Histopathological, Biochemical, and Microbiological Evaluation of Oxygen‑Boric Acid (OKSIBOR®), Ciproϐloxacin, and Hydrogen Per‑ oxide in the Rat External Ear Canal

Ear canal dynamics

We report the case of a 10-year-old boy with prolonged fever who was found to have tularemia of the middle ear. Otolaryngologic cases including oropharyngeal and glandular or ulceroglandular forms of the head and neck region are estimated to account for 12% of all tularemia cases, but to date we have not seen a report of tularemia in the middle ear. The possibility of tularemia may not occur to a physician because of the wide variation of clinical manifestations.

Aim: to identify the patterns of the external and middle ear disease course in children and adults during the holiday season. Patients and Methods: 212 patients participated in the study: 98 children (46.2%) and 114 (53.8%) adults who visit an otorhinolaryngologist with complaints of ear pain, discharge from the external auditory canal and ear congestion that occurred during their stay in hot climatic conditions and in close proximity to the aquatic environment. The patients were divided into 2 groups: group 1 — 98 children from 0 to 17 y.o. inclusive (mean age 7.1±2.5 y.o.), group 2 — 114 patients older than 17 y.o. (mean age 43.4±15.9 y.o.). The patients underwent standard otorhinolaryngological examination, digital videotoscopy and endootoscopy. Given the discharge from the external auditory canal, a bacteriological and mycological study was conducted. Patients received systemic and topical treatment. According to the indications, ear drops were used, the active substances of which were polymyxin B sulfate + neomycin sulfate + lidocaine hydrochloride. Results: the ear disease structure somewhat differed in adults and children and was represented by the following pathologies: diffuse acute otitis externa — in 38 (38.8%) children and 74 (64.9%) adults; limited otitis externa (furuncle in the external auditory canal) — in 3 (3.1%) children and 7 (6.1%) adults; otomycosis — in 2 (2%) children and 3 (2.6%) adults; acute otitis media — in 39 (39.8%) children and 18 (15.8%) adults; otitis media with effusion — in 7 (7.1%) children and 3 (2.6%) adults; exacerbation of chronic suppurative otitis media — in 2 (2%) children and 4 (3.5%) adults; external auditory canal injuries — in 2 (2%) children and 2 (1.8%) adults; eardrum injuries — in 2 (2%) children and 1 (0.9%) adult; foreign bodies in the external auditory canal — in 3 (3.1%) children and 2 (1.8%) of adults. Patients in both groups had concomitant ear pathologies, as well as diseases of the rhino-orbital area and pharynx: acute adenoiditis — in 22 (22.4%) children; acute tonsillopharyngitis — in 11 (11.2%) children and 15 (13.1%) adults; acute rhinosinusitis — in 19 (19.4%) children and 21 (18.4%) adults. Besides, 4 (4.1%) children had acute rhinosinusitis combined with acute dacryocystitis. According to the treatment results, there was a positive trend in 91 (92.8%) children and 109 (95.6%) adults with inflammatory external and middle ear pathologies (based on the otoscopy and subjective perception results) during a 7-day follow-up. Conclusion: the holiday period, which commonly implies the bathing and hot weather seasons, is characterized by a certain pathology spectrum of the external and middle ear, affecting both adults and children: diffuse and limited external otitis, otomycosis, acute otitis media, otitis media with effusion, exacerbation of chronic suppurative otitis media, foreign bodies in the external auditory canal, and external auditory canal injuries. KEYWORDS: holiday season, aquatic environment, ear, external otitis, acute otitis media, otitis media with effusion, chronic suppurative otitis media, rhino-orbital area pathology, otoscopy, ear drops. FOR CITATION: Baranov K.K. External and middle ear disease patterns in the holiday season. Russian Medical Inquiry. 2023;7(8):518–523 (in Russ.). DOI: 10.32364/2587-6821-2023-7-8-7.

