Anterior Epitympanic Recess Research Articles

Computed Tomography Analysis of the Anterior Epitympanic Recess and Sinus Tympani Depths Among Filipino Adults at the De La Salle University Medical Center

Objective: To assess the depths of the anterior epitympanic recess (AER) and the sinus tympani (ST) among Filipino adults and to classify the AER and ST according to grade and type, respectively. Methods: Design:Retrospective Review of CT Scans Setting: Tertiary Private Teaching Hospital Participants:Scans of 182 non-pathologic ears from patients aged 18 and above with non-pathologic temporal bones (paranasal sinus, screening sinus, temporal bone, facial and cranial) with 0.62mm cuts seen from CT scans from January 01, 2010 to September 31, 2022 were analyzed. The depths of the AER and ST were measured separately and classified according to AER grade and ST type. Results: The mean depth of the AER (AER-D) was 3.64 mm (SD 1.17). No significant difference was seen between right and left ears. The AER grading of the anterior-posterior depth was found to be Grade 1 (<3mm) in 54 ears (29.7%), Grade 2 (3-5mm) in 106 ears (58.2%), and Grade 3 (>5mm) in 22 ears (12.1%). The mean depth of the sinus tympani (ST-D) was 3.30 mm (SD 0.80). Out of the 182 ears, 121 (66.5%) had Type A, 50 (27.5%) had Type B while 11 (6%) had Type C. Conclusion: Majority of the AER depths measured 3-5mm while most of the sinus tympani were Type A. These hidden recesses should be separately analyzed in preoperative planning for cholesteatoma surgery in order to prepare the adequate equipment to be used and approach towards these areas thereby reducing the risk for residual cholesteatomas and recurrence.

Морфофункциональная оценка слизистой оболочки надтубарного кармана и переднего эпитимпанального синуса

Based on autopsy and biopsy material, a morpho-functional assessment of the mucous membrane of the anatomical spaces of the medial wall of the tympanic cavity — separated by fold of the tensor tympani muscle —was carried out. It has been shown that in most cases samples of the mucous membrane of the supratubal recess are represented by multirow or pseudostratified epithelium with loose connective tissue of the lamina propria. On the other hand, the mucous membrane of the anterior epitympanic recess in most cases is represented by flat epithelium with compact connective tissue of the lamina propria, which determines the high gas-absorbing capacity of the mucous membrane. Establishing the boundary of the mucous membrane with a high gas-absorbing capacity in practical terms determines the formation of the tympanic segment when performing open-type tympanoplasty.

Anterior epitympanic recess volume and Cog process length in temporal bones with Körner's septum: A radio- anatomical investigation

ObjectiveKörner's septum is a dense bony lamina dividing the mastoid cavity into superficial squamous and deeper petrosal portions at the level of antrum. In this study, we aimed at investigating the association of the Körner's septum with the length of the Cog process and the volume of anterior epitympanic recess (AER), using the 3-dimensional reconstruction models based on high resolution computed tomography sections of the temporal bone. MethodsUsing OsiriX software for MacOS (version 3.8.1, Pixmeo), we measured the volumes from three- dimensional models of anterior epitympanic recess. Anterior epitympanic recess volumes and Cog process lengths of the temporal bones with and without Körner's septum were compared. ResultsCog process length was significantly higher, and AER volume was significantly lower in patients with Körner's septum compared to the patients without. (p < 0.001). Additionally, Cog process length was significantly (p = 0.008), negatively, but weakly (rho= −0.24) correlated with AER volume. ConclusionTemporal bones with Körner's septum had a longer Cog process and a smaller AER.

MRI as an Alternative to Second Look Mastoid Surgery

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma.

Cause analysis of non dry ear after canal wall down mastoidectomy

Objective:To investigate the possible causes of non dry ear after canal wall down mastoidectomy(CWD).Method:Clinical data of 42 patients undergoing revision CWD in our hospital were analyzed retrospectively,which included history,symptoms,signs,audiological examination,imaging examination, intraoperative findings and postoperative follow-up.All patients underwent CWD and tympanoplasty under general anesthesia.Result:Twenty-six cases were insufficient opened of sinodural angle,36 cases remained mastoid air cell(9 cases is mastoid tip air cell remained),13 cases were inadequate exposured of anterior epitympanic recess, 23 cases were inadequate exposured of posterior tympanum, 25 cases had high facial ridge, posterior facial nerve and labyrinth air cell were 5 cases,3 cases had granulation in round window, 5 cases had dysfunctional eustachian tube, 32 cases had narrow external acoustic meatus. During 3 months,6 months and 1 year follow-up, all 42 cases patients under revision CWD presented with dry ears.Conclusion:Insufficient opened of sinodural angle and mastoid air cell,inadequate exposured of anterior epitympanic recess and posterior tympanum, high facial ridge, narrow external acoustic meatus are all the possible causes of no-dry ear after CWD; As the location of concealment, posterior facial nerve and labyrinth air cell are difficult to clean. The dressing cavity do not be cleaned in time after operation is also the underlying cause of postoperative non-dry ear.

