Process Of Incus Research Articles

Morphometric study of stapes and its variation in Eastern Indian population

: For audiological prosthesis surgery morphometry of stapes is of utmost importance. Previous studies were mainly based on foreign and northern Indian population. Hence the present study.: To measure the morphometric parameters of stapes and compare the same with the previous studies.: This cross sectional observational study, performed on the ear ossicle, stapes obtained from 26 cadaveric heads. A total of (26 x 2) = 52 sets of stapes were taken out for the study. Measurements of various parameters of the ossicles were done with micrometer. Comparison among them with respect to sex, laterality and race were made. Age variation was not considered as the ossicles reach their full size at birth. Statistically significant difference in the total height of stapes was observed between male and female ossicles, but no such disparity was found between ossicles of the two sides. Height of stapes in males (mean: 3.35mm) was found to be significantly higher (p value: 0.00001) as compared to females (mean:3.18mm) in this present study. In surgeries for otosclerosis, the stapes superstructure is removed and replaced by a prosthetic ‘piston’, the selection of which is determined by the distance between the lenticular process of incus and the footplate of stapes, which in turn corresponds to the height of stapes superstructure. This measurement is vital for a properly fit piston and thus to the outcome of the surgery in terms of hearing improvement and lack of complications like expulsion of the piston, intractable vertigo, etc. When the mean values found in this study were compared with those of previous foreign and Indian studies, some of the values were found to be similar. : The height of stapes was shorter in our study as compared to studies based on North Indian population. These differences might point towards geographic or ethnic variations in the stapes which might call for further research work into this topic.

Intra-Operative Ossicular Chain Status in Patients with Chronic Otitis Media.

The Objective of the study was to assess the ossicular status in chronic otitis media (COM)-mucosal and squamosal type and statistically evaluate the extent of ossicular destruction intraoperatively in COM patients. The findings of this study could help us to predict preoperatively the probability of having ossicular chain destruction in COM ears and thus patients could therefore be properly consented about these potential issues before surgery. The study was carried out in ENT department of tertiary health care hospital, between January 2019 to January 2020. All patients of all age groups and both genders, diagnosed with COM Mucosal and Squamosal Type with complaints of ear discharge and hearing loss with good cochlear reserve and requiring surgery were included in the study, after taking informed written consent in vernacular language. All the patients included in the study were evaluated with detailed history, clinical examination including otomicroscopy, tuning fork tests and pure tone audiometry. The patients were then posted for ear surgery and the middle ear status and ossicular chain status were assessed using a microscope intraoperatively. Out of 98 patients, 45(45.9%) had mucosal and 53 (54.08%) had squamosal disease. Ossicular chain was eroded in 69 cases (70.5%). 23 out of 45 (51.1%) mucosal cases and 46 out of 53 squamosal cases (86.7%) reported ossicular erosion. Most frequently involved was long process of incus > stapes > malleus. From our study, we concluded that there is a significant relationship between type of disease pathology in middle ear and ossicular erosion being higher in Squamosal type of COM, with malleus being the most resistant and incus being the most susceptible ossicle.

Importance of Diameter of Long Process of Incus in Stapedotomy-New Findings From In Vivo Study.

Introduction Stapes surgery for otosclerosis is a precise surgical procedure. To achieve excellent hearing results, a firm and stable attachment of the prosthesis to the long process of incus (LPI) is necessary. The present study provides details on the attachment site in two dimensions to choose an appropriate prosthesis and to ensure firm attachment for better surgical outcomes. Objective To study the diameter of the LPI and its relevance in determining the piston, used in stapes surgery by an in vivo method. Methods This study was conducted in 41 patients who underwent stapedotomy, where both Anteroposterior (AP) and Mediolateral (ML) diameters of the LPI were measured at the site of attachment of the piston using specially designed instruments, intraoperatively. Radiological data were obtained to measure the LPI diameter from the normal ears of 46 patients. It was measured from both the right and left side, hence 92 LPI diameters were obtained. Results The most commonly used site for prosthesis attachment is between 1-1.5 mm away from the tip of the LPI. We found great variability in the diameters of LPI in the attachment site, with the AP diameter ranging between 0.6 -1.5mm and the ML diameter ranging between 0.5mm-1.2 mm. Conclusion Pistons by design have characteristics of gripping incus that will vary between types. Based on LPI dimensions, ideal piston types with appropriate inner loop diameters are suggested in this study. HRCT before surgery should include measurements of the LPI as a guide to the choice of the prosthesis during surgery.