Hydrogen peroxide ototoxicity in unblocking ventilation tubes: A chinchilla pilot study

Symptoms

BACKGROUND AND OBJECTIVE: Synthetic antiparasitic medications are often associated with drug resistance and adverse side effects. In traditional medicine, Ferula asafoetida has been widely used in the treatment of parasitic infections, and various studies have confirmed the anti-leishmanial, anti-Giardia, and antifungal properties of this medicinal herb. This study aimed to evaluate the antiparasitic effects of the methanol extract of asafoetida. METHODS: This experimental study was conducted on 100 male rats equally divided into 10 groups. To induce infection, animals were fed the eggs of nematode Syphacia obvelata and cestode Hymenolepis nana via gavage. Animals in groups one and two were considered as control subjects for cestode and nematode, respectively and received no medications. The third group was administered with a standard anticestodal dose of praziquantel (25 mg/kg), and the fourth group was administered with a standard antinematodal dose of piperazine (20 mg/kg). Infected animals in experimental groups five, six and seven received treatment with 2.5%, 5% and 10% concentrations of asafoetida methanol extract, respectively. Moreover, induction of nematode infection was performed on the animals of experimental groups 8, 9 and 10, which were administered with 2.5%, 5% and 10% concentrations of asafoetida methanol extract, respectively. Treatment of the animals continued for two weeks. Number of parasite eggs in the fecal samples was determined at the end of the first and second week of treatment. After the intervention, total number of the intestinal parasites was calculated and assessed in the experimental groups. FINDINGS: In the first week of treatment, no statistically significant difference was observed between the number of Syphacia obvelata eggs in rats administered with the methanol extract of asafoetida even at the highest concentration compared to control subjects (166.4±3.11 vs. 235±9.5). Similarly, treatment of nematode infection with the methanol extract of asafoetida could not decrease the number of eggs and parasites by the end of the second week of treatment (P>0.05). However, rats with cestode infection receiving different concentrations of asafoetida extract showed a significant reduction in the number of eggs and parasites compared to control subjects (p<0.05). CONCLUSION: According to the results of this study, the methanol extract of Ferula asafoetida had no antinematode properties in vitro, while it exhibited anticestode effects on laboratory animals with induced parasitic infection

Most salivary fistulae of the parotid gland open on to the skin surface and are a consequence of trauma to the main duct (Hemenway &amp; Bergstrom, 1971) or to the gland itself (Joffe, 1967) or following surgical procedures. Despite the close proximity of the parotid gland to the external auditory meatus, post-surgical and traumatic fistulae into the external auditory meatus are extremely rare. Richards (1960) reported a case produced by an endaural incision for mastoid surgery. Even rarer is the formation of a spontaneous parotid salivary fistula into the external auditory meatus. A search of the English literature revealed only one previous report (Sharma &amp; Dawkins, 1984) who postulated a patent foramen of Huschke and the repeated trauma of jaw movement on the parotid as the cause of the abnormal connection. However, investigation, including sialography, could not confirm this. We report a case of salivary fistula in which sialography was confirmatory, and both conventional and computed tomography (CT) of the external auditory meatus were helpful. A 58-year-old woman presented with a 9-month history of recurrent discharge from the right ear. Examination revealed typical otitis externa with accumulated squamous debris and red, oedematous canal skin. The tympanic membrane was seen to be intact. The left ear was normal. The condition settled with topical antibiotic drops but over the next 2 years she was seen repeatedly for further episodes of this unilateral otitis externa which settled each time with the same treatment.

