Posterior Wall Of External Auditory Canal Research Articles

Comparison of Preoperative Computerized Tomograghic Scan of Temporal Bone Findings with Intra Operative Findings in Patients with Chronic Otitis Media Undergoing Tympanomastoidectomy: A Descriptive Study

Background: Since ancient times, chronic suppurative otitis media (CSOM) has been a significant contributor to middle ear illness. Antibiotics have been extremely helpful, but (CSOM) is still a frequent condition, and its consequences present a challenge to both otologists and radiologists. Due to the intricate anatomical nature of the middle ear and inner ear, radiological assessment of the temporal bone is challenging.
 Aim of the Study: To compare between preoperative CT scan findings of the temporal bone with the operative findings in patients with CSOM undergoing tympanomastoidectomy.
 Methodology: A Descriptive cross-sectional prospective has been adopted and 35 patients with Chronic Suppurative Otitis Media were admitted at the Department of Otolaryngology/ Alsulaymaniyah Teaching Hospital of Otolaryngology, Head and Neck Surgery, and Zhian Hospital during the period from February to December 2015. A detailed history and careful physical examination, clinical tests revealed that all of the patients had Chronic Suppurative Otitis Media, typically with discharge from the ear and hearing loss. Each patient had their clinical history collected, and they all underwent a thorough ear, nose, and throat examination as well as an attentive otoscopic and microscopic ear examination. Additionally, all patients underwent an audiological evaluation that included pure tone audiometry, tympanometry, and HRCT.
 Results: Thirty -five patients were included in this study. The mean age of the patients was 33 years; 51.4% were males and 48.6% were females. The most common presenting symptom was aural discharge in 71.4%; the second one was hearing loss in 28.6%. Mastoid pneumatization was found in 82.9% by CT while by surgery, it was found in 17.1%. CT findings showed that middle ear involvement in 11.4%, mastoid involvement in 11.4%, mastoid with middle ear involvement in 54.3%, and EAC, mastoid, and middle ear involvement in 17.1%. While the surgical findings showed middle ear disease in 20%, mastoid involvement in 11.4%, mastoid with middle ear involvement in 57.1%, and EAC, mastoid and middle ear involvement in 11.4%. The CT findings for eroded Malleus, Incus integrity, and stapes in 31.4%, 37.1%, not visualized while surgical findings showed eroded Malleus, Incus, and stapes integrity that 28.6%, 54.3%, and 28.6% respectively. The CT findings for an eroded facial canal, the lateral semicircular canal, the posterior external auditory canal wall, and sigmoid sinus plate integrity were 12.4%, 8.6%, 22.9%, and 11.4% in that order, while the surgical findings of the eroded facial canal, the lateral semicircular canal, and the posterior external auditory canal wall were found in 20.0%, 5.7%, 17.1%, and 14.2% respectively. Both CT and surgical findings of Integrity of the tegmen showed that 32 patients (91.4%) were found to have intact tegmen, and 3 patients (8.6%) had eroded tegmen and both showed that the eroded scutum found in 25.7%.
 Conclusions: The current study concluded a positive correlation between CT and surgical findings that has many advantages in preoperative planning for the eradication of the disease, choosing the best approach & has a very important role in the orientation of the surgeon during the surgery to avoid any possible complications.

Zygomatic root abscess: A rare entity not to be forgotten!

Zygomatic root abscess is a rare extracranial extratemporal complication of otitis media. To the best of our knowledge, there are only a few scattered cases of zygomatic root abscesses reported in the literature. We present an unusual case of a zygomatic root abscess in a 24 years old adult. He presented with one month duration of right zygomatic swelling. Otoscopic examination revealed superior and posterior external auditory canal wall sagging with an intact tympanic membrane. High Resolution Computed Tomography (HRCT) temporal bone revealed a rim enhancing lesion lateral to the zygomatic process with fluid filled mastoid air cells. He was managed with antibiotics and staged surgical interventions. He recovered well. Our case serves to shed light on the pathways of infection, clinical manifestations and timely staged surgical intervention in this rare pathology.

