Mastoid Surgery Research Articles

Training in revision mastoid Surgery: Challenges, Pitfalls and Tips

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The treatment experience of purulent perichondritis of auricle caused by middle ear mastoid surgery with diabetes

The treatment experience of purulent perichondritis of auricle caused by middle ear mastoid surgery with diabetes

Tuberculous Otitis Media—A Rare Entity or a Missed Diagnosis

Objective: The aim of the study is to look for indicators of Tuberculous Otitis Media in all cases of chronic suppurative otitis media. Study Design: This is a retrospective study. Setting: This study was conducted in a tertiary care centre. Subjects and Methods: Detected cases of tuberculous otitis media (TBOM) cases studied retrospectively from January 2011 to December 2013 were included in the study. Investigations for tuberculosis were considered in the cases showing suspicious pale granulation tissue in the external auditory canal and middle ear and also in cases showing exuberant pale granulation tissue during mastoid surgery where Zeihl Nielson staining, histopathology, molecular genetic study was done. Cases showing positive result were included in the study. Results: During the study period 751 cases of CSOM were seen in outpatient room of which 18 cases of TBOM were diagnosed. Three patients were diagnosed preoperatively and 181 underwent surgery of which 15 cases were diagnosed positive, from the tissue obtained during the procedure. Direct smear was positive in four cases, concentration techniques in seven cases. Line probe assay was taken as diagnostic in all the cases. None of the cases were positive on histopathology. Conclusion: Tuberculous otitis media is often missed as the classical features are not seen in all cases of TBOM. The absence of these should not stop the clinician from diagnosing the disease. Suspicious tissue should therefore be tested properly to avoid missing the diagnosis and to prevent any complications.

Septic Lateral Sinus Thrombosis: Sinus Exploration Is Unnecessary.

The algorithm of treatment of septic lateral sinus thrombosis (SLST) has undergone a paradigm shift with the understanding of the natural history of sigmoid sinus thrombosis. Thus, the recent medical literature promulgates the management of these cases with no sinus exploration. However, in view of marked paucity of literature on the cited subject, not much is known about this form of treatment. We present our experience of treating two paediatric cases of SLST with mastoid surgery and no sinus exploration: both cases had excellent recovery. Finally, conclusions are drawn in light of contemporary literature on this subject.

Evaluation of Role of Mastoid Surgery in the Management of Safe Chronic Suppurative Otitis Media.

This study evaluates the outcome of type 1 tympanoplasty with and with out mastoidectomy. The comparative study comprises of 40 patients with CSOM safe type in dry ear. All cases were operated during a period of one and a half years. 20 of these cases were selected for tympanoplasty alone (Group A) and 20 cases were selected for Tympanoplasty with cortical mastoidectomy (Group B). Patients were reviewed after 3weeks for inspection of the operated ear. The second and third postoperative reviews were done 6 and 12weeks respectively for clinical assessment of the operated ear with respect to graft status, ear discharge and hearing improvement. The postoperative audiograms were recorded after 3months. Type I tympanoplasty with cortical mastoidectomy has better graft uptake (100%) as compared to without mastoidectomy (95%). Post-operative A-B gap closure is better in tympano-mastoidectomy (20.48dB) than tympanoplasty (15.75dB) with p value <0.05. Post-operative hearing gain and graft uptake were both better with tympano-mastoidectomy and tympanoplasty.

Revision surgery for canal wall down mastoidectomy: intra-operative findings and results

Conclusion: Canal wall down mastoid surgery following multiple earlier surgical failures can be revised by a well-trained experienced surgeon. A dry and safe ear is obtainable in most patients, and hearing preservation is also possible. Objectives: To analyze the intra-operative findings in revision surgery for canal wall down (CWD) mastoidectomy and to ascertain the prognosis.Methods: A total of 76 revision mastoidectomies with tympanoplasties performed from March 2008 to May 2014 at the First Affiliated Hospital of Zhengzhou University in China were reviewed. The pre-operative, intra-operative, and post-operative data was recorded and analyzed. Results: The possible reason of previous surgical failures were confirmed by the operative findings, which included inadequate mastoidectomy or persistent air-cell disease (66/76 [86.8%]), recurrent or persistent cholesteatoma (44/76 [57.9%]), excessive opened cavity combined with complications (9/76 [11.8%]), and infected cavities (68/76 [89.5%]). In this study, disease control was achieved in 70 (92.1%) patients. Complications following previous surgery were modified by revision surgery. Hearing was significantly improved in the 54 cases with ossicular replacement prosthesis. After a mean follow-up of 22 months, the group of revision surgery with ossiculoplasty as a whole experienced a statistically significant hearing gain of 16.57 ± 11.96 dB (p < 0.05) at air conduction pure tone average (PTA).

