Chronic Ear Disease Research Articles

Middle ear pressure during sleep and the effects of continuous positive airway pressure

PurposePrior studies evaluating Eustachian tube physiology, baseline middle ear pressure (MEP), and the effects of continuous positive airway pressure (CPAP) have been performed on awake patients. No study to date has specifically investigated MEP during sleep despite the fact that the average individual spends a third of their lifetime sleeping. The primary objectives of the current study are to quantify normal physiologic MEP during sleep and to evaluate the effects of escalating CPAP levels. Materials and methodsProspective observational study at a tertiary academic referral center evaluating serial tympanometry on sleeping adult patients during polysomnography. MEP was recorded awake, at 1-hour intervals during diagnostic polysomnography, and at all CPAP levels during titration. Changes in MEP with duration of sleep and escalating CPAP levels were analyzed. ResultsTen adults were included (4 females; 6 males; mean age 58years). The mean MEP while awake was 3 decapascals (daPa). The mean MEP during sleep without CPAP rose steadily from 14 daPa at 1hour to 41 daPa at 4hours (r=0.52; p<0.001). The mean MEP during sleep at a CPAP level of 5cm of water was 54 daPa. The mean MEP rose steadily with increasing CPAP levels, and was 104 daPa at 10cm of water, (r=0.82; p<0.001). The mean MEP during sleep without CPAP was 26 daPa, which was significantly lower than the mean MEP during sleep with CPAP between 5–10cm H2O (p<0.01). ConclusionsMEP naturally increases with duration of sleep. CPAP therapy causes a supraphysiologic elevation in MEP that rises with increasing pressure levels. These findings may help guide future studies examining the safety of CPAP following otologic surgery and the potential therapeutic benefit in patients with chronic middle ear disease.

Cholesteatoma: a disease of the poor (socially deprived)?

Cholesteatoma is a condition describing the accumulation of squamous epithelium and keratinocytes within the middle ear space. There is conflicting evidence regarding the influence of socioeconomical status on the prevalence of cholesteatoma. Hospital episode statistics (HES) data detailing the numbers of cholesteatoma surgeries performed per area were compared with the Index of Multiple Deprivation 2010 (IMD 2010) data that give a statistical measure of deprivation per local health authority in the UK. Statistical analysis of this data was performed to identify correlations between prevalence of cholesteatoma and deprivation. A trend was identified showing that health authorities associated with an overall low IMD 2010 value indicating more deprived, had higher numbers of mastoid operations. Our results have found that increasing levels of deprivation are associated with greater numbers of mastoid operations and thus greater numbers of cholesteatomas. Our work suggests that there is a need for additional input in deprived areas to accommodate the increased numbers of mastoid operations and chronic middle ear disease.

Temporal Bone Radiology: Beyond the Basics

Program Description: Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve their interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography and magnetic resonance imaging examinations and their importance in creating and narrowing a differential diagnoses. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus. Educational Objectives: (1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. (2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.

Temperature Changes Associated with Middle Ear Endoscopy in a Human Temporal Bone Model

Objectives: Endoscopic ear surgery is rapidly gaining popularity as a minimally invasive approach to address chronic ear disease. However, little is known about the potentially damaging temperature increases associated with endoscopy in the middle ear. Specifically, neither temperature change nor heat distribution associated with the endoscope has been quantified. In this study, we aim to measure temperature changes throughout the middle ear during rigid endoscopy in a human temporal bone model. Methods: Fresh human temporal bones were maintained at physiologic temperature during middle ear endoscopy with a 3-mm 0° Hopkins rod. Temperature changes were measured as a function of the distance between the endoscope tip and the round window membrane. Thermal gradient was determined by infrared imaging. Control studies conducted at room temperature were also performed. Results: An endoscope with a xenon or light-emitting diode light source on maximal power induced a rapid temperature elevation up to 46°C within 0.5-1 mm of the tip of the endoscope within 30-124 seconds. Elevated temperatures occurred at distances up to 8mm from the endoscope tip. Temperatures rapidly returned to baseline within 20-88 seconds after turning off the light source. Conclusions: Our findings have direct implications for endoscopic ear surgery and affirm the importance of avoiding excessive temperature elevation. We recommend employing submaximal light intensity and repositioning the endoscope frequently to provide rapid cooling. Ongoing studies use an animal model to explore the in vivo effects of prolonged middle ear endoscopy and evaluate for potential threshold shifts in auditory brainstem responses.