Background and Objective: Anal fissure can be associated with trauma caused by passing hard stools or prolonged diarrhea. The present study aimed to determine the effectiveness of topical hydrocortisone in the treatment of anal fissures in patients under medical treatment referred to Fatemi Hospital and Kausar Clinic of Ardabil Medical Sciences, Ardabil, Iran, in 2019. Materials and Methods: In this clinical trial study, 200 patients with anal fissures were randomly divided into two groups. The intervention group was treated with diltiazem gel, psyllium powder, lactulose syrup, and hydrocortisone topical ointment. Hydrocortisone ointment was not used in the control group. Results: The mean scores of initial pain were 8.06±0.7 and 7.79±1.02 in the intervention and control groups, respectively. The mean pain at the end of the first week was 2.5±1.06 in the intervention group and 3.34±0.89 in the control group. Pain reduction was significantly higher in the intervention group than in the control group in the first week of treatment. Two weeks later, the pain was 1.46±0.7 in the intervention group and 1.86±0.74 in the control group. There was a significant difference between the two groups in the first and second weeks of treatment. Conclusion: The therapeutic combination of a topical corticosteroid with a calcium channel blocker at the beginning of treatment for chronic fissures during the first week of treatment led to a faster response in the form of pain reduction

With the passage of time progress is inevitable. For those of us who provide hearing healthcare, progress means offering new technologies, implementing new procedures, and expanding our services to our patients. Ultimately, progress requires us to make changes in our practice model to keep pace with consumer demands. It is helpful to look back to where our profession was when we started and where it is today so that we can more effectively navigate where we want to be positioned in the future. Who thought 35 years ago that clinicians would be fitting instruments so small they would fit completely in the ear canal and yet accommodate multiple user programs? Who back then could have imagined the vast array of fitting algorithms and the amazing versatility that today's hearing instruments offer—or that an average retail price for a pair of hearing aids would be around $4000? Advances in technology over the past three decades have created the need for more and better training. For example, the introduction of completely-in-the-canal (CIC) technology in the early 90s required that ear impressions be taken within 5 mm of the eardrum. Given the potential risks associated with operating in the bony portion of the ear canal, how could deep impressions be taken safely? And what would happen to even small amounts of ear wax lodged in the canal during the impression process? Where would it go? MOTIVATION TO MANAGE CERUMEN The advent of deep-canal impressions has raised new questions about the issue of cerumen and made more and more hearing care providers consider learning how to remove it themselves. After all, how can a deep-canal impression—or really any type of impression—be performed safely if there is wax in the canal? And is referral to a physician for wax removal called for when only a small amount of wax is observed? Might not a referral add to the patient's cost, inconvenience, and anxiety and lead to delay or possible inaction? It's no wonder then, as we work with hundreds of dispensing professionals around the country, that we find that more than 50% of them are removing ear wax at some level. The introduction of video otoscopy made it possible for clinicians to view the ear canal and eardrum in much greater detail than they could with a traditional otoscope. A traditional otoscope provides a smaller work area and therefore is more cumbersome for instrumental methods. In contrast, video otoscopy provides significantly greater magnification to explore the ear, making ear wax removal much safer. Video otoscopes are now in routine use in many dispensing facilities. As mentioned above, it appears that more than half of all dispensing clinicians perform cerumen management, in many cases with little or no training. As more hearing care providers practice cerumen management, the need increases for professional training to ensure that they do so in a safe and effective manner. CAVEATS TO PRACTITIONERS This article will discuss the five procedures routinely used for the removal of ear wax; Q-tip®, curette, forceps, lavage, and vacuum methods. However, before we begin, we must emphasize to readers that they must not perform cerumen management unless they meet the following criteria: Licensed hearing healthcare providers must be certain they are permitted to perform cerumen management under the regulations of the state or provincial agency governing their profession. Clinicians need in-depth knowledge of the outer ear structures and must have fine-tuned their skills commensurate with the difficulty level of the procedure(s) they intend to perform. Clinicians must have the appropriate instruments and must follow proper sterilization, sanitation, and