Adjunctive tenotomy during middle ear surgery

INTRODUCTION We describe indications and surgical technique for dividing the stapedius and tensor tympani tendons during middle ear surgery. Middle ear muscle reflexes involve contraction of the tensor tympani muscle (TTM) and stapedius muscle (SM) to increase impedance of the middle ear, and may shield the inner ear from loud, continuous nonimpact noise. Sectioning SM and TTM tendons has been advocated for a number of conditions, including improving access to anterior epitympanic (supratubal) recess, releasing a medialized malleus during tympanoplasty and ossiculoplasty, tensor or stapedial myoclonus, reflexive vertigo, and Meniere disease.

Endoscope-assisted surgery: a major adjunct in cholesteatoma surgery

EnAbstractObjectiveThe purpose of this study was to evaluate the role of middle-ear endoscopy in the effective control over cholesteatoma through visualizing hidden areas of the middle-ear cleft.Materials and methodsA total of 60 ears with retraction pocket cholesteatoma were operated upon. They were subdivided into 40 cases operated upon using the canal wall up technique and another 20 cases operated upon using transcanal atticotomy. Endoscopically guided ear surgery was incorporated complementary to the microscope as a principal part in the procedure.ResultsThe incidence of cholesteatoma in the facial recess that was visualized by the endoscope was 25% compared with 20% by the microscope, whereas the incidence of detection of cholesteatoma in the sinus tympani by the endoscope was 35% compared with 5% by the microscope. Cholesteatoma in the anterior epitympanic recess was detected by the endoscope in 10% of ears compared with 0% by the microscope. In this series, no morbidity or complication was encountered secondary to the use of endoscopes in the mastoid or the middle ear.ConclusionEndoscope-assisted ear surgery has many benefits in cholesteatoma surgery as endoscopy helps explore hidden areas of the middle-ear cavity with a much lesser requirement for surgical exposure and the need to drill healthy bone; therefore, effective control over the disease can be achieved, thus establishing the concept of functional endoscopic ear surgery.

Endoscopic Management of Acquired Cholesteatoma

Objective The purpose of this study was to examine the utility of using an endoscope in cholesteatoma surgery and to demonstrate how it allows a reduction in the incidence of residual disease. Methods A prospective study. A total of 53 ears with acquired cholesteatoma (primary) were resected. 20 cases were resected using a canal wall up (CWU) technique, 6 cases using a canal wall down (CWD) technique, and in 27 cases a transcanal tympanotomyatticotomy was performed. All of the patients in our study group underwent an explorative and operative endoscopic ear surgery complementary to the operating microscope to uncover and remove residual cholesteatoma. Results In the primary surgery after completion of microscopic cleaning, the overall incidence of intraoperative residual disease detected with the endoscope was 37.5%. The sinus tympani was the most common site of intraoperative residuals, followed by the anterior epitympanic recess and protympanum. Out of the 20 CWU cases, 12 second-look endoscopies were performed. Two recurrences were identified, both in the sinus tympani. There were no significant complications associated with the 53 endoscopic procedures. Conclusions The endoscope allowed a better understanding of cholesteatoma and improved eradication of residual disease from hidden areas such as the anterior epitympanic recess, retrotympanum and hypotympanum not yet controllable by operating microscope.