Individual computer-assisted 3D planning for surgical placement of a new bone conduction hearing device.

To evaluate the benefit of a preoperative three-dimensional (3D) planning tool for surgically placing the bone conduction floating mass transducer (BC-FMT) of the Bonebridge (BB) bone conduction implant. Adult patients (n = 5) and one pediatric patient (n = 1) with conductive or mixed hearing loss caused by chronic ear disease, malformation, or single-sided deafness. Development of a preoperative planning tool that allowed free adjustment of the implant in an individual 3D model of the skull to evaluate completely fitting the BC-FMT into a bony bed and to identify an optimal implant position. Implantation of the BB with mastoid or retrosigmoid placement after individual preoperative planning and "virtual surgery". Feasibility of the preoperative 3D planning process, transfer into the intraoperative situation, and audiologic results after BB implantation. Individual preoperative planning was considered beneficial especially in cases of small mastoid bone volume, for example, because of previous canal wall down mastoidectomies, and in the case with malformation. For optimal placement of the BC-FMT of the BB, preoperative 3D planning is recommended especially in primarily small poorly pneumatized mastoids, hypoplastic mastoids in malformations, reduced bone volume after canal wall down mastoidectomy, or the small mastoids in children. Effort should be made to reduce segmentation and surgical planning time by means of automation.

Bone cement: how effective is it at restoring hearing in isolated incudostapedial erosion?

To determine the effectiveness of biocements in rebridging isolated incudostapedial erosion. A review of the use of biocements for isolated incudostapedial joint erosion was performed on publications from 1998 to 2012 available from Medline, Embase and Pubmed. Inclusion criteria were papers published in English, case series or comparative studies with more than 10 patients, isolated incudostapedial erosion through chronic ear disease, minimal air-bone gap less than 20dB (or air-bone gap less than 10dB) and follow up for at least one year. In 108 patients, rebridging ossiculoplasty was performed using hydroxyapatite cement. Closure of air-bone gaps less than 20dB and less than 10dB was achieved in 80-94.4 per cent and 29-75 per cent, respectively. Glass ionomer cement was used in 318 patients. Closure of air-bone gaps less than 20dB and less than 10dB was achieved in 74-94 per cent and 40-76 per cent, respectively. Biocements can be successfully used to close isolated incudostapedial erosions. Larger comparative prospective studies documenting the length of eroded incus and types of reformation of the incudostapedial joint, with standardised reporting, are needed in the future.

The use of cartilage in revision stapedectomy.

To evaluate the incidence of stapedectomy patients who developed significant chronic ear disease resulting in reconstruction of the tympanic membrane with cartilage and concomitant revision stapedectomy. Audiometric results of this subgroup within revision stapedectomy are analyzed, and the salient features of the reconstruction method are discussed. Retrospective study of revision stapedectomy patients during the years 2003-2012. Tertiary referral center. Cartilage tympanoplasty and revision stapedectomy. Seventeen patients (18 ears) of 144 revision stapes patients were studied who required cartilage tympanoplasty and revision stapedectomy. One-half underwent revision stapedectomy with a modified Lippy prosthesis (MLP), and one-half required a total ossicular prosthesis (TOP). The mean postoperative air-bone gap (ABG) was 11.1 dB with mean pure tone average (PTA) hearing improvement of 15.6 dB.The rate of ABG closure was 55.6% <10 dB and 38.8 % >10 dB and <20 dB. The number of patients requiring revision stapedectomy due to significant chronic ear disease is small. This paper discusses the management and successful outcome of these more difficult revisions.