Obliteration of mastoid cavities: 30 years of experience with recommendations for surgical strategy

The obliteration of mastoid cavities is an appropriate intervention to sustainably improve patients' quality of life. After 30 years, 843 cases of mastoid obliteration were analyzed from the pool of data resulting from 16,000 surgical procedures on the ear. The materials used by the authors included cartilage/bone, Palva flaps, and bone pâté; as well as alloplastic material such as hydroxyapatite (HA) and bioactive glass granules (BAG S53P4) from BonAlive® (BonAlive Biomaterials Ltd., Turku, Finland). Pathological findings included rejection with inflammation, granulation of the auditory canal reconstruction, unclear retraction pockets, as well as shrinkage and cicatricial contraction. The follow-up interval was at least 4 months, with an average of 33 months (standard deviation ± 27.8 months). Use of HA was discontinued after 18 cases, because rejection and retraction occurred in 33% of patients. The same applied for bone pâté after 33 cases, with a pathological finding in 21%. The Palva flaps (145 cases) showed pathological findings in 21% of cases, primarily in the form of shrinkage (7%) and retractions (10%). Cartilage/bone pieces (516 cases) and BAG S53P4 (133 cases) only showed abnormal postoperative findings in 8% and 3%, respectively. It is recommended to focus particularly on auditory canal and canal entrance expansion during mastoid obliteration surgery. When using the bioactive glass granules, postoperative use of a mini-drain for 1-2 days is beneficial, in order to avoid accumulation of seroma fluid in the mastoid. In our experience, a combination of BAG S53P4 and cartilage as cover is a suitable material for cavity obliteration.

SURGICAL RECONSTRUCTION OF THE POSTERIOR MEATAL WALL BY BIOGLASS VERSUS TITANIUM MESH

Canal wall down mastoidectomy has many drawbacks including chronic otorrhea not responding to medications, granulations, dizziness on exposure to cold or hot water, and tendency of debris accumulation in the mastoid cavity, necissating periodic cleaning. Many of these proplems can be solved by reconstruction of the posterior meatal wall. Aim of work: To solve the cavity proplems after CWD mastoidectomy via reconstruction of posterior meatal wall, and to compare between the outcomes of the Bioglass versus titanium mesh in reconstruction of posterior meatal wall. Patients and methods: This study was applied on 40 patients that have chronic sappurative otitis media. All cases were subjected to canal wall down mastoid surgery with complete elimination of the disease and reconstruction of the posterior meatal wall. Patients were divided to 2 groups: group (A) was managed by canal wall down mastoidectomy with reconstruction of the posterior meatal wall by Bioglass and the group (B) was managed by canal wall down mastoidectomy with reconstruction of the posterior meatal wall by titanium micromesh; all patients were exposed to full preoperative evaluation, and full postoperative assessment of complications, appearance of the external auditory canal contour, and the hearing gain expressed by the change of the air bone gap postoperatively. Results: There is a significant difference between the two groups regarding postoperative complications mainly the postoperative granulations and discharge, the postoperative appearance of the external auditory canal contour, and the hearing gain in favor of group (A) but there is no significant difference between the 2 groups as regard the intraoperative difficulties, the other postoperative complications like wound infection, canal stenosis, extrusion or displacement of the materials and recurrence of cholesteatoma. Conclusion: Reconstruction of posterior canal wall can eliminate many of the cavity proplems after CWD mastoidectomy especially by using the Bioglass which shows better advantages than the titanium micromesh Keywords: canal wall reconstruction, Bioglass, titanium, mastoidectomy, mastoid cavity oblitration

Role of High Resolution Computed Tomography of Mastoids in Planning Surgery for Chronic Suppurative Otitis Media.

Chronic suppurative otitis media (CSOM) presents with a typical history of recurrent otorrhoea with tympanic membrane perforation. The diagnosis of cholesteatoma is usually made on otologic examination. High resolution computed tomography (HRCT) is indicated to evaluate the extension and the complications of cholesteatoma. The aim of the work was to study the role of HRCT in detecting, evaluating diagnosing and managing CSOM. All patients presenting with CSOM who were planned for mastoid exploration surgery in department of ENT, Gauhati Medical College and Hospital within a period of 2years-from 1st January, 2013 to 31th December, 2014, were taken up for the study. HRCT mastoids done routinely before cholesteatoma surgery, but with improved resolution, to characterize all middle ear structures and complications of the disease prior to surgery, might guide as road map during mastoid explorations for unsafe CSOM. The important role of HRCT lies on the early detection of cholesteatoma, and more conservative surgical procedures can be used to eradicate the disease.