외이도 재건을 위해 잔존 외이도 후벽을 보존한 채 시행한 개방형 유양동 삭개술 4예

The aim of cholesteatoma surgery is to completely eradicate cholesteatoma and to reconstruct the normal anatomy of the middle ear. Canal wall down mastoidectomy (CWD) is often applied for the complete eradication of cholesteatoma and prevention of recurrence in patients with cholesteatoma. However, CWD involves a significant destruction of the middle ear and the mastoid anatomy, that leads to potential complications including chronically draining cavity, retention of debris that requires frequent cleaning, and difficulty in fitting a hearing aid. To resolve these problems, surgeons have attempted to reconstruct posterior external auditory canal wall with a variety of techniques and materials. We recently experienced four cases of patients who had tympanomastoid surgery because of cholesteatoma. In the operation, superior segment of posterior canal wall was removed but remnant inferior segment of posterior canal wall was preserved. CWD with preservation of the remnant canal wall was performed unlike the conventional CWD operation. Surgical view was sufficient to eradicate the entire cholesteatoma. Canal wall reconstruction was done with remnant canal wall and conchal cartilage, and then mastoid obliteration was done with Tissue glue mixed demineralized bone matrix. This procedure was enough to eradicate cholesteatoma without lowering facial ridge. Saucerization, mastoid tip amputation and meatoplasty were not even needed. We report these four cases with a review of literature. (J Clinical Otolaryngol 2020;31:63-69)

On the Representative CT Image of an Otic-Disrupting Fracture

Dear Editor:
 In the article entitled “Facial Paralysis in Longitudinal versus Oblique and Otic-Sparing versus Non Otic-Sparing Temporal Bone Fracture” published in the Vol 34 No 2 issue of the Philippine Journal of Otolaryngology Head and Neck Surgery, the authors included an image (Figure 4) that was representative of an otic-disrupting fracture. The arrow clearly shows the fracture line running through the mastoid air cell system nearly parallel to the posterior external auditory canal wall and ending just posterior to the ossicular chain.
 However, the fracture line does not unequivocally appear to proceed medially towards the otic capsule, which is the densest portion of the temporal bone that surrounds the osseous labyrinth, and includes the cochlea, vestibule and semicircular canals. The otic capsule likewise is located within the petrous portion of the temporal bone.1 The otic capsule lies within the oval ring in the smaller figure above which is an enlarged image of the original figure in the article.
 This issue is relevant because the authors are classifying subjects according to the visual presence of a fracture that may or may not involve the otic capsule. Misidentification of the type of fracture in a representative image raises the question of a systematic misidentification in the entire data set, thus rendering the results of the study invalid.

Cautionary High-resolution Computed Tomography Findings for the Presence of Facial Canal Dehiscence in Patients with Cholesteatoma.

ObjectiveThis study aimed to investigate the abnormal high-resolution computed tomography (HRCT) findings in cholesteatomatous chronic otitis media (CCOM) patients preoperatively and the coexistence of abnormal HRCT findings with facial canal dehiscence (FCD) observed intraoperatively to identify the predictive factors associated with FCD.MethodsThe medical records of 151 CCOM patients who had undergone tympanomastoidectomy at our center were retrospectively examined in terms of the patients’ age and gender, preoperative HRCT findings [scutum defect, posterior wall of external auditory canal (PWEAC) defect, lateral semicircular canal (LSSC) defect, tegmen defect, and sigmoid plate erosion]. Operation records containing information about FCD were also analyzed.ResultsThe prevalence of FCD was found to be 33.8% (51/151). There was a significant correlation between the presence of scutum, PWEAC, LSSC, and tegmen defects and the presence of FCD. However, no statistically significant correlation was found between the presence of sigmoid plate erosion and the presence of FCD. The results of regression analysis of the coexisting pathologic findings for FCD showed that the risk of FCD was highest in patients with LSSC + scutum defects (34.3-fold increase), followed by LSSC + PWEAC defects (31.6-fold increase).ConclusionOur study revealed that the presence of scutum, PWEAC, LSSC, and tegmen defects on HRCT indicates a higher risk of FCD preoperatively. This risk is even greater when multiple abnormal findings coexist.

