and requires further audiological diagnosis (brain-stem auditory evoked potentials).