Stapes Superstructure Research Articles

Malformations of the middle and inner ear on CT imaging in 22q11 deletion syndrome.

The 22q11 deletion syndrome (22q11DS), the most frequent microdeletion syndrome in humans, presents with a large variety of abnormalities. A common abnormality is hearing impairment. The exact pathophysiological explanation of the observed hearing loss remains largely unknown. The aim of this study was to analyze the middle and inner ear malformations as seen on computer tomographic imaging in patients with 22q11DS. We retrospectively reviewed the charts of 11 22q11DS patients who had undergone a CT of the temporal bone in the past. Of the 22 examined ears, two showed an abnormal malleus and incus, 10 presented with a dense stapes superstructure, and three ears had an abnormal orientation of the stapes. With regard to the inner ear, 12 ears showed an incomplete partition type II with a normal vestibular aqueduct. In four ears the vestibule and lateral semicircular canal were composed of a single cavity, in 14 ears the vestibule was too wide, and three ears had a broadened lateral semicircular canal. These findings suggest that malformations of the stapes, cochlea, vestibule, and lateral semicircular canal are frequent in 22q11DS. To our knowledge, the current study involves the largest case series describing middle and inner ear malformations in 22q11DS. © 2016 Wiley Periodicals, Inc.

Canal Wall down Mastoidectomy and Tympanoplasty in Cholesteatoma Surgery: Ten Years’ Experience

Tympanomastoid surgery for cholesteatoma is a procedure designed to eliminate the disease and maintain a safe and dry ear. This retrospective study was designed to evaluate the functional results of cholesteatoma patients who underwent canal wall down mastoidectomy in conjunction with a tympanoplasty. Operated ears due to chronic otitis media with cholesteatoma were considered for the study. The study was carried out in 120 ears. The choice of technique for tympanoplasty is based on the pathology encountered in the stapes superstructure. Patients were divided into three: 1) Group A, a type II TPL with stapes columella reconstruction; 2) Group B, a type III TPL with major columella reconstruction; and 3) Group C, a type IV TPL using a temporalis fascia and thick cartilage to shield the round window. The operated ears of Groups A and B, as compared to Group C, presented a significant decrease in the pre-operative Air-bone gap and an increase in the number of operated ears with an Air-bone gap between 0 - 20 dB. The study emphasizes the importance of functional separation of the two acoustic windows by fascia and cartilage graft when the stapes superstructure is missing but the footplate is mobile.

A Case of Fracture of the Stapes Superstructure with an Intact Incudostapedial Joint Caused by Indirect Trauma

A Case of Fracture of the Stapes Superstructure with an Intact Incudostapedial Joint Caused by Indirect Trauma

Virtual Endoscopy to Plan Transtympanic Approach to Labyrinthine Windows.

The aim of this study was to evaluate the position and the accessibility of labyrinthine windows through the external auditory canal (EAC) by virtual endoscopy based on computed tomographic scan images. Prospective cross-sectional study. Tertiary referral center. Sixty-three high-resolution temporal bone computed tomographic scans were obtained from 34 adult patients undergoing various otologic procedures. Images were analyzed by the virtual endoscopy function included in Osirix (www.osirix-viewer.com). The endoscope was constrained in the EAC. The visible surfaces of target anatomic structures were assessed on multiplanar reconstruction views. The optimal angles of the virtual endoscope position showed a relatively high interindividual variability in the axial plane (64 ± 2.4 degrees for the oval window [OW] and 60 ± 2.5 degrees for the round window [RW]) position, but a low interindividual variation was noted in the coronal plane (107 ± 1.5 degrees for the OW and 112 ± 1.7 degrees for the RW). The RW was accessible in 87% of cases. The OW accessibility could be staged as follows: 1, invisible stapedial superstructure (10% of cases); 2, stapedial posterior crus partly visible (33%); 3, entire posterior crus and pyramid visible (44%); 4, posterior and anterior crus visible (13%). Virtual endoscopy through the EAC can evaluate the accessibility of the OW or RW via a transcanal route. This technique seems to be helpful in preplanning minimally invasive procedures by this approach such as cochlear implantation.