Study of ossicular chain status in chronic otitis media patients at a tertiary care hospital in southern Bihar

Background: The objective is to assess the ossicular status and statistically evaluate the extent of ossicular destruction intraoperatively in chronic otitis media (COM) patients. Knowledge of pattern of involvement of ossicular chain in COM cases may help us to determine the type of reconstruction needed during surgery. The findings of this study could be exploited to predict preoperatively the probability of having ossicular chain destruction in COM ears and thus patients could therefore be properly consented about these potential issues before surgery. Methods: Prospective observational study conducted over 2 years in diagnosed patients posted for surgical management and fulfilling the inclusion criteria. Intraoperative status of ossicles was noted for various types of COM and outcome was evaluated. Results: Out of 92 patients, 59 (64.1%) had mucosal and 33 (35.9%) had squamosal disease. Ossicular chain was eroded in 41 cases (44.6%). 9 out of 59 (15.3%) mucosal cases and 32 out of 33 squamosal cases (97%) reported ossicular erosion. Most frequently involved was long process of incus (44.6%) >stapes (9.8%) >malleus (8.7%). Order of involvement (Austin-Kartush classification) was found as: type A (26.1%)>B (9.8%)>C (8.7%). 67.4% belonged in the group 15-30 years. Male: female ratio=1:1.5. Conclusions: Degree of ossicular destruction is much greater in squamosal COM, owing to overproduction of cytokines and inflammatory mediators and due to presence of cholesteatoma and/or granulations. The long process of incus was found to be most vulnerable. Malleus was found to be the most resilient among all ossicles.

Hearing Outcome After Incudo-stapedial Joint Reconstruction Using Conchal Cartilage Interposition Graft.

Ossicular chain defects secondary to Chronic otitis media most frequently involves the incudo-stapedial joint. This study observes the effect of incudo-stapedial joint reconstruction using conchal cartilage interposition graft on hearing of the patient. Fifty-three patients with chronic otitis media of inactive mucosal type with incudostapedial necrosis of less than half of long process of incus were posted for tympanoplasty with incudostapedial joint reconstruction using autologus conchal cartilage. Their hearing outcome was analysed by comparing the pre-operative and 12 weeks post-operative Pure Tone Audiogram. A statistically significant improvement is seen in air conduction by 14.66 dB after incudo-stapedial joint reconstruction using conchal cartilage (p value 0.0001), whereas improvement seen in bone conduction was statistically insignificant. 52 (98.1%) patients had ≤ 40 dB post-op AC and 1 (1.9%) had > 40 dB.. Conchal cartilage is an easy-to-harvest, biocompatible and cost effective graft material. It gives hearing results comparable to other materials.

Clinical Profile of Squamosal Chronic Otitis Media among Paediatric and Adult Patients in Rural Population of Central India: A Cross-sectional Study

Introduction: Chronic Otitis Media (COM) is one of the major preventable causes of hearing impairment, especially in children. Hearing loss in children affects speech, language, communication, auditory processing, psychosocial and cognitive development, and academic progress. Since studies addressing and comparing COM in the paediatric and adult population are few and far between, present study attempted to fill this research hiatus. Aim: To analyse and compare the clinical profile of squamosal COM in paediatric and adult populations. Materials and Methods: The present cross-sectional study was carried out in the Department of Otorhinolaryngology, Acharya Vinod Bhave Hospital, Sawangi, Wardha, Maharashtra, India, from December 2020 to December 2022. All the selected patients with squamosal COM (active or inactive) in the paediatric age group (0-15 years) and adult age group (16-60 years) was considered in this study. The study included 26 patients and was evaluated based on intraoperative and radiological findings such as grades of retraction pocket, extent of ossicular erosion, extent, and spread of granulation and cholesteatoma, and pneumatisation pattern among both age groups were carefully analysed. Chi-square test (χ2 ) of independence was used to compare data between the two groups. A p-value ≤0.05 was considered statistically significant. Results: Erosion of scutum was predominantly noted in 6 (42.9%) paediatric patients. In both age groups, attic perforation were more common than marginal perforation, which was found to be statistically significant (p-value=0.045). Grade-2 Posterosuperior Retraction Pocket (PSRP) in paediatric (2, 14.2%) and Grade-4 PSRP in adults (4, 33.3%) were commonest whereas none of the paediatric patients showed Grade-4 PSRP. This difference in PSRP grade in both age groups was found statistically significant (p-value=0.038). Short process of incus was more frequently involved in 3 (25.0%) paediatric and long process of incus in 6 (60%) adult (p-value=0.040). There was frequent involvement of protympanum in 7 (50%) paediatric patients (p-value=0.035). Diploic pattern of pneumatisation was least common in both age groups. Conclusion: Greater grades of PSRP were found among adult patients. This might be contributed to the longer duration of exposure to disease pathogenesis in adults. One of the vital features in the ossicular involvement is the total absence of incus and malleus more frequently in paediatric patients indicating its extensiveness