hygiene protocols. Any practitioner performing cerumen management should be certain that a physician with a specialty in otolaryngology is available nearby in case of a medical contingency. Last, but not least, clinicians who plan to perform cerumen management should have adequate professional liability insurance. BEFORE YOU BEGIN An understanding of the human body's general circulatory and lymphatic systems, the ear's innervation system, and commonly observed disorders of the outer ear is essential for those planning to perform cerumen management. Take a patient history Before starting cerumen management, determine if the patient has a history—old or recent—of eardrum perforation, ear surgery, prior wax removal or other medical procedures of the ear. Also, find out if the patient is taking Coumadin, aspirin, or other blood-thinning medications, has diabetes, or is on insulin. Special precautions should be taken prior to performing cerumen management when any of these or other otologic “red flag” conditions are present. Whenever you are in doubt, the prudent course is to make a medical referral. Determine type and location of cerumen Other key facts to ascertain prior to cerumen management include the consistency, volume, and location of the ear wax in the ear canal. The cartilaginous outer third of the ear canal is a safer and easier area in which to do cerumen management than the inner portion. The outer part of the canal is lined with skin, cartilage, fatty tissue, and muscle, which offer some protection to patients and make them less likely to feel discomfort during cerumen management. In contrast, the inner bony portion of the ear canal is lined with only a thin layer of skin over the bone. Without a cushioning lining in the bony portion, removing cerumen from this area requires the practitioner to have an especially high level of skill and accuracy. Determine patient sensitivity Palpation, sensitivity to touch, is another key factor in determining which method of cerumen removal to select. Does your patient experience no pain or, at most, mild discomfort to your touch? Or does he or she feel discomfort or pain? Knowing this will help you determine which of the five recommended procedures will produce the best result.Figure 1: Proper positioning and handling of the video camera are extremely important for cerumen management.Inspect the ear Prior to removing ear wax, the clinician should carefully examine the ear by means of Direct Video Otoscopic Inspection (DVOI) of the ear. The results of this inspection and an analysis of the wax criteria will help you decide which removal method to use. Direct Video Otoscopic Guidance (DVOG) provides a real-time view of the ear canal and eardrum as the Q-tip or other instruments are inserted beyond the tip of the camera. DVOG enables the clinician to navigate the ear canal, position the Q-tip or instrument, and execute the most appropriate technique to clear the ear wax. Maintain a sterile work area Proper hygiene protocols must be followed. They include maintaining a clean and sterile work area, hand washing, and wearing latex gloves and protective clothing such as a lab coat. To prevent the spread of germs, instruments should be sterilized in a bactericide, viruscide, and fungicide disinfectant medical solution according to the manufacturer's recommended soak times. Although it is not necessary to hot-sterilize instruments in an autoclave, doing so will provide maximum protection from the spread of germs. METHODS FOR CERUMEN REMOVAL (1) Q-tip method One of the safest and least invasive procedures for cerumen removal is to use a Q-tip. This is most effective when a minor amount of soft recent wax is located in the pinna or the outer third of the ear canal. Applying several drops of baby oil or MiraCell to the Q-tip will make it act as a magnet when it comes into contact with ear wax. Rotating the Q-tip as you remove it from the ear canal can easily clear the canal of any wax. The procedure can be repeated as often as necessary. This method is one of the most comfortable for a patient and an excellent starting point for a clinician as he or she develops skills and gains confidence. If possible, take before and after photos of the ear canal and eardrum and make them a permanent part of the patient file. (2) Curette method The curette method is the most widely used instrumental method among dispensing professionals. This procedure can be used on a wax mass of any color and of consistencies ranging from soft to hard so long as the wax is not attached to the eardrum. It can be used to remove wax that occupies only a small part of the ear canal or that occludes the entire canal. Pain thresholds range from no discomfort to pain. Ideally, the curette creates a gap in the wax mass that ena-bles the clinician to maneuver the instrument behind the wax so it can be removed in one scoop. However, most often, it will take several att-empts to clear the en-tire mass.Figure 2: Skillful handling of the curette will help create a gap in the wax mass.Executing the curette method requires skillful handling of the instrument based upon sensitivity and touch (palpation). The