Transcanal Endoscopic Antrostomy Hole : Its Utility in Restoring Ventilation Pathway to Epitympanum and Mastoid Antrum During Tympanoplasty

Aim: To evaluate the role of newly created transcanal endoscopic antrostomy hole as a passage in restoring the aeration of epitympanum and mastoid antrum.Materials &amp; Methods: Study design: Retrospective case series study. Study duration: From January 2013 to January 2014. Study place: Private tertiary care hospital. Patients: 27 ears of 23 adult patients (age ranging from 15years to 54years) underwent transcanal endoscopic tympanoplasty for their chronic middle ear diseases in presence of inflamed middle ear mucosa along with radiological shadows of stagnant fluid in their epitympanum and mastoid antrum. Structured three months follow-up was ensured in every case. Intervention: A hole was created at a selected site of posterior meatal wall purely through transcanal endoscopic approach that established direct communication between mastoid antrum and external auditory canal. Thereafter this newly created passage was used for three purposes- assessment of the condition of mastoid antrum, performing the water test for checking epitympanic patency and in few cases placement of temporary tube for postoperative ventilation and drainage of middle ear. Main out come measures: The feasibility, performance and management of transcanal endoscopic antrostomy hole as passage for reestablishing the aeration of epitympanum and mastoid antrum.Results: The chosen site for antrostomy hole was found effective and safe in providing convenient entrance into the mastoid antrum in every case in this study with out facing technical complexity and failure. Postoperative healing of skin over antrostomy hole was found complete in all ears without any inward growth of skin in to mastoid antrum. Available post operative CT scan imaging of temporal bones showed improved aeration in their epitympanum and mastoid antrum.Conclusions: The role of transcanal antrostomy hole has been proved worthy in restoring ventilation pathway to epitympanum and mastoid antrum during tympanoplasty. This antrostomy hole has the potentiality to be considered in future for placement of long term mastoid ventilation tube in order to treat persistent atelectatic middle ear.

Studies on distribution of α1-antitrypsin, lysozyme, lactoferrin, and mast cell enzymes in diseased middle ear mucosa

Conclusion: Antimicrobial agents (AMAs) and mast cells in chronic otitis media (COM) may play a protective role in the pathogenesis of COM. Among them, our results indicated that lysozyme may be the most important parameter of the mucosa infectivity in COM. Objectives: AMAs include alpha 1-antitrypsin (α1-AT), lysozyme, and lactoferrin and exhibit innate immune activity that is known to play a critical role in mucosal defenses. In addition, proteases expressed in mast cells contribute to mucosal defenses. The aim of this study was to identify AMAs responsible for COM as well as their association with middle ear mucosal diseases. Methods: Middle ear mucosa (MEM) was intraoperatively collected by biopsy from patients, diagnosed as COM without or with cholesteatoma, and immediately processed for immunohistochemical study to evaluate expression of AMAs and mast cell proteases (chymase and tryptase). Results: The AMAs and mast cell enzymes were observed prominently in the chronic middle ear diseases whereas immunoreactivity of α1-AT and lysozyme was not significantly increased in the COM with cholesteatoma compared with that in COM without cholesteatoma. Lactoferrin was not detected in the diseased MEMs.

Labyrinthine fenestration for stapes fixation in chronic ear disease others than otosclerosis.

The objective of this study is to assess the results of labyrinthine fenestration for fixed stapes in chronic ear disease. Using a prospective database, pre- and postoperative audiometric data from patients undergoing labyrinthine fenestration for fixation of the stapes in chronic ear disease others than otosclerosis between 2002 and 2012 were evaluated. Twenty-three labyrinthine fenestrations in chronic ear disease were performed (17 malleo-stapedotomies, 4 incus-stapedotomies, 1 neo-malleus-stapedotomy, 1 TORP-stapedotomy). Overall, the mean short-term (2 months) and long-term (42 months) postoperative air-bone gap (0.5-3 kHz) were 17.5 and 16.5 dB, respectively; long-term air-bone gap of <20 dB was obtained in 73 % of patients. There was no significant difference in air-bone gap closure between tympanosclerotic and post inflammatory osteogenic fixation of the stapes (p = 0.267). Hearing benefit success using the 'Belfast rule of the thumb' was achieved in 48 %. Normal bilateral hearing was achieved in 17 % and bilateral symmetric hearing impairment in 26 %. Only in 4 %, bone conduction worsened by more than 5 dB. Labyrinthine fenestration is an option in selected cases of stapes fixation in chronic ear disease and provides hearing gain without significant risk for sensorineural hearing loss. In those already selected cases, hearing benefit success 'Belfast rule of the thumb' is achieved only in half of the cases. This and the possible alternatives, should therefore be discussed preoperatively.