Long-term outcomes of retrospective case series of middle ear implantation with Vibrant Soundbridge in children with congenital aural atresia.

to assess audiological performance in quiet and noise, quality of life and side effects of Vibrant Soundbridge (VSB) in children with congenital aural atresia (CAA). A retrospective study including consecutive patients with unilateral or bilateral CAA implanted with VSB from 2009 to 2020 in a tertiary referral centre. 18 patients with CAA and a present stapes were included (3 simultaneous bilateral VSB implants) and 21 ears: 17 VSB were attached to the short incus process, and four to the stapes. Age at implantation ranged from 4.7 to 15.8years. Average follow-up was 6.5years (± 3.7years). In unilateral VSB, air conduction pure tone average (ACPTA) thresholds increased from 75.3 ± 15.2 to 32.6 ± 8.3dB post-operatively (VSB activated) (n = 15; p < 0.01). The speech reception threshold (SRT) and the word recognition score (WRS) were significantly improved from 81.5 ± 10.4 to 43.9 ± 7.6dB and 0% to 84.8 ± 8.5% postoperatively (n = 15; p < 0.01). The signal to noise ratio (SNR) was significantly improved from 2.1 ± 2.9dB VSB inactivated to 0.3 ± 2.7dB VSB activated (n = 15; p < 0.01). There was no significant difference in performance according to floating mass transducer (FMT) placement. 5/15 children were non-users at last follow-up in unilateral VSB and 0/3 in bilateral. CAA ears with VSB activated had a significant improvement of ACPTA, WRS, SRT and SNR. A third of patients with unilateral CAA became non-users at last follow-up. The main challenge is to target the indications for the implantation of the VSB to avoid its discontinuation.

Influence of the Coupling on the Hearing Outcome After Implantation of an Active Middle Ear Implant: Comparison of the Transmission Behavior in Temporal Bone Experiments With Clinical Data.

The active middle ear implant, Vibrant Soundbridge (VSB), can be implanted with a variety of couplers. Hearing outcome after implantation has been investigated in both temporal bone (TB) experiments and patient studies, but the relationship between experimental and clinical data is still weak in the literature. Therefore, experimental data from TB experiments should be compared with patient data in a retrospective study, in which the floating mass transducer is used with couplers of the third generation. Actuator coupling structures included the long (LP coupler) and short (SP coupler) incus process, the stapes head (Clip coupler), and the round window membrane (RW soft coupler). In the TB experiments, the sound transmission after vibroplasty on the above-mentioned actuator coupling structures was determined in 32 specimens by means of laser Doppler vibrometry on the stapes footplate. Data of 69 patients were analyzed. The main target audiometric parameters were the postoperative aided word recognition score (WRS) in the free field at 65 dB SPL (WRS 65 dB in %), the preoperative and postoperative pure-tone average (PTA4, including the frequencies 0.5, 1, 2, and 4 kHz) of the bone conduction hearing threshold (PTA4BC), the aided postoperative air conduction hearing threshold in the free field (PTA4FF) and the direct threshold (Vibrogram) at least 6 months postoperatively. The coupling efficiency of the actuator (Vibrogram-PTA4BC) as well as the effective hearing gain (PTA4FF-PTA4BC) was compared between the couplers. The analysis in the main speech range (0.5-4 kHz) indicated that in the TB experiments, the LP coupler tends to have the best coupling quality at low frequencies (500-1000 Hz). This was up to 15 dB above the worst actuator (RW soft coupler). However, the results missed the significance level ( p > 0.05). In the high frequencies (2000-4000 Hz), the Clip coupler showed the best coupling quality. This was 15 dB above the worst actuator (SP coupler). However, the results missed the significance level ( p > 0.05), too. The postoperative WRS at 65 dB SPL and the postoperative PTA4FF were independent of the actuator coupling structure. The PTA4BC was stable at 6 months postoperatively. For the PTA4 of the coupling efficiency, there were no significant differences between the actuator coupling structures (LP 8.9 dB ± 12.9; SP 9.5 ± 6.5 dB; Clip 5.2 ± 10.5 dB; RW 12.7 ± 11.0 dB). However, the tendential inferiority of the RW soft coupler with regard to transmission in the low-frequency range and the tendential superiority of the Clip coupler in the high-frequency range that have already been displayed experimentally could be confirmed in the clinical results. However, the clinical results missed the significance level, too ( p > 0.05). In vivo, there are no significant differences in the postoperative outcome stratified according to coupling the target structure. The differences known from the experimental setting were repressed by individual biasing factors. However, to ensure sufficient postoperative speech intelligibility, the frequency-specific transmission behavior of the couplers should be taken into account when setting the indication for VSB implantation.