curette should be held so that it floats between the fingers. When properly handled the curette will slide backwards or out of the ear rather than farther into the ear, which can cause injury. Maintaining an assortment of curettes in different sizes and shapes is helpful. (3) Forceps method Alligator forceps work best when there is a wax flap in the ear canal. Often, forceps are used in conjunction with other cerumen management methods. As with both the Q-tip and curette methods, forceps should be guided over and in front of the video camera providing you with a clear view that helps you complete the procedure successfully. It is very important never to close the alligator forceps until you are certain that it will grab the wax mass or wax flap. The alligator forceps can also be used to remove hair follicles or other foreign objects from the ear canal. (4) Vacuum/suction method The required equipment for the vacuum/suction method includes a suction tube known as an aspirator/canalith and a suction pump. The consistency of the wax can range from soft to medium and it can occupy a small area of the canal or the entire space. To clear the ear canal using the vacuum method, place the canalith directly at the tip of the wax mass. By applying negative air pressure the pump begins to vacuum the wax mass until it is removed. Although this method is one of the safest and requires minimal skill, it appears to be the least utilized by dispensing professionals.Figure 3: Extreme caution is required before closing the forceps to ensure that only the wax mass or wax flap is grabbed.(5) Lavage/irrigation/flush method This method is often preferred by healthcare professionals from outside hearing healthcare. And, contrary to the wishes of the authors, flush kits are sold over the counter for self-use. The lavage/flush method can be used in cases ranging from soft, newly formed wax to hard, old wax impactions. This method can be ideal when there is a gap between the skin of the ear canal and the wax mass. The goal is to direct water past the wax mass toward the canal wall so that it indirectly hits the eardrum and then flows back in a return stream that washes out the wax. This is accomplished by inserting the tip of the syringe into the ear canal between the first and second bends. A stream of warm water should be gently applied toward the canal wall with a clockwise rotation movement. Either the patient or assistant should hold a basin directly under the ear to catch the warm water, wax, or other debris. Repeat the procedure until the wax mass is gone and keep emptying the basin as needed. This method must never be used on patients with a history of perforations, large or small, or who have any present perforations. With this method, the patient should wear a protective gown. CONCLUSION Small amounts of ear wax can interfere with the performance of hearing instruments and lead to costly repairs and inconvenience, both for the patient and the clinician. Therefore, maintaining clean, healthy ears adds value and efficiency to any dispensing practice. This also applies to the increasing number of patients wearing open-fit hearing aids who often do not require ear impressions. Clinicians with insufficient experience in this area need to obtain proper training before attempting cerumen management. Until recently, few training programs specifically for cerumen management were available. A great many of the professionals who first began providing cerumen management received minimal training or none at all. That is not to say that self-taught clinicians aren't performing cerumen management safely and effectively. However, now that training is readily available, practitioners have no excuse for not being trained before venturing into this area of practice. Acquiring advanced skills and gaining experience with the various methods of cerumen management will enable clinicians to perform it safely and with confidence. Ultimately, the beneficiary in this process is the patient. WHAT TO DO IF BLEEDING OCCURS The skin layer lining the ear canal is extremely thin, especially in the inner two-thirds, and is therefore prone to bleeding when an object is introduced into the canal. Generally, a minor amount of bleeding is not cause for alarm, as there are no major arteries in or surrounding the ear canal. Often bleeding in the ear canal may look more severe than it really is. There are several steps clinicians can take when bleeding occurs. Observe, but take no action. Usually minor bleeding will stop within minutes, dry, and eventually exit the ear during the ear's normal epithelial migration. If bleeding does not stop quickly, apply hydrogen peroxide to the affected area until the bleeding stops. Hydrogen peroxide serves as a hemostatic treatment and contains chemical components that act as an antiseptic that cleans and disinfects an area to prevent infection and also to help stop or control bleeding. Should bleeding continue, refer the patient to an ENT physician. As mentioned above, any practitioner who performs cerumen management should make sure that a physician with a specialty in otolaryngology is readily available.