A Clinico-Radiological Study: Veria Technique of Cochlear Implant-A Study of 50 Cases.

Main limitation of classical technique is limited access to cochlea in terms of cochlear rotations and related structures, thus causing difficulty in electrode insertion. Veria technique allows full access to cochlea after raising tympanomeatal flap. To our best knowledge this is first clinic-radiological study for Veria technique studying distance between tympanic segment of facial nerve and posterior wall of external auditory canal (EAC) demonstrating facial nerve safety. Prospective study was done on 50 patients having bilateral sensori-neural hearing loss. Patients underwent cochlear implant surgery irrespective of age and gender. Preoperative high-resolution computed tomography temporal bone and magnetic resonance imaging head was done, distance between tympanic segment of facial nerve and posterior wall of EAC and basal turn angle were measured. Intraoperative NRT followed by orbito-meatal X-ray was done in post operative period. 25 (50%) were male, 25 (50%) female. 35 patients (70%) showed that the distance between tympanic segment of facial nerve and posterior wall of EAC was more than 3mm with mean 4.41mm (± 0.63 SD). Distance calculated was greater in older age group than younger group. Patient having inner ear malformation, mean was 3.96mm (± .44 SD). Whereas patients having acquired disease, mean distance was 4.30mm (± .47 SD). On gender comparison of basal turn angle score, no significant difference was observed male (54.34° ± 4.48°) versus female (55.66° ± 4.15°) (p = 0.282). Mean of basal turn angle (BTA) in ≤ 5years age group was 54.89° ± 3.65°, in 6-10years age group was 55.21° ± 5.23° and in age group ≥ 11years was 54.93° ± 4° with no significant difference in mean value between the groups (p = 0.282). High jugular bulb was seen in 4 patients (2 in right side, 2 in left side), hypoplastic jugular bulb was seen in 10 patients (9 in left, 1 in right), otosclerosis in 2 patients. Veria technique is safe for facial nerve, as preoperatively distance between tympanic segment of facial nerve and posterior canal wall can be identified. It is suitable method for rotated cochlea (identified preoperatively through BTA) and deformed cochlea as it offers a wide visibility and accessibility as compared to posterior tympanotomy approach. BTA and distance between posterior canal wall of EAC and tympanic segment of facial nerve should be done in all cases to see any cochlear rotation and feasibility of surgery.

Significance of intraoperative findings in revision tympanomastoidectomy

PurposeThe study was designed to assess correlations between intraoperative findings in revision tympanomastoidectomy as predictors of cholesteatoma recurrence. Materials and methodsA retrospective single-institution cohort of 101 patients who underwent surgical treatment for recurrent chronic otitis media in a tertiary referral otology centre. ResultsOut of 101 patients, 65 had canal wall up and 36 canal wall down revision surgery. There were 35 cholesteatoma recurrences. Sites most commonly associated with recurrent disease were residual facial ridge cells in 46 (45.5%), ossicular chain sites in 46 (45.5%) patients, posterior external auditory canal wall erosions in 38 (37.6%) patients and mastoid apex recurrence in 35 (34.7%) patients. Ossicular and posterior external auditory canal wall erosion and incomplete removal of mastoid apex cells correlate well with cholesteatoma recurrence accompanied by canal wall up surgery (p=0.009). Residual mastoid apex cells, posterior external auditory canal wall erosion and presence of residual facial ridge cells were identified as the strongest positive predictors of cholesteatoma recurrence, identifying high risk patients associated with canal wall down procedures (p=0.0036). ConclusionsCorrelations between intraoperative findings and cholesteatoma recurrence could improve preoperative and intraoperative planning and reduce the rates of postoperative failures1 due to mismanagement of high risk areas.