A comparative study of outcome of ossiculoplasty using cartilage graft, bone and different alloplasts in chronic otitis media

Objective: The objective was to determine which material, among autologous cartilage, autologous incus and partial ossicular replacement prosthesis (PORP), gives better postoperative hearing result in ossiculoplasty. Study Design: Nonrandomized prospective cohort (longitudinal study). Settings: Tertiary referral center. Materials and Methods: Patients were selected from outpatients department with the clinical diagnosis of chronic suppurative otitis media with cholesteatoma or granulation tissue. Patients underwent necessary preoperative investigations including pure tone audiometry (PTA). Total 67 patients were selected for this study, among them 12 patients did not fit the selection criteria and 5 patients lost during follow-up. Hence, total 50 patients were taken in the study group. Intervention: Ossiculoplasty with cartilage, incus and PORP after modified radical mastoidectomy. Main Outcome Measure: Hearing results were measured by PTA-air bone gap (PTA-ABG) after 6 months of operation. Results: Selecting the criteria <20 dB ABG as success when stapes superstructure is present, cartilage has 60% success rate, incus has 73.68%, and PORP has 56.25% success. Extrusion rate of different prosthesis shows, PORP has 25%, cartilage has 20% extrusion. Incus has the lowest (5.26%) extrusion rate. Conclusion: Among the ossiculoplasty materials, autologous incus gives best postoperative hearing gain and lowest extrusion rate.

キヌタ–アブミ関節離断を伴わない介達性アブミ骨骨折例

キヌタ–アブミ関節離断を伴わない介達性アブミ骨骨折例

A rare stapes abnormality.

The aim of this study is to increase awareness of rare presentations, diagnostic difficulties alongside management of conductive hearing loss and ossicular abnormalities. We report the case of a 13-year-old female reporting progressive left-sided hearing loss and high resolution computed tomography was initially reported as normal. Exploratory tympanotomy revealed an absent stapedius tendon and lack of connection between the stapes superstructure and footplate. The footplate was fixed. Stapedotomy and stapes prosthesis insertion resulted in closure of the air-bone gap by 50 dB. A review of world literature was performed using MedLine. Middle ear ossicular discontinuity can result in significant conductive hearing loss. This can be managed effectively with surgery to help restore hearing. However, some patients may not be suitable or decline surgical intervention and can be managed safely conservatively.

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.

Comparison of different computed tomography post-processing modalities in assessment of various middle ear disorders

Several anatomic structures of the middle ear are not optimally depicted in the standard axial and coronal planes. Several 2D and 3D image-processing modalities are currently available for CT examinations in clinical radiology departments. Till now 3D reconstructions of the temporal bone have not been widely used yet, and attracted only academic interest. The aim of this study was to compare axial (source images), 2D and 3DCT post-processing modalities, and to evaluate the value of 3D reconstructed images/virtual endoscopy (VE) in assessment of various middle ear disorders for identification of the best modality/view for assessment of a particular middle ear structure or pathology. 40 patients with various middle ear disorders, planned for surgical intervention were included in prospective study. Multi-slice CT was performed for all patients. Scans were acquired in the axial plane. The axial source datasets were utilized for generation of 2D reformations and 3D reconstructed images. All studied images were divided into three categories: axial (source images), 2D reformations (MPR and sliding-thin-slab MIP) and 3D reconstruction (virtual endoscopy). The visibility of middle ear structures and pathologies with each modality were scored qualitatively using three-point scoring system in reference to operative findings. Stapes superstructure and footplate, incudostapedial joint, oval and round windows, tympanic segment of the facial nerve and tegmen were not optimally depicted in the axial plane. Sinus tympani and facial recess were best visualized with axial images or VE. 3D reconstruction/VE allowed good visualization of all parts of ossicular chain except stapes superstructure. Regarding pathologic changes, 2D reformations and 3D reconstructed images allowed better visualization of erosion of ossicles and tegmen. 3D reconstruction/VE did not allow detection of foci of otospongiosis. 2D reformations can be considered the mainstay in assessment of most middle ear structures and pathologies. 3D reconstruction/VE seems to provide a useful method for a preoperative general overview of the middle ear anatomy, particularly for the ossicular chain, round window and retrotympanum.