Verrucous carcinoma is a variant of squamous cell carcinoma. It is of low grade malignancy and rarely present with distant metastasis. Oral cavity is the commonest site of this tumor, other sites are larynx, oesophagus, and genitalia. Verrucous carcinoma in external auditory canal is extremely rare. This is the presentation of a 45-year-old woman who came to the ENT and Head Neck Surgery department of Delta Medical College with discharg from left ear and impairment of hearing on the same side for 7 years. Otoscopic examination showed that the skin of external auditory canal was thickened, papillary and blackish. External auditory canal bone was found eroded. Cytology from external auditory canal scrap showed hyperkeratosis and parakeratosis. Excision of the external auditory canal mass was done under G/A. Whole skin from external auditory canal was excised under microscope. Split thickness skin grafting was done in external auditory canal. The specimen was sent for histopathological examination which revealed as verrucous carcinoma. Subsequently, she was treated by radiotherapy. Six months follow-up shows no recurrence.

Microtia is a congenital disorder characterized by an anomaly in the auricle. It is often associated with atresia, stenosis, or obstruction of the external auditory canal. In cases of microtia, the incidence of a normal external auditory canal, congenital external auditory canal stenosis, and congenital complete closure of the external auditory canal (aural atresia) is reported to be 8%, 8%, and 84%, respectively. Congenital stenosis of the external auditory canal can sometimes be accompanied by intractable otorrhea and otalgia, raising the possibility of complications of external auditory canal cholesteatoma. Here, we report a case of an adult with microtia and external auditory canal stenosis who presented to our clinic with complaints of otalgia. A large external auditory canal cholesteatoma was found in the patient's left ear. Although cholesteatoma is common in cases of canal stenosis, its extensive spread within the temporal bone is quite rare. A temporal bone-targeted computed tomography scan revealed a soft tissue shadow in the left external auditory canal with distensible expansion and bony destruction in the upper, anterior, and posterior walls of the external auditory canal. In patients with microtia who experience severe aural pain, the possibility of latent extended cholesteatoma should be considered.

1. Charles D. Bluestone, MD* 2. Jerome O. Klein, MD† 1. 2. *Eberly Professor of Pediatric Otalaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3. 4. †Professor of Pediatrics, Boston Univerisity School of Medicine, Boston MA. Dr Klein is a consultant to Eli Lily Company; is a consultant to and lecturer for Bristol Myers Squibb and SmithKline Beecham; is a consultan to and has grant support from Abott Laboratories abd Pfizer Pharmaceuticals; and is a consultant to a, lecturer for, and has grant support from Roche Laboratories. Chronic suppurative otitis media (CSOM) is a chronic infection of the middle ear cleft (including eustachian tube, middle ear, and mastoid) that is defined by three elements: 1) perforation of the tympanic membrane due to acute infection or tympanotomy tube, 2) discharge from the middle ear (otorrhea), and 3) prolonged duration (;gt;2 wk). The initial therapy of most cases is use of appropriate topical and systemic antibiotics, which can be managed by the pediatrician. Otolaryngologic referral is necessary in four circumstances: 1) if otomicroscopy is required for initial or subsequent examination, 2) if the patient fails to respond to initial therapy, 3) if a cholesteatoma or other mass is present, and 4) if a suppurative complication occurs. CSOM affects diverse racial and cultural groups living not only in temperate climates but in climate extremes ranging from the Arctic Circle to the equator. Among the groups affected most are the Inuits of Alaska (30% to 46%), Australian aborigines (12% to 25%), and certain Native Americans (eg, Apache and Navajo tribes) (4% to 8%). Studies from industrialized nations have reported low rates of CSOM due to acute infection with perforation, but many cases of CSOM are associated with use of tympanotomy tubes. No population-based data are available regarding the incidence of CSOM associated with tympanotomy tubes. Risk factors attributed to high rates of CSOM are similar to factors associated with recurrent acute otitis media (AOM): lack of breastfeeding, overcrowding, poor hygiene, poor nutrition, passive smoking, high rates of nasopharyngeal colonization with potentially pathogenic bacteria, and inadequate and unavailable health care. Data from Thailand and Kenya indicate that public health measures and appropriate medical care are effective in decreasing the rate of CSOM. When hearing is assessed in children who have otitis media with effusion (OME), the median level is 25 dB (equivalent …