Speech performance and subjective satisfaction of middle ear implant in congenital aural atresia.

SUMMARYObjectivesTo evaluate the safety, speech performance in noise and subjective satisfaction of patients with congenital aural atresia (CAA) implanted with the active middle ear implant.MethodsThis retrospective study included 13 patients (15 ears) implanted with middle ear implants with different methods of floating mass transducer attachment. In 6 ears, the floating mass transducer (FMT) was coupled with the short process of incus; in 8 ears, a clip coupler was used; and in one ear, a round window coupler was used. Patients were assessed preoperatively, and at one, three, and six months postoperatively. The assessment included Pure Tone Average (PTA4), Speech Reception Threshold (SRT) and Speech Discrimination Score (SDS). The Speech Spatial and Qualities of Hearing scale (SSQ12) was also used to evaluate levels of satisfaction.ResultsThe mean aided PTA4 using Vibrant Sound Bridge (VSB) was 26.44 4.03 dB HL compared to 61.88 ±1.53 dB HL unaided. The SDS improved significantly (p = 0.002) from 51% (± 9.17%) to 94.60% (± 4.43%). Furthermore, there was a significant improvement in SDS in noise (p = 0.008) and SSQ12 responses (p < 0.0001).ConclusionsPatients with hearing loss due to CAA can substantially benefit from VSB, with highly satisfactory subjective results and a negligible rate of complications.

Automatic Detection and Segmentation of Short Process of Incus in Different Microscopic Surgical Scenarios via Convolutional Neural Networks and Transfer Learning

Automatic Detection and Segmentation of Short Process of Incus in Different Microscopic Surgical Scenarios via Convolutional Neural Networks and Transfer Learning

Using Semantic Segmentation to Identify Short Process of Incus in Different Microscopic Surgical Scenarios Via Transfer Learning

Using Semantic Segmentation to Identify Short Process of Incus in Different Microscopic Surgical Scenarios Via Transfer Learning

Long-Term Safety and Quality of Life after Vibroplasty in Sensorineural Hearing Loss: Short/Long Incus Process Coupler

Objective: The study shows the long-term effectiveness, safety, and quality of life after Vibrant Soundbridge (VSB) implantation in sensorineural hearing loss (SNHL) using the short process coupler (SP) or the long process coupler (LP). Methods: This retrospective study evaluated 77 VSB cases. Follow-up (F/U) time-dependent objective measurements (audiological outcomes), subjective data collection (quality-of-life questionnaire), and safety measures are presented. Results: Sixty-two ears were included in the analysis with up to 116 months of postsurgical F/U data (mean 32.15 ± 37.97 months LP and SP coupler). Fifty-three ears (13 bilateral cases) received the LP coupler and 9 subjects the SP coupler. The post-operative bone conduction thresholds remained stable and, in both groups, <10 dB. The benefit in word recognition scores measured at 65 dB SPL and 80 dB SPL showed no significant difference between the couplers (p = 0.559 and p = 0.088, respectively). The functional gain was not significantly different (p > 0.05) with a mean of 20.91 ± 9.77 and 17.19 ± 5.75 for LP and SP coupler, respectively. The utility score deciphered from the Assessment of Quality-of-life Questionnaire-8 dimensions revealed a mean score of 0.75 ± 0.16 which is not significantly different to the age- and sex-matched healthy control group with 0.81 ± 0.02 (p = 0.3547). Conclusion: The Incus Vibroplasty utilizing both couplers is a safe and effective method to treat mild-to-severe SNHL. Both fixation methods of the floating mass transducer exhibit good clinical and audiological outcomes with high patient quality of life. The SP coupling method can be a good alternative when the long process is anatomically inaccessible, or the approach is limited due to anatomical reasons.