Patient Outcomes in Magnet-Based Implantable Auditory Assist Devices

Magnet-based implantable auditory assist devices (MIAADs) are a recent development in bone-anchored hearing devices. This report increases the number of children studied with specific outcome criteria and provides detailed solutions to avoid device use difficulties in other centers considering this device. To assess hearing thresholds, use rates, and complications in children implanted with a MIAAD for conductive hearing loss. Retrospective analysis of children implanted with an MIAAD at an ambulatory care quaternary referral center since the Food and Drug Administration approved the Sophono device (Sophono Inc) for use in the United States (May 2011 through January 2013). Ten pediatric patients were implanted for conductive hearing loss (14 ears; mean age at implantation, 9 years [range, 3.8-17.2 years]). Diagnoses included aural atresia (n = 7) and chronic ear disease and cholesteatoma (n = 3). Implantation of MIAAD and management of skin complications. Demographics, hearing thresholds, use rates, and complications were assessed. After fitting with the magnetic baseplate and sound processor, the mean (SD) aided pure-tone average was 20.2 (6.0) dB hearing level (HL), with a mean (SD) functional gain of 39.9 (12.4) dB HL. There were no surgical complications. Negative outcomes were assessed following fitting of the sound processor. The skin complication rate was 35.7%, including skin breakdown (n = 2) and pain and erythema (n = 5), which resulted in decreased use of the device for these patients. Intervention included decreasing the magnet strength, graduated wearing schedule, antibiotic ointment, barrier protection, and reoperation for well widening with Alloderm (LifeCell Corporation) placement. Patients without skin complications are consistent users of their device, with an average daily use of 8 to 10 hours. The MIAAD device has equivalent levels of hearing restoration to other previously described methods of intervention for children with conductive hearing loss. This early report indicates high rates of skin difficulties and a need for improved methods of implantation, magnetic baseplate fitting, and device use. We suggest decreased magnet strength at the initial fitting, a graduated wearing schedule, caution with patients who have a history of skin issues from a bone-anchored hearing aid or multiple surgical procedures, and parent counseling regarding potential skin irritation.

A study of middle ear reconstruction, the degree of functional restoration and causes of graft failure following chronic ear disease

Aims and objectivesTo determine the results of various types of tympano-ossiculoplasties and the degree of functional restoration following surgery. Materials and methodsThis prospective study comprises 51 consecutive patients with chronic suppurative otitis media (CSOM) – tubotympanic disease (TTD) and atticoantral disease (AAD), who presented to the academic department of Otorhinolaryngology – Head & Neck Surgery, in a tertiary care hospital in South India. All patients underwent a thorough examination and appropriate investigations. Eustachian tube function (ETF) was assessed preoperatively by methylene blue dye test and saccharin test. The size of the mastoids was measured by using a graph paper, on which the X-ray film of the mastoid taken in the lateral oblique view (Law’s view) was superimposed. Patients with CSOM (TTD) with less than 3months of dry ear and small size mastoids on X-ray were subjected to cortical mastoidectomy and type I tympanoplasty; whereas patients with dry ear more than 3months underwent type I tympanoplasty alone. Type III tympanoplasty was carried out in those with erosion of incus/malleus by placing temporalis fascia over the stapes superstructure. Patients with AAD underwent modified radical mastoidectomy (MRM) and ossicular reconstruction was carried out depending on the remnant of the ossicles. Partial Ossicular Replacement Prosthesis (PORP) made of plastipore was used for Austin’s type b ossiculoplasty; while Plastipore/Gold was used as Total Ossicular Replacement Prosthesis (TORP) in type d ossiculoplasty. Patients were reviewed after 15days, 1 and 3months post-operatively for a clinico-audiological assessment of the operated ear to evaluate the graft status and hearing improvement. The postoperative audiograms were recorded on the 2nd and 3rd visit. Results and observationsOf the 51 patients with CSOM; 37 had TTD and 14 had AAD. Of the 37 patients with TTD, 35 patients had normal ETF and 2 of them had partial dysfunction. With normal ETF, the graft uptake rate was 80% compared to partial ETF which had only 50%. Patients with large and medium size mastoids had 89% of graft uptake. Patients with small and medium size perforations had 100% graft uptake; whereas large and subtotal perforations had 75% and 71.43% respectively. A total number of 34 tympanoplasties and 17 ossiculoplasties were done. Of these; 29 were type I and 5 were of type III. Out of 17 ossiculoplasties, 3 were type b and 14 cases were of type d. We used 7 Gold and 7 Plastipore TORP for the type d ossiculoplasty and PORP in 3 of the cases. Using temporal fascia as graft material 34 patients underwent tympanoplasty in whom the graft uptake was 79.41%, while 17 patients underwent ossiculoplasty using temporalis fascia as graft, the graft uptake was 88.23%. Tympanoplasty done for small and medium size perforations had 100% hearing improvement with A–B gap <20dB but patients who had large or subtotal perforations had 80% and 67% respectively. Hearing improvement to an A–B gap <20dB was noted in 91% and 60% following type I and type III tympanoplasty respectively. Hearing improvement to an A–B gap <20dB was noted in all the cases of type b ossiculoplasty and with type d ossiculoplasty (42%). ConclusionPatients with normal Eustachian tube function, large and medium size mastoids, small and medium size perforations of the tympanic membrane would have a good rate of graft uptake with tympano-ossiculoplasties thereby returning to normal hearing postoperatively.