Sir: The senior author (D.G.P.) reported the first successful replantation of a severed human ear by microvascular reanastomosis in 1980.1 In the nearly 30 years since then, there have been fewer than 30 reported cases worldwide. (We include only microvascular cases where complete amputation had taken place. It is well known that an ear can survive on a very small strip of intact skin. Cases where microsurgery has claimed success in those instances must be treated with skepticism.) We were able to review the original patient described in 1980, some 29 years 7 months after his surgery. The patient had sustained a complete avulsion injury of his left ear in July of 1979, in a motor vehicle accident. Successful replantation of the ear was completed 9.5 hours after the injury. The patient, aged 54, still lives in the same mountainous area where winter temperatures frequently fall below 0°C, a factor that would influence cold intolerance. The patient's original history was confirmed; he was questioned about symptoms and examined physically. New photographs were compared with the original photographs taken at the time of the replantation episode (Fig. 1).Fig. 1.: Results at 30 years after replantation of the patient's avulsed ear.Some recovery of sensation was noticed by the patient within months of the injury, but full recovery had taken approximately 3 years. After that, he could not distinguish a difference between the two ears. He had never experienced cold intolerance despite his ear being exposed to near-0°C temperatures. He felt that hearing in the replanted ear was better than in the uninjured ear. Aural hygiene was slightly affected: it was a little more difficult to clean the canal of that ear. Results of physical examination are listed in Table 1. Ear dimensions, including thickness, were measured with a standard engineering caliper accurate to 0.01 mm. Two-point sensory discrimination was measured with the same caliper at the upper helix, mid-conchal region, and earlobe. Temperature sensation was tested with a refrigerated drink can and a warmed metal object. Light touch was tested with a thin strip of paper. Both ear canals were inspected with an otoscope. No formal evaluation of hearing was undertaken.Table 1: Results of Physical ExaminationThe replanted external meatus is oblique because of lack of cartilage support resulting from cartilage loss at the time of injury (Fig. 2), but there was no cicatricial stenosis. The ear drum and canal appeared normal. The conchal fossa is somewhat distorted, because some cartilage from the concha was lost in the injury and the remaining cartilage of the concha was fractured extensively. The left ear is shorter and wider than the opposite ear because of conchal distortion and perhaps some scar contracture (Fig. 2).Fig. 2.: Comparison of right (uninjured) and left (replanted) ears.In a 25-year review of ear replantations since our case, Steffen et al.2 found only 26 genuine microsurgical replantation cases, with an overall success rate of 90 percent. Venous anastomosis improved survival in total ear replants, but not in partial replants. However, when adjuvant treatments such as bleeding and leeches were used instead of venous anastomosis, high transfusion rates and increased morbidity resulted. They concluded that successful replantation was superior to secondary reconstruction, a conclusion with which we agree. Because of the rarity and technical challenges, use of a clear technical protocol is wise. Our original article stressed the importance of a particular order of procedure as follows: Bench preparation of the amputated ear. Identification and tagging of all potentially anastomosable vessels. Use of vein grafts to allow bench suturing of the auricular artery to the vein graft under high magnification and ideal conditions. Arterial revascularization first to help identify veins. We stand by that protocol. You only have one good shot at an ear replantation, so it is essential to make the conditions as advantageous as possible. The use of the superficial temporal vessels as donors for revascularization has been criticized on the grounds that, should replantation fail, this would preclude the use of a vascularized temporalis fascial flap for subsequent ear reconstruction. Our original venous anastomosis was end-to-side with the temporal vein, preserving the continuity of the vein. There is no reason why an arterial input vein graft could not also be end to side, thus preserving the vascularity of the temporal fascia. Our patient highlights the long-term superior aesthetic quality and durability of microsurgical replantation compared with secondary reconstruction. Sensory recovery is complete within 3 years. Canal stenosis is preventable using a silicone stent for 3 months. Cartilage atrophy does not occur, as demonstrated by thickness measurements. The stability is not affected if there is not excessive cartilage loss. Minor aesthetic changes in shape are to be expected, depending on the extent of original injury, and are proportional to the amount of tissue loss. Since 1979, patient retrieval facilities, operating microscopes, instrumentation, and sutures have improved, as has public awareness of these procedures. If anything, the likelihood of success with replantation should be considerably greater than 30 years ago. Our patient demonstrates that the effort is worthwhile (Fig. 3).Fig. 3.: Patient at 30 years after surgery.PATIENT CONSENT The patient provided written consent for the use of his images. David G. Pennington, F.R.C.S.(Ed.), F.R.A.C.S. Thomas E. Pennington, B.Sc., M.B., B.S. Royal Prince Alfred Hospital Sydney, New South Wales, Australia