Evaluation of the middle ear in water buffaloes (Bubalus bubalis) by gross anatomy and cone-beam computed tomography

The purpose of this study was to provide a description of gross middle ear morphology in water buffaloes, augmented with additional data on the osseous structures of middle ear derived from cone-beam computed tomography (CBCT). Skulls of 10 young adult male water buffaloes were used to examine their middle ears. Anatomical features noted included the presence of tympanic cells in the tympanic bulla, the location of malleus head and neck, and all of incus in the dorsal epitympanic recess, the oval tympanic membrane, absence of a prominent notch on the articular surface of malleus, positional variations of the lateral process of malleus relative to the muscular process and muscular process relative to the rostral process of malleus, absence of complete coverage of the articular facet of malleus head by incus body, and presence of the lenticular process of incus. In CBCT images, the osseous part of external acoustic meatus, the petrous part of temporal bone and the details of the ossicles were seen, except for stapes. Although tympanic membrane, malleus and stapes of water buffaloes are similar to those of ox, the incus of water buffaloes is more similar to that of goats. The heaviest ossicles among the ruminants studied belonged to water buffaloes; the mean length of malleus head and neck, total length and width of incus body as well as length of stapes head were greatest in water buffaloes too. The auditory ossicles of water buffaloes show 'transitional type' morphological characteristics. These features suggest a relatively wide frequency range of hearing, but not one biased towards especially low or especially high frequencies.

Use of Glass Ionomer Cement for Incudostapedial Rebridging Ossiculoplasty.

Introduction:The ossicles of the middle ear are affected by the erosive effect of pathology in chronic otitis media. Ossicular reparation can be done via autologous incus or with alloplastic materials. Glass ionomer cement (GIC) is simple to use and saves considerable operative time and expenses especially in developing countries where costly ossicular prosthesis are not affordable for the majority of the patients.Materials and Methods:Twenty-five chronic otitis media patients who underwent surgery were included in this study. The reconstruction material used in this study was glass ionomer cement. All patients had erosion of the long process of incus and a normal stapes. Results: Pure tone average in pre-operative and post-operative period of study patients were 50.09 & 29.92 dB respectively (P=0.01) and the air-bone gap was 24.85 dB preoperatively and 14.05 dB postoperatively. The closure of the air-bone gap was statistically significant (P= 0.01). Conclusion:The study showed that the use of GIC ossiculoplasty is an efficient method for the reparation of the long process of the incus. The results are encouraging and indicate that it is worthwhile to conduct more trials using this method.

Preoperative predictors of Ossicular Discontinuity in non-Cholesteatoma Chronic Otitis Media

Background: Though ossicular discontinuity is more common in cases of cholesteatoma, it may happen in non-cholesteatoma COM. The long process of incus is more frequently involved ossicle. Peroperative assessment of ossicular integrity is the gold standard way. But the discontinuity of the ossicular chain can be assumed before surgery by analyzing perforation edge adherent to medial wall and wide air-bone gap The purpose of the study was to find out the preoperative findings which can predict the ossicular discontinuity in non-cholesteatoma cases.&#x0D; Methods: This cross-sectional study was conducted in the department of Otolaryngology-Head &amp; Neck Surgery, Bangabandhu Sheikh Mujib Medical University from January 2013 to June 2014. 81 patients of COM without cholesteatoma were selected as per inclusion and exclusion criteria. Relevant data were collected in a predesigned data collection sheet and analyzed with standard statistical method. Statistically significant inferred for P value &lt;0.05. No groups whose ability to give voluntary informed consent questionable was not included. No potential risks exist in designed this study.&#x0D; Results: Air-bone gap &gt; 40 dB was found in 60% cases of ossicular discontinuity, followed by air bone gap 31-40 dB(20%), 21-30 dB(13.33%) and 11-20 dB( 6.67%) respectively. So ossicular discontinuity was more in higher air-bone gap group and it was statistically highly significant (p&lt;0.001). Perforation edge attached to medial wall where ossicular discontinuity was 93.3% and perforation edge free from medial wall was 6.7%.Ossicular discontinuity was higher when perforation edge was found attached to medial wall which was highly statistically significant (p&lt;0.001). Out of 25 granulation tissue cases ossicular discontinuity was found 21(84%) and ossicular chain intact was found 4(16%). That was statistically significant (p&lt;0.01).&#x0D; Conclusion: Non-cholesteatoma COM may cause ossicular disconnection. Majority ossicular discontinuity found when average air bone gap &gt; 40 dB. Ossicular discontinuity was also found more in cases where there is attachment of perforation edge to medial wall, and presence of granulation tissue. If preoperative information can be gathered to determine whether or not the ossicular chain is intact, the patient can be better informed, counseled for ossiculoplasty before surgery.&#x0D; J Dhaka Medical College, Vol. 29, No.1, April, 2020, Page 47-52