Inflammatory Chronic Otitis Media and the Anterior Epitympanic Recess

To demonstrate the important role of the anterior epitympanic recess (AER) in the surgery of noncholesteatomateous chronic inflammatory middle ear disorders. To establish selective criteria as to the indication of surgical intervention on the AER, aiming to create a permanent anterior aeration pathway for the attic. In addition, to point out the mandatory role of preoperative temporal bone computed tomography (CT) demonstrating whether the AER is involved and thus contributing, within the clinical context, to the indication for this surgery and its appropriate approach. Prospective study on patients with persistent or recurring chronic inflammatory middle ear disease for at least 3 years, after failure of conventional medical or surgical treatments. Tertiary referral university centre. Between November 2002 and July 2003, every patient presenting with clinical findings suggestive of an AER pathology was included in this study. Surgical approach of the AER during a mastoatticotomy and tympanoplasty with excision of the Cog and the tensor tympani fold, preserving the ossicular chain in almost all cases. Absence of postoperative otorrhea, satisfactory otoscopic examination, and improvement in the air-bone gap postoperatively in case the presurgery hearing level was abnormal and not due to an ossicular chain abnormality. Eight patients were included in the study. The preoperative CT scan showed AER opacities in all patients that were either isolated or associated with a diseased meso- or hypotympanum or the mastoid cavity. The measurement of the relevant transverse diameter of the AER is proposed to evaluate preoperatively the distance between the Cog laterally and the facial nerve canal medially to minimize the risk of a perioperative injury. During the operation, we found granulation tissue and adhesions in the AER in all cases A clinical follow-up 3 months after the intervention showed good local control in all patients, absence of otorrhea, and almost complete closure of the air-bone gap at audiometric evaluation. The last clinical follow-up in August 2004, a mean of 18 months after our intervention, did not reveal any relapse of symptoms in any case. CT control could be obtained in five of eight cases, within 13 to 21 months after the intervention, showing a reaerated tympanic cavity and AER. The AER plays a major role in sustaining some noncholesteatomateous chronic or recurrent inflammatory middle ear disorders that do not respond to conventional medical treatment. Definitive control of this pathology will be obtained by approaching the AER through an excision of the Cog and the tensor tympani fold, exenterating the inflammatory tissues, and creating a sufficient and permanent anterior atticomesotympanic communication. The indication for such a surgical approach is highly dependent on clinical findings correlated to temporal bone CT. Familiarity with the AER and its critical role should become part of every resident's training program in otology.

Facial nerve schwannoma in the cerebellopontine cistern. Findings on high resolution CT and MR cisternography

We report a case of facial nerve schwannoma originating in the cerebellopontine cistern, diagnosed by cochlear sensorineural hearing loss, and involvement in the facial nerve canal and the anterior epitympanic recess. Precise analyses of neuro-otological and neuroradiological studies are crucial to obtain an accurate preoperative diagnosis.

耳管上陥凹のＣＴによる観察 正常耳，中心穿孔を伴う単純化膿性中耳炎，真珠腫性中耳炎の比較

The structures of the anterior epitympanic recess and its surrounding tissues were examined among non-inflammatory ear, chronic otitis media with central perforation and cholesteatoma, using axial scans of high resolution computed tomography. The length and width of the recess, as well as the number of the slices where the cog was determined, had no significant differences among them. Thus, the bony structure of the recess was considered to be seldom influenced by inflammatory processes. In the non-inflammatory ear, the degree of pneumatization around the recess was similar to that of the petrous apex cells and lower than that of the mastoid cells. In the chronic otitis media with central perforation and cholesteatoma, the pneumatization of the whole temporal bones was suppressed and the tendency was also found that the cells around the recess were less pneumatized than the mastoid cells. When cholesteatoma invaded into the anterior epitympanic recess, the destruction of the bony protrusion of the lateral wall between the recess and the epitympanum was recognized, as well as the disappearance of the cog. The bony protrusion was considered to be an inferior extension of the cog toward the anterior tympanic spine.

Observations of the Anterior Epitympanic Recess in the Human Temporal Bone

The structure of the anterior epitympanic recess was examined in 50 human temporal bones. The recess was found in 48 temporal bones (96%) and showed three different structural types. In type A, the least developed type (38%), a main cavity is seen above the tensor tympanic fold. The recess is divided into two cavities by the tensor tympanic fold, which stretches to the anterosuperior tympanic tegmen in type B, the intermediate type (40%). The tensor tympanic fold is fused with the superior mallear fold in type C, the best-developed type (18%), with the recess being contiguous with the eustachian tube. The shape of the anterior epitympanic recess is influenced by the ratio between the cavities above and below the tensor tympanic fold, ie, by the embryologic development of the saccus anticus and the anterior saccule of the saccus medius. The structural variations in this recess must be kept in mind during the surgical management of middle ear diseases.

耳管上陥凹の手術解剖

The anterior epitympanic recess has following three structural types: type A, a main cavity seen above the tensor tympanic fold (TTF); type B, the recess divided into two cavities above and below the TTF; type C, the recess contiguous to the eustachian tube. Several distances related to each type of recess were measured in 48 human temporal bones. The following distances were significantly increased in the order of types A, B, and C: (1) the length of the TTF; (2) the distance from the top of the cavity below the TTF to the inferior border of the tensor tympanic semicanal; (3) the distance from the cog to the anterior wall of the recess.In addition, a route from the epitympanum to the eustachian tube was made by the intact canal wall method, in 12 human temporal bones. In type C, the route could be widely developed by removal of the cog and TTF. Removal of the bony plate to which the TTF attached was also necessary in types A and B, especially in cases of short TTF.In the surgical intervention, it is essential to keep in mind the structural variations of the anterior epitympanic recess and the position of its adjacent tissues. The recess should be handled by the method of choice appropriate to each type.