Acquired external auditory canal (EAC) stenosis is an uncommon condition with an incidence of 0.6 in 100,000 population. Road traffic accidents and otology surgeries are the frequently reported causes for it to occur. The high rate of restenosis makes this condition difficult to manage. A 50 year old lady presented with history of accidental instillation of acid in her left ear at 6 months of age by the care giver. The patient developed stenosis of left EAC with hearing loss. Examination revealed pin point stenosis of left EAC. Puretone audiogram revealed a moderately severe conductive hearing loss. Computed tomogram showed soft tissue lesion obliterating the entire EAC and extending into the middle ear and antrum. Intra operatively only the cartilaginous EAC was stenosed. Surgical excision of the fibrotic scar with a tympanomastoidectomy and wide meatoplasty was done. Regular post operative aural toileting, packing with merocele strips and application of topical antibiotic -steroid preparations was done. 6 months post-surgery a patent EAC and healed tympanic membrane was achieved. In this report, we present a rare case of lateral EAC stenosis secondary to corrosive acid injury, highlighting the surgical steps, post operative care and surgical outcomes. A limited review of literature is also presented.

This study was to measure the sound pressure level distribution by ear canal resonance in the human left and right external auditory canals (EAC). The gain for different stimulus frequencies was analyzed at four different measuring depths (0.5 cm, 1.0 cm, 1.5 cm and 2.0 cm) from the entrance of the ear canal bilaterally. Comparative evaluation showed that the gain for different stimulus frequencies at a depth of 2.0 cm was consistent with the results of Dillon’s study. In addition, the gain for the right EAC at 4000 Hz was larger than that of the left EAC by 1.2 dB at 0.5 cm, 1.8 dB at 1.0 cm, and 0.8 dB at 1.5 cm. This seems to suggest that gain at 4000 Hz is more affected by depth in the right EAC than in the left EAC. This study further found that the gain at the stimulus frequency of 4000 Hz was more affected by the depth than at 2000 Hz for the bilateral ear canals respectively. These gain differences between the right and left ears were statistically significant (p&lt;0.05) at any of four measuring depths. The findings of this study may have an understanding of gain distribution to have implications for microphone placement of custom-made bilateral hearing aids (i.e. ITC or CIC) as these are placed at different depths within the ear canal. Keywords: Sound pressure level; Canal depth; Ear canal resonance; Real ear measurement; External auditory canal