The Isolated Vestibular Anomaly with Normal Cochlea: An Analysis of Radiologic and Clinical Findings

RESULTS: Three patients were affected bilaterally and five patients were affected unilaterally. One ear was excluded due to chronic middle ear disease. The fused vestibule-lateral semicircular canal was associated with superior semicircular canal and/or posterior semicircular canal dysplasia in eight ears. The hearing capacity was as follows: normal in four ears; mixed hearing loss in four ears; conductive hearing loss in one ear; and sensorineural hearing loss in one ear. Vestibular tests were normal in seven patients. One patient had orthostatic hypotension.

ICP, BMI, Surgical Repair, and CSF Diversion in Patients Presenting With Spontaneous CSF Otorrhea

To assess intracranial pressure (ICP), body mass index (BMI), surgical repair, and cerebrospinal fluid (CSF) diversion in patients presenting with spontaneous CSF otorrhea. Retrospective series review. Tertiary referral center. Thirty-two patients were treated surgically from 2004 to 2013 for spontaneous CSF otorrhea by the principal investigators. Patients with a history of chronic ear disease and cholesteatoma, previous mastoid surgery, head trauma, or iatrogenic injury were excluded. Average age was 56 years. Twenty-two patients (69%) were female. Middle fossa repair, transmastoid repair, lumbar puncture, V-P shunt, L-P shunt, and magnetic resonance imaging. Patients underwent middle fossa or transmastoid repair of tegmen defects. Intracranial pressures were determined with lumbar puncture at time of surgical repair or shortly after surgery. CSF diversion procedures were performed in patients who were found to have elevated ICP, which was not controlled medically, presented with recurrent leak or had ICP of 25 cm or greater of H2O. Preoperative BMI was calculated. Thirty-two patients underwent 37 operations. Average BMI was 35.0 kg/m2 (median, 34.7; range, 18.7-53.2 kg/m2). There were 21 repairs on the left and 16 on the right. The majority underwent a middle fossa craniotomy for repair (27/32). Two patients had bilateral repairs. Three patients (8%) underwent revision surgery, of which, 2 had untreated intracranial hypertension (ICP 24.5 and 24 cm H2O). ICP measurements were available for 29 patients. The mean ICP was 23.4 cm H2O (median, 24; range, 13-36 cm H20). Twenty-two patients (69%) had ICP of 20 cm or greater of H20; of those, 13 had an ICP of 25 cm or greater of H20. Seventeen patients (53%) underwent CSF diversion procedures. Our findings of elevated ICP and BMI in patients presenting with spontaneous CSF otorrhea are consistent with previous reports in the literature. The percentage of patients that underwent CSF diversion procedures was high at 53% and represents an aggressive stance in managing elevated ICP in a population that may be at risk for subsequent leaks.

