Intricacies of the Epitympanum-Endoscopically Revisited.

Endoscopic demonstration of the temporal bone and its related structures is a better tool specially for understanding the complex intricacies of the middle ear. In this study we aim to understand the anatomy of the epitympanum/attic with the aid of Otoendoscopy using transmastoid and transattic approaches. Fifty four adult cadaveric temporal bones were dissected at our centre. Transcanal and transmastoid approaches were performed to visualize the middle ear spaces. We could demonstrate Cog, a ridge of bone that extends inferiorly from the tegmen plate just anterior to the head of malleus, epitympanic diaphragm by exploring the three malleal ligamental folds, Prussak's space and its boundaries, pathways of ventilation. Better understanding of the ventilation pathways of the middle ear, restoration of adequate air access in the attic help in better healing and prevent recurrences of diseases. Thus having a three dimentional orientation of the attic and its contents aid the surgeon in performing better surgery and thus provide disease free ear.

Extensive Cholesteatomas: Presentation, Complications and Management Strategy.

To document the clinical presentation, complications, management strategy and post-operative outcomes of extensive cholesteatomas. Cholesteatoma is a well demarcated cystic lesion derived from an abnormal growth of keratinizing squamous epithelium in the temporal bone. Cholesteatomas commonly involve the middle ear, epitympanum, mastoid antrum and air cells and can remain within these confines for a considerable period. Bony erosion is present confined to ossicular chain and scutum initially, but as the cholesteatoma expands, erosion of the otic capsule, fallopian canal and tegmen can occur. Erosion of the tegmen tymapani or tegmen mastoideum may lead to development of a brain hernia or cerebrospinal fluid leakage. Invasion of jugular bulb, sigmoid sinus, internal carotid artery are noticed in extensive cholesteatoma and are quite challenging and requires expertise. Neurosurgical intervention should be considered along with the otological management in the same sitting in all possible cases. A retrospective review of 12 patients were carried out to assess the clinical presentation, complications, surgical management and postoperative outcomes of extensive cholesteatomas presenting at our centre between January 2017 and December 2019. CT or MRI findings, extent of cholesteatoma intra-operatively along with the status of major neurovascular structures and disease clearance, and the post-operative outcomes including morbidity and mortality were noted. All patients underwent canal wall down mastoidectomy with or without ossiculoplasty. Post operatively all patients were treated with intravenous antibiotics and if required intravenous steroids. Amongst the 12 patients of extensive cholesteatoma (EC), all of them (100%) presented with foul smelling, purulent ear discharge. 9 (75%) patients presented with otalgia. 4 (33.33%) patients had temporal headache. 10 (83.33%) patients complained of hard of hearing. 7 (58.33%) patients gives history of vertigo at the time of presentation. In 8 (66.66%) patients there was tegmen plate erosion noticed in CT scan. In 3 (25%) patients, the disease was invading the sigmoid sinus and in 1 (8.33%) patient jugular bulb was involved. In 3 (25%) cases of EC, blind sac closure was performed. In two patients who developed cerebellar abscess, drainage procedure was performed. 2 (16.66%) patients developed sigmoid sinus thrombosis, 1 (8.33%) patient had petrositis.