A tailored approach in cholesteatoma surgery.

PURPOSE: In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient. METHODS: Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes. RESULTS: Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB). CONCLUSION: The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

Audiological Outcome in Myringoplasties with an Intact Ossicular Chain: Is there a Difference between Chronic Otitis with or without Cholesteatoma?

Introduction Chronic otitis media (COM) with a central perforation or a concomitant cholesteatoma are both inflammatory lesions, however, with different etiologies. Both entities may present with an intact chain, and the final reconstruction is quite similar. Does it also apply for the hearing outcome? Objectives In a retrospective analysis, we investigated the preoperative hearing and the final hearing outcome of two groups of patients: those with COM and those with cholesteatoma, and compared various factors. Methods Patients operated between 2010 and 2019 were entered prospectively into a research database, and the integrity of the ossicular chain, the extent of the cholesteatoma, and the findings on computed tomography (CT) scans were retrospectively analyzed and correlated to the final hearing outcome. Results Out of 210 tympanoplasties for COM, 162 (80%) presented with an intact chain, and 85 (40%) ears could be analyzed. Out of 283 cholesteatoma surgeries, 53 (19%) ears presented with an intact chain. The preoperative air-bone gap (ABG) was worse in the COM group, but the postoperative ABG over the frequencies of 0.5 kHz and 4 kHz was the same (10 dB to 12 dB) in both groups, and remained within 20 dB in 90% (40 and 78 patients, respectively). The extension of the disease was rather limited in the cholesteatoma group (stages Ch1a and 1b), and better pneumatization and ventilation were beneficial for a good result. Postoperatively, the frequency of 4 kHz had the largest ABG (14 dB and 18 dB). Conclusion Overall, 80% of the patients with COM and less than 20% of those with cholesteatoma had an intact and mobile chain at surgery. Using equivalent surgical techniques for the tympanoplasty, the final outcome was almost the same for both groups, with a mean ABG of 10 dB to 12 dB.

Audiological Outcome in Myringoplasties with an Intact Ossicular Chain: Is there a Difference between Chronic Otitis with or without Cholesteatoma?

Abstract Introduction Chronic otitis media (COM) with a central perforation or a concomitant cholesteatoma are both inflammatory lesions, however, with different etiologies. Both entities may present with an intact chain, and the final reconstruction is quite similar. Does it also apply for the hearing outcome? Objectives In a retrospective analysis, we investigated the preoperative hearing and the final hearing outcome of two groups of patients: those with COM and those with cholesteatoma, and compared various factors. Methods Patients operated between 2010 and 2019 were entered prospectively into a research database, and the integrity of the ossicular chain, the extent of the cholesteatoma, and the findings on computed tomography (CT) scans were retrospectively analyzed and correlated to the final hearing outcome. Results Out of 210 tympanoplasties for COM, 162 (80%) presented with an intact chain, and 85 (40%) ears could be analyzed. Out of 283 cholesteatoma surgeries, 53 (19%) ears presented with an intact chain. The preoperative air-bone gap (ABG) was worse in the COM group, but the postoperative ABG over the frequencies of 0.5 kHz and 4 kHz was the same (10 dB to 12 dB) in both groups, and remained within 20 dB in 90% (40 and 78 patients, respectively). The extension of the disease was rather limited in the cholesteatoma group (stages Ch1a and 1b), and better pneumatization and ventilation were beneficial for a good result. Postoperatively, the frequency of 4 kHz had the largest ABG (14 dB and 18 dB). Conclusion Overall, 80% of the patients with COM and less than 20% of those with cholesteatoma had an intact and mobile chain at surgery. Using equivalent surgical techniques for the tympanoplasty, the final outcome was almost the same for both groups, with a mean ABG of 10 dB to 12 dB.

[Benefit of Bimodal Stimulation with Cochlear Implant and Hearing Aid in Elderly Patients]. / Cochlea-Implantation ab dem 70. Lebensjahr ­ Nutzen der bimodalen Versorgung mit Hörgerät und CI.

Cochlear implant (CI) surgery is the standard of care for postlingual deafness in adults. A hearing aid (HA) for the non-implanted ear is normally used if residual hearing is available. There is limited data on bimodal stimulation in elderly patients. We compare the outcome of bimodal stimulation and analyzed the correlation of bimodal benefit and residual hearing in elderly patients. 22 patients≥70 years were implanted with a single-sided CI from 2002 till 2014. 17 patients use a HA on the non-implanted ear (bimodal). In a retrospective chart review we analyzed the audiological benefit (pure tone average, speech recognition). Time to follow-up was 6 month to 12 years. The subjective benefit was assessed using a structured questionnaire. The speech recognition (monosyllabic word testing in quiet @ 65 dB SPL) showed a score of 61% in bimodal condition vs. 53% with CI alone (p=0.35). There was no statistically significant correlation between residual hearing in the lower frequencies (250 Hz, 500 Hz and 1 kHz) and bimodal benefit. Most elderly patients benefit from bimodal stimulation. In quiet and in comparison with CI alone, most patients showed some improvement in word recognition scores using bimodal fitting, and all of them were using the contralateral hearing aid all day long. Postlingual deafened elderly patients fitted with a unilateral CI require a short rehabilitation period. In case of contralateral hearing aid fitting, regular control of the hearing aid should not be overlooked.