Middle ear surgery in only hearing ears and postoperative hearing rehabilitation.

Background and ObjectivesThe aim of this study was to evaluate surgical interventions and hearing rehabilitation in patients with chronic middle ear disease of only hearing ears.Subjects and MethodsThirty-one patients with chronic middle ear disease of only hearing ears were enrolled in this retrospective study. Patients were classified into three groups according to the hearing level: groups A [pure tone audiometry (PTA)<40], B (40≤PTA<70), and C (PTA≥70). We evaluated hearing results and patterns of auditory rehabilitation.ResultsThe main consideration for a surgical procedure was the presence of recurrent otorrhea and structural destruction. The reasons for surgical intervention in only hearing ears were otorrhea caused by chronic otitis media (68%), cholesteatoma (29%), and cholesterol granuloma (3%). The causes of contralateral deaf ears were chronic otitis media (81%) and sensorineural hearing loss (19%). Although there was hearing deterioration in some patients with severe hearing loss (PTA≥70), all patients achieved dry ears after surgery and functional hearing using auditory rehabilitation. Hearing aids were used in most patients with moderate to moderately severe hearing loss and cochlear implants were used for auditory rehabilitation in patients with severe to profound hearing loss.ConclusionsProper evaluation and indications for surgery in only hearing ears are important for successful eradication of inflammation and hearing preservation. Surgical interventions can achieve dry ear and enable further auditory rehabilitations using hearing aids and cochlear implantation.

Blind Sac Closure of the External Auditory Canal for Chronic Middle Ear Disease

To determine the rate of complications in patients who underwent blind sac closure of the external auditory canal for chronic middle ear disease. Retrospective case review of 29 patients from combined public tertiary and private centers who underwent blind sac closure between 2000 and 2011. All patients undergoing blind sac closure with minimum follow-up period of 1 year were included. There were 14 male and 15 female subjects with a mean age of 54 years at time of surgery. Complications were identified as major and minor complications, with particular attention to the rate of residual cholesteatoma. Thirty-two cases of blind sac closure were identified in 29 patients, with 3 patients undergoing bilateral procedures. We identified 8 major and 6 minor complications. Of the major complications, 3 were infections, and 5 involved residual cholesteatoma. Recurrent cholesteatoma was identified between 2 years 8 months and 6 years 6 months. Although blind sac closure of the external ear canal is a functionally useful procedure, it is associated with a significant rate of complications. In particular, we noted a higher rate of residual cholesteatoma in our series, when compared with the published literature. Appropriate patient selection to ensure long-term follow-up compliance for at least 8 years is essential for the detection of recurrent cholesteatoma.

Alternative to Canal Wall–Down Mastoidectomy for Sclerotic Mastoid Cavities

Surgical procedures for chronic ear disease can be grossly divided into two tympanoplasty procedures: canal wall-up and canal wall-down (CWD) mastoidectomies. The choice depends on the surgeon's preference. Epitympanoplasty with mastoid obliteration (EMO) has shown postoperative results similar to those of CWD mastoidectomy with long-term follow-up. In this study, we compared the outcomes of EMO and CWD mastoidectomy in preoperatively sclerotic mastoid cavities with cholesteatoma, chronic otitis media with poor eustachian tube function, or adhesive otitis media. The operations were performed by the same surgeons in order to eliminate any effect of surgeon preference on the surgical outcomes. We reviewed the medical records of patients who underwent tympanoplasty with EMO (EMO group) or CWD mastoidectomy (CWD group) and followed them for more than 28 months. The postoperative outcomes were analyzed and compared. The EMO and CWD groups comprised 132 and 110 ears, respectively. In both groups, the air-bone gaps were significantly reduced after operation. The relapse rates of the groups were similar. Cavity problems were the most common complication in the CWD group. The overall complication rate in the EMO group was significantly lower than that in the CWD group (p = 0.044). Epitympanoplasty with mastoid obliteration can be considered an alternative procedure to CWD mastoidectomy in patients with preoperatively sclerotic mastoid cavities. It gives similar surgical results and has fewer complications.