Intact meatal skin, canal wall down approach for difficult cochlear implantation

The intact posterior meatal skin, canal wall down technique for difficult cochlear implantation provides expanded access to the middle ear for cochleostomy in cases of obscured middle-ear landmarks, limited facial recess access and limited mastoid cavity dimensions. Careful preservation of the posterior canal wall skin in this procedure obviates the need for obliteration of the middle-ear mucosa and closure of the external auditory canal. To present a canal wall down technique for cochlear implantation, which preserves the intact posterior external auditory canal wall skin. This approach is employed when a standard facial recess cochleostomy is not possible. Three cases of intact posterior meatal skin, canal wall down cochlear implantation are presented together with long-term follow-up results. In all three cases, implantation via a facial recess approach was not possible. One patient suffered from severe cochlear otosclerosis with obliteration of the round window niche. The second patient had severe middle-ear fibrosis with encasement of all middle-ear structures and obliteration of routine landmarks. The third patient had an anterior sigmoid sinus obscuring access to the facial recess. Cochlear implantation via the canal wall down, intact posterior canal wall skin technique was successfully performed in each of these patients. All three patients were successfully implanted, with full electrode insertion achieved. All patients subsequently became active implant users. One patient did suffer from a minor wound complication post-operatively, unrelated to the approach. Patient follow up ranged from four to six years.

Posterior canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for radical cavities

To investigate posterior external ear canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for open mastoids. Retrospective case review. Tertiary referral centre. As a preliminary study, 15 selected patients underwent reconstruction of a posterior ear canal wall defect with titanium mesh. Large defects of the posterior external auditory canal wall, resulting from canal wall down tympanoplasty or present in revision surgery, were eliminated by reconstruction using a titanium mesh. The mesh was covered with conchal cartilage and attached to the cortical mastoid bone using 3-mm titanium screws. All patients maintained a normal contour of the external ear canal, without depression, extrusion or infection. There were no failures, based on short-term post-operative controls. However, two procedures had to be revised due to incomplete coverage of the titanium mesh. This study shows that reconstruction of the posterior ear canal wall with a composite cartilage titanium mesh is a valuable method for preserving the morphology of the external auditory canal in selected cases. Problems occurring in canal wall down tympanomastoidectomy and radical cavities may therefore be avoided. However, long-term results have yet to be evaluated.

Hearing results after cholesteatoma surgery: the Iowa experience.

This study compared the hearing outcome of canal-up and canal-down mastoidectomies for removal of cholesteatoma in 455 ears. An intact canal wall procedure was performed in 92 patients while the remainder (N = 363) underwent a canal-down operation. The hearing results for both procedures are dependent on the presence of the stapes superstructure. When the stapes superstructure was intact, 52% of the patients with canal-up operations had an air-bone gap of less than 20 dB. The corresponding figure for canal-down cases was 37%. When there was no stapes superstructure, 54% of the canal-up cases and 19% of the canal-down cases obtained a similar ABG closure. Preserving the posterior external auditory canal wall results in slightly better hearing function. However, when the stapes superstructure is intact, the difference in hearing function is not remarkable, and must be weighed against the potential for residual disease or recurrence associated with canal-up procedures.

Modified transotic approach to the cerebellopontile angle.

A modification of the transotic approach to the cerebellopontile angle involves complete removal of the otic capsule bone, obliteration of the middle ear cleft, and removal of the posterior external auditory canal wall, while leaving the fallopian canal intact. The major advantage of this technique is that it allows more direct visualization of the most vulnerable portion of the facial nerve medial to the anterior wall of the internal auditory canal during acoustic tumor removal.