Pre-operative simulation of pediatric mastoid surgery with 3D-printed temporal bone models

ObjectivesAs the process of additive manufacturing, or three-dimensional (3D) printing, has become more practical and affordable, a number of applications for the technology in the field of pediatric otolaryngology have been considered. One area of promise is temporal bone surgical simulation. Having previously developed a model for temporal bone surgical training using 3D printing, we sought to produce a patient-specific model for pre-operative simulation in pediatric otologic surgery. Our hypothesis was that the creation and pre-operative dissection of such a model was possible, and would demonstrate potential benefits in cases of abnormal temporal bone anatomy. MethodsIn the case presented, an 11-year-old boy underwent a planned canal-wall-down (CWD) tympano-mastoidectomy for recurrent cholesteatoma preceded by a pre-operative surgical simulation using 3D-printed models of the temporal bone. The models were based on the child's pre-operative clinical CT scan and printed using multiple materials to simulate both bone and soft tissue structures. To help confirm the models as accurate representations of the child's anatomy, distances between various anatomic landmarks were measured and compared to the temporal bone CT scan and the 3D model. ResultsThe simulation allowed the surgical team to appreciate the child's unusual temporal bone anatomy as well as any challenges that might arise in the safety of the temporal bone laboratory, prior to actual surgery in the operating room (OR). There was minimal variability, in terms of absolute distance (mm) and relative distance (%), in measurements between anatomic landmarks obtained from the patient intra-operatively, the pre-operative CT scan and the 3D-printed models. ConclusionsAccurate 3D temporal bone models can be rapidly produced based on clinical CT scans for pre-operative simulation of specific challenging otologic cases in children, potentially reducing medical errors and improving patient safety.

The effect of drill-generated noise in the contralateral healthy ear following mastoid surgery: The emphasis on hearing threshold recovery time.

In mastoid surgeries, contralateral ear noise exposure is a known, identified factor leading to high-frequency hearing loss due to the wide variety of surgical devices that may be used during the surgery. However, the hearing threshold recovery time after this trauma was uncertain. The present study aimed to assess this time. In this prospective survival analysis study, 28 consecutive patients with chronic otitis media who were undergoing tympanomastoidectomy were assessed. Standard pure-tone audiometry (PTA) and distortion-product otoacoustic emission (DPOAE) were measured in all contralateral ears before and 6 h, 24 h, 48 h, 72 h, and 96 h after the surgery. Based on the PTA postoperative hearing loss, survival rates at frequencies of 3000 Hz, 4000 Hz, 6000 Hz, and 8000 Hz were 44.4%, 36.4%, 51.7%, and 47.4%, 24 h after surgery; 11.1%, 9.1%, 10.3%, and 13.2%, 48 h after surgery; and 0%, 0%, 3.4%, and 2.6%, 72 h after surgery, respectively. Based on the PTA and DPOAE, survival rates at all frequencies were 0%, 96 h after the surgery. According to the PTA, mean hearing recovery times were 61.98 ± 26.76 h (3000 Hz), 62.73 ± 26.50 h (4000 Hz), 67.08 ± 25.90 h (6000 Hz), 70.70 ± 24.13 h (8000 Hz), and with regard to DPOAE the recovery times were 58.58 ± 28.39 h (2000 Hz), 63.32 ± 28.83 h (4000 Hz), 65.22 ± 29.13 h (6000 Hz), and 75.14 ± 22.70 h (8000 Hz), respectively. To conclude, high-frequency hearing loss usually occurs following mastoid surgeries that is mainly temporary and reversible after 72 h.

How Reliable is Preoperative Temporal Bone CT in Mastoid Surgery?

How Reliable is Preoperative Temporal Bone CT in Mastoid Surgery? Objective: To evaluate the reliability of high resolution computerized tomography (HRCT) of the temporal bone in assessing local complications of active squamous chronic otitis media (cholesteatoma) preoperatively. Methods: 156 patients having undergone mastoid surgery were identified. Prospectively collected intraoperative information was compared to preoperative findings for four specific parameters. Results: Relatively low sensitivities for all four parameters were found ranging from 11% for facial nerve canal dehiscence to 35% for ossicular chain erosion. Conclusions: This study emphasises the need for surgeons not to be misled by preoperative HRCT. The role of imaging in anticipating complications is by no means definitive.

Pediatric Masked Mastoiditis Associated with Multiple Intracranial Complications.