Radiographic Features of Superior Semicircular Canal Dehiscence in the Setting of Chronic Ear Disease

To determine if radiologic chronic otitis media (COM), both with and without cholesteatoma, is associated with superior semicircular canal dehiscence (SSCD). Retrospective review of consecutive high-resolution computed tomography (HRCT) scans of the temporal bone. Tertiary care medical center. Two hundred consecutive patients undergoing HRCT of the temporal bone beginning January 1, 2012. Imaging was evaluated by 3 reviewers (2 neuroradiologists and 1 neurotologist). All scans were assessed for the presence of SSCD, cholesteatoma, chronic otomastoiditis, tegmen dehiscence, and for abnormalities of the cochlea, vestibule, facial nerve, and temporal bone vasculature. Ears with COM associated with chronic otomastoiditis or cholesteatoma were compared with those without COM with respect to the presence of SSCD or other temporal bone abnormalities. Statistical analysis was performed to assess for differences between the groups studied. One-hundred ninety-four patients (388 ears) were included. Cholesteatoma was identified in 48 ears (12.4%) and chronic otomastoiditis in 62 ears (16%). Ten ears with cholesteatoma had ipsilateral SSCD, and 8 ears with chronic otomastoiditis had ipsilateral SSCD. In 340 ears without either cholesteatoma or chronic otomastoiditis, SSCD was found in 18 (5.3%). SSCD was found to occur significantly more often in patients with ipsilateral radiologic cholesteatoma. No cases of SSCD were associated with cochlear, facial nerve, or vascular abnormalities. Our findings suggest that COM with cholesteatoma is associated with the presence of SSCD, although the nature of this association is unclear.

Prevalence of ventilation blockages in patients affected by attic pathology: A case‐control study

Using a retrospective video evaluation of exclusive endoscopic middle ear procedures, we analyzed the different anatomical and pathological findings between patients with attic disease or cholesteatoma and patients without attic disease. A case-control study based on a retrospective chart review in a tertiary university referral center. Videos from endoscopic middle ear procedures carried out between February 2007 and August 2012 were reviewed. We analyzed and compared two groups of patients who underwent surgery in our university hospital: patients with selective attic disease (e.g., non-self-cleaning attic selective retraction pockets or attic cholesteatoma) were compared with subjects without attic disease (e.g., chronic middle ear disease, congenital cholesteatoma, or secondary cholesteatoma). In total, 152 patients were included in the study. Of these, 102 were affected by primary acquired cholesteatoma (84/102) or severe pars flaccida retraction pockets (18/102), whereas 50 cases were controls. A blockage of the isthmus was present in almost all cases (98/102) compared with a lower prevalence in controls (3/50) (P < .0001). Similarly, a complete tensor fold was identified in 99/102 patients compared to controls (9/46; data were not available in four controls) (P = .001). Selective epitympanic dysventilation occurred when a blockage of the isthmus was present and associated with a complete tensor fold, causing ventilatory separation between the epitympanum and mesotympanum. This mechanism could be the basis for a selective decrease in pressure in the attic, with the subsequent development of attic retraction pockets and cholesteatoma even in subjects with a normally functioning eustachian tube.

Build a Better Ear: What's New in Chronic Ear Disease

Program Description: There is a growing interest in implementing surgical techniques and using novel materials for tympanic membrane perforation repair. Bioactive materials, cartilage and fascia grafts derived from the recipient patient, novel partial ossicular replacement prostheses and total ossicular replacement prostheses, and novel technologies (ie, otoendoscopy) are in continuous evolution, striving for higher quality and longer duration and stability in otologic surgery grafting. The presenters will provide descriptions and show videos demonstrating the function of these different materials and techniques. In addition, a non-committee panel will present an evidence-based medicine (EBM) algorithm for treatment:”What Literature says—an EBM decision Algorithm as Key to Success.” Educational Objectives: 1) Describe the variety of grafting materials, protheses, and different techniques available for surgical repair of tympanic membrane perforations. 2) Discuss the advantages and limitations of using these technologies and materials. 3) Assess the validity of the studies presented to evaluate the efficacy of these surgical tools.