Tympanoplasty in chronic otitis media patients with an intact, but severely retracted malleus: a treatment challenge.

OBJECTIVE: To analyze the outcome of patients with chronic otitis media (COM) with an intact, but markedly medialized ossicular chain, treated by removing the malleus head and interposing an autologous incus and then an underlay myringoplasty. STUDY DESIGN: Retrospective clinical study. SETTING: Tertiary referral center. PATIENTS: The search criteria within the prospective surgical database was COM with a central perforation (without cholesteatoma) with a markedly medialized malleus handle (the umbo adherent to the promontory) with an intact ossicular chain (study, n = 15) or an incus necrosis at the lenticular process (incus, n = 23). Only primary surgeries performed at our otorhinolaryngology department were included. INTERVENTION: All patients underwent the same surgical procedure consisting of an autologous incus interposition and underlay myringoplasty with temporalis fascia. MAIN OUTCOME MEASURE: The patients' audiological and follow-up data were retrieved from the database. The postoperative audiogram (0.5-3 kHz) with the longest follow-up was used. RESULTS: The preoperative air-conduction thresholds were less impaired in the study group than in the incus group. After their surgery, all, except 3 patients, improved their hearing, and 97% had an intact tympanic membrane at a mean follow-up of 2 years. The air-bone gap was closed within 20 dB in 80% (study) and in 87% (incus), in one third of all patients even within 10 dB. Although the largest improvement was seen in the lower frequencies, closure of the air-bone gap at 4 kHz was difficult to achieve. CONCLUSION: Patients presenting with COM, a (central) perforation, a medially rotated malleus and intact ossicular chain are a treatment challenge. Lateralizing the malleus handle may require disconnection of the ossicular chain and an autologous incus interposition to bring back the reconstructed tympanic membrane in its original position and improve the hearing.

Otoplasty using a modified anterior scoring technique: standardized measurements of long-term results.

OBJECTIVE: To evaluate long-term results of otoplasty using standardized measurements. METHODS: We performed a retrospective study of patients who underwent otoplasty using a modified anterior scoring technique combined with postauricular fixation sutures. Two hundred twenty-two consecutive patients (421 primary otoplasties) were included. Each auricle was examined before surgery, after surgery, and at a long-term follow-up visit, and the distance between the lateral helical rim and the mastoid surface was measured at 3 points. In addition, patient satisfaction was evaluated using a questionnaire. RESULTS: Seventy-two percent of 222 patients were examined at a long-term follow-up visit. Follow-up of 301 auricles was on average 6.25 years (range, 44-106 months). The mean preoperative measurements among all auricles were 23.3 mm at the uppermost point of the helix, 28.6 mm at the middle, and 25.9 mm at the lobule; these values were 14.2, 14.0, and 16.1 mm, respectively, at the end of the operation and 16.0, 17.5, and 17.4 mm, respectively, 6 years later. Long-term data revealed a median 2-mm lateralization of the auricle. The aesthetic result of otoplasty was rated as "very good" by 71.8% of patients and as "good" by 19.4% of patients; 6.9% of patients thought the result was "satisfactory" and 1.9% "unsatisfactory." Complete recurrence of the protrusion was seen in 7 ears (2.3%) and partial recurrence within the upper third of the pinna in 26 ears (8.6%). CONCLUSIONS: Otoplasty using a modified anterior scoring technique combined with postauricular fixation sutures provides long-term improved results in 91.2% of cases. Complications and sequelae are few, and rates are comparable to those of other long-term studies. A 2-mm lateralization of the auricle may be expected. Standardized measurements of the auricle are important because they supplement the overall aesthetic evaluation of the corrected ear and provide an objective baseline for long-term follow-up.

Non-invasive treatment of intractable posterior epistaxis with hot-water irrigation.

Posterior nose bleeding is a frequent and challenging emergency. The authors report their experience using hot water irrigation as a non-invasive treatment option for posterior epistaxis. Between January 2003 and January 2005 a group of 103 patients were enrolled in this prospective study evaluating the effectiveness of a "hot water irrigation" technique to control acute posterior nose bleeding. All patients with posterior epistaxis were included, whereas anterior epistaxis was controlled using conventional methods. The patient's nose was initially anaesthetized with topical Tetracain 4% (without vasoconstriction) and a modified epistaxis-balloon-catheter was introduced into the bleeding nasal cavity obstructing the choana. The bleeding nasal cavity was continuously irrigated using 500 ml of 50 degrees C hot water. In a total of 84 patients (82%) the bleeding was successfully and permanently stopped. Forty-seven of these patients (56%) regularly took antiplatelet agents or anticoagulants. The method failed in 19 of 103 patients (18%). In the group with unsuccessful irrigation, 11 patients (58%) were receiving treatment with antiplatelet agents or anticoagulants. Their proportion was not different from the successfully treated group. The success rate of hot water irrigation as non-invasive treatment of posterior epistaxis appears at least as effective as conventional methods. However it avoids painful packing, hospitalizations, or immediate surgery, and allows the patient to breath normally through his open nasal cavities.