Masked mastoiditis is a distinct form of mastoiditis with little or no symptomatology, characterized by its potential to generate severe otogenic complications. Therefore, suspected masked mastoiditis should be diagnosed and treated without delay. This study reports a rare case of masked mastoiditis, manifested by multiple intracranial complications in an immunocompetent girl. The child exhibited headache and neurological symptomatology. Imaging studies revealed an epidural and a large cerebellar abscess and the patient was immediately treated with a triple antibiotic therapy. Mastoid surgery and drainage of the epidural abscess took place after the stabilization of the patient's neurologic status, on the 3rd hospitalization day. The cerebellar abscess was treated by craniectomy and ultrasound-guided needle aspiration in the 3rd week of hospitalization. The girl was finally discharged in excellent condition. Two years later, she is still in good health, without otological or neurological sequelae. Masked mastoiditis is an insidious disease which requires increased clinical awareness and adequate imaging. Should clinical and/or radiological findings be positive, mastoidectomy must follow in order to prevent severe otogenic complications that can be triggered by masked mastoiditis.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB). A prospective evaluation study. Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR). Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4-5), GC of 4 (IQR: 4-5), TSC of 4 (IQR: 3-4), and CR of 4 (IQR: 4-5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4-5), GC: 5 (IQR: 4-5), TSC: 5 (IQR: 4-5), and CR: 5 (IQR: 5-5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu. Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.

Morbidity rates following mastoid surgery

Morbidity rates following mastoid surgery

Intratemporal and intracranial complications of acute otitis media in a pediatric population

ObjectiveTo review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013. MethodsRetrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies. ResultsIn our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and “no growth” in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess. ConclusionComplications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism.

Mycological study on cholesteatoma keratin obtained during primary mastoid surgery.

Established middle-ear cleft cholesteatoma is associated with keratinous debris, which is likely to be an ideal medium for saprophytic fungal colonisation. This prospective case study aimed to explore the incidence and nature of fungal elements in cholesteatoma keratin samples obtained during primary mastoid surgery. All cases of middle-ear cleft cholesteatoma treated with primary mastoid surgery at the El-Sahel Teaching Hospital over a seven-month period were included. Keratinous debris obtained from the mastoid antrum was subjected to mycological analysis at the Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University. A literature search was performed to determine the clinical and pathological relevance of fungal colonisation in cholesteatoma. Eighteen patients underwent primary mastoid surgery for cholesteatoma (nineteen ears in total) in a seven-month period starting 30 March 2013. Patients included 13 males and 5 females, with an age range of 9 to 45 years (mean 23 years). Fungal cultures were obtained from 17 keratin samples (89 per cent). Of these, five fungal isolates belonged to the dermatophyte group (21 per cent). Fungal colonisation in middle-ear cleft cholesteatoma probably plays a significant role in disease progression. Moreover, saprophytic fungal colonisation in cholesteatoma keratin may be responsible for the fetor commonly associated with the ear discharge.

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.

Management options for cochlear implantation in patients with chronic otitis media

ObjectivePatients with chronic otitis media with/without cholesteatoma present a significant challenge to safe cochlear implantation (CI). The aim of our study is to describe our experience and propose management options for CI in patients with chronic otitis media. Study designRetrospective case study. SettingTertiary academic center. Subject and methodsWe enrolled the 9 ears of 8 subjects who received CI in the ear with chronic otitis media from 2006 to 2013 by a single surgeon. CI was performed as a single-stage or staged operation with mastoid surgery according to the activity of ear infection. ResultsSix patients had bilateral chronic otitis media and 2 patients had long history of sensorineural hearing loss at contralateral ear. CI was performed with simultaneous radical mastoidectomy with closure of the EAC as a single-stage in 3 ears with a history of previous open cavity mastoidectomy and no active discharge. Staged CI was performed in 6 ears, after radical mastoidectomy with closure of the EAC in 3 ears and after intact canal wall mastoidectomy in 3 ears, due to active inflammation or complications related to otitis media. In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence. ConclusionDecision whether implantation as a single-stage or staged operation depends on the presence of active inflammation. Single-stage CI with proper mastoid surgery can be performed in patients without active inflammation. Staged procedure need to be done in ears with active inflammation. Proper application of mastoid surgery leads to safe CI for patients with chronic otitis media.

Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery

There is a growing trend for the routine use of the facial nerve monitor (FNM) in chronic ear surgery. We aimed to examine current patterns in the use of FNMs in chronic ear surgery. Descriptive design (survey). Academic health center. A 10-question survey was designed to identify level of training, scope of practice, specific otologic surgeries where monitoring was most used, and the opinion of respondents regarding the use of FNMs as standard of care for chronic and/or middle ear surgery. A randomized list of 2000 board-certified members of the American Academy of Otolaryngology-Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a self-addressed return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically. Forty-three percent of respondents were in private practice, and 31% were fellowship trained in otology/neurotology. Sixty-five percent used a FNM in their training and 95% had regular access to a FNM. Revision mastoid surgery, cholesteatoma, canal wall down mastoidectomy, and facial recess approach were the settings where a FNM was most used. Forty-nine percent of respondents felt that a FNM should be used as the standard of care in chronic ear surgery; this represents an increase from 32% in a similar study done approximately 10 years ago. There is a growing trend for routine facial nerve monitoring in the setting of chronic ear surgery.