Long Process Incus necrosis in Revision Stapedotomy: Retrospective Clinical Study.

We describe our experience with long process incus (LPI) necrosis in revision stapedotomy and discuss the different management methods proposed in the literature to identify surgical techniques that can lead to satisfactory results over time. Twenty-two stapedotomy revisions, in 21 patients with the necrosis of the long process of the incus, are performed from 1997 to 2017. In cases of erosion or minimal necrosis of LPI, a new prosthesis of the same type or an angled prosthesis was applied higher on the residual incus stump. In cases of partial necrosis of LPI, a Donaldson type ventilation tube reshaped and placed on the residual incus stump to stabilize prosthesis, or glass ionomer bone cement was used. In cases of subtotal necrosis of LPI, a cup piston prosthesis in polycel was applied on incus residual stump. Pre- and postoperative (≥1 year) pure tone audiometry was performed for all cases. Air conduction threshold, bone conduction (BC) threshold, and air-bone gap (ABG) were documented according to the American Academy of Otolaryngology Head and Neck Surgery Committee of Hearing and Equilibrium guidelines. At 1-year follow-up, postoperative ABG was reduced to ≤10 dB in 13 (59%) cases and ≤20 dB in 19 (86.4%) cases. The mean postoperative ABG significantly decreased in each group. There was no significant change in postoperative BC thresholds, and there were no cases with postoperative SNHL. Excellent functional results can also be achieved in cases of long incus process necrosis. The choice of technique should be considered according to the degree of necrosis. Piston replacement with the same type or angled type prosthesis, in cases of erosion or minimal LPI necrosis, and modified Donaldson type ventilation tube, in cases of partial LPI necrosis, provided excellent hearing results.

Tendoplasty and its effectiveness in the rehabilitation of hearing loss in patients with otosclerosis

The article briefly presents the physiology of the stapes muscle tendon (SMT), and features in its defeat. Its length was studied using high-resolution multispiral computed tomography of the temporal bones. We also studied the possibility of its restoration using the author's method of tendoplasty using metallized stapes prostheses. Tendoplasty with stapedoplasty was performed in 74 patients with otosclerosis (OS), and 48 patients had stapedoplasty without tendoplasty. As a result of research, the average length of the SMT was 2.38±0.02 mm, which explains the need to use a 3 mm long venous autograft for tendoplasty. The author's method of tendoplasty for stapedoplasty allows restoring the acoustic reflex in 54.1% of OS patients using artificial stapes prostheses. The preservation of the vascular bed in the thickness of the restored tendon can improve the trophy of the long incus process and reduce the risk of its dystrophic changes in the postoperative period. In addition, this fact confirms the importance of the stapes muscle in the acoustic reflex.

Cholesteatoma Masquerading as Cerumen

Cerumen is composed of glandular secretions and desquamated epithelial cells. It protects and lubricates the external auditory canal. Impacted cerumen causes canal occlusion and pressure over the tympanic membrane, causing ear discomfort, conductive hearing loss, itching, etc. Up to 6% of the general population are affected with impacted cerumen, which includes 10% of children, more than 30% of the elderly and people with cognitive impairment. Persistent symptoms despite resolution of impaction and patient repeatedly should raise suspicion of alternative diagnosis and prompt for further evaluation. A 20-year-old female patient came with complaints of decreased hearing and ear discharge. On otoscopic examination of left ear, impacted cerumen was seen in the attic region. On removal of wax with the aid of oto-endoscopy, attic region was found to be filled with cholesteatoma debris. On pure tone audiometry, patient had mild conductive hearing loss of 30 db and computed tomography of left temporal bone revealed ill-defined soft tissue density in the middle ear (epitympanum) with erosion of head of malleus and short process of incus. Blunting of scutum was also seen. Attic reconstruction and type III tympanoplasty was performed. On histopathological examination, the section showed keratin flakes with bacterial colonies which were consistent with cholesteatoma. In conclusion, any case of impacted cerumen should not be ignored by otorhinolaryngologist. Further evaluation with thorough examination under otomicroscope/otoendoscope has to be done which can lead to different diagnosis and treatment plan.

Conductive hearing loss after surgical treatment of otosclerosis - long-term observations.

&lt;b&gt;Introduction:&lt;/b&gt; For many years, surgical treatment of otosclerosis has been a widely accepted approach. Hearing improvement following stapes surgery is sometimes spectacular, and good treatment results are obtained in many centers in over 90% of patients. However, in the subsequent years after the treatment, some patients develop permanent or progressive conductive hearing loss. &lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The aim of the study is to present a group of patients with conductive hearing loss after the first otosclerosis surgery and to analyze the causes of its occurrence. &lt;br&gt;&lt;b&gt;Materials and Methods:&lt;/b&gt; The retrospective review covered patients who underwent the initial surgery in the years 2000-2009. We analyzed the patients' medical records from before the end of 2019, which provided results of at least 10 years of postoperative follow-up. The group consisted of 1118 patients aged 14-82, including 802 women and 316 men.&lt;br&gt;&lt;b&gt; Results:&lt;/b&gt; Reoperations due to conductive hearing loss were performed on 93 patients, who accounted for 8.3% of the originally operated patients. They were much more common in patients after stapedectomies (19.7%) than in patients after stapedotomy (5.5%). Prosthesis dislocation was found to be the most frequent intraoperative observation (44.1%) and was often associated with erosion or necrosis of the long process of incus (28%). Less frequent reasons for hearing loss were: adhesions around the prosthesis (10.8%), too small hole in the stapes footplate (8.6%), too short prosthesis (8.6%), progression of otosclerosis (7.5%), too long prosthesis (6.4%), presence of a granuloma around the prosthesis (5.4 %), and displacement of incus (4.3%). &lt;br&gt;Conclusions:&lt;/b&gt; Surgical treatment of otosclerosis is a widely accepted and good method. It allows to achieve an improvement in hearing in the vast majority of patients treated in this way. Unfortunately, over the years some patients develop recurrent conductive hearing loss. Reoperation creates an opportunity for finding the cause and improving hearing in the majority of cases.

Intra-operative findings of attico-antral type of chronic suppurative otitis media: A study of 85 patients.

Objectives: Chronic suppurative otitis media is the most common ear disease in Otolaryngology OPD and Head &amp; Neck surgery in tertiary care hospitals worldwide. Due to its life threatening complications and management difficulties, attico-antral disease, a type of CSOM poses a huge challenge to otolaryngologists. Study Design: Descriptive study. Setting: Department of Otolaryngology and Head &amp; Neck Surgery Allied Hospital (FMU) Faisalabad. Period: From January 2016 to December 2018. Material &amp; Methods: Eighty five patients with CSOM of attico-antral type were included. Results: Forty six patients (54.1%) were male and thirty nine patients (45.9%) were female, aged 07 to 58 years with an average age of 23.7 years. 42 patients (49.4%) had a right ear disease and 43 patients (50.6%) had a left ear disease. Granulation tissue was observed in 50 patients (58.8%), cholesteatoma in 27 patients (31.7%) and both granulation tissue and cholesteatoma in 08 patients (09.5%). The main pathology was observed to involve the attic area only of 04 patients (04.7%), attic and middle ear of 44 patients (51.7%), attic and antrum of 16 patients (18.9%) and attic, middle ear, antrum and other mastoid air cells in 21 cases (24.7%). The malleus handle was found eroded in 10 patients (11.8%), head &amp; handle in only 02 patients (02.4%). In 23 patients (27%) long process of incus was damaged while incus was completely eroded in 03 patients (03.5%). The suprastructure of stapes was found eroded in 03 patients (03.5%). Conclusion: Granulation tissue is the most common primary lesion along with cholesteatoma associated with attico-antral type of CSOM. Due to this pathology, the incus is the most frequently eroded small bone of the middle ear. In addition the management of granulation tissue and cholesteatoma poses a huge challenge to the otolaryngologists. Therefore, the general practitioners are needed to be educated for early referral to otolaryngologist for early and rapid management to prevent complications due to attico-antral type of CSOM.