Cortical bone total ossicular replacement prosthesis

Objectives: Evaluate an autologous cortical bone total ossicular replacement prosthesis (B TORP) made of cortical bone for cost effective and sustainable hearing results. Materials and Methods: A prospective study was undertaken in the patients who underwent tympanoplasty with new B-TORP from January 2011 to December 2011. All patients had an absent superstructure of the stapes and long process of the incus due to chronic otitis media. Totally 40 patients were evaluated. Hearing results were evaluated using four-frequency average pure tone air conduction and air-bone gap (ABG) measured at 0.5, 1, 2, and 3 kHz after a period of 12 months. Pre- and post-operative continuous variables were compared using a paired t-test and data from unequal groups were assessed for significant differences using unpaired t-test. Results: Successful rehabilitation of the ABG to 20 dB or less was achieved in 95% of patients. Overall mean improvement in ABG was 25.8 ± 5.6 dB, which was statistically significant (t = 26.8, P 0.5). Conclusion: The new autologous B-TORP provides sustainable hearing improvement and is bio-compatible, stable, and magnetic resonance imaging compatible.

Bilateral congenital absence of the stapes superstructure in two siblings.

Middle ear ossicle malformations are an uncommon event. Among them, the congenital absence of the stapes is a very rare condition that is seldom described in the literature. We report the cases of two women, aged 19 and 22 , who presented with a long history of conductive deafness. An exploratory tympanotomy was performed and the absence of the stapes superstructure and an abnormal position of the facial nerve could be observed. A bone anchored hearing aid (BAHA) was implanted in both patients with good results. It is believed that stapes agenesis is related to an abnormal development of the facial nerve, which by the 5th to 6th week of gestation would interpose between the otic capsule and the stapes blastema, preventing these structures from contacting. A long history of nonprogressive hearing loss from birth or early childhood is the key to reach a diagnosis. Several treatment options have been described. The authors opted for a hearing aid due to the high risk of facial nerve lesion, with good functional results.

Minor ossicular anomalies in the middle ear: role of submillimeter multislice computed tomography.

The objective was to elucidate clinical effectiveness of submillimeter multislice 2- and 3-dimensional computed tomography (CT) for diagnosis of congenital middle ear anomaly. Preoperative CT and operative findings were retrospectively analyzed in 36 ears of 33 patients. The distance between the malleal handle (MH) and the incus long process (ILP) was measured in 28 normal ears. Mean ± SD MH-ILP distance in normal ears was 1.8 ± 0.3 mm. In patients with middle ear anomaly, overall specificity, accuracy, and positive and negative predictive values were 99.7%, 98.7%, 91.7%, and 99.1%, respectively. Overall sensitivity was 82.1%, with relatively low sensitivities for detecting fused incudomalleolar joint, lenticular process defect, stapedial footplate defect, and oval window atresia and high sensitivities (80%-100%) for stapedial crural anomaly and certain fibrous connections. Submillimeter CT improved detectability of anomalies of the stapedial superstructure; however, it is still difficult to identify abnormalities of the footplate.

Differences in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas

This study investigated the difference in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas for the purpose of increasing the preoperative detectability of dehiscence. A total of 189 ears of patients 7-80 years of age (mean 42 years) with pars flaccida cholesteatoma and 63 ears of patients 9-84 years of age (mean 50 years) with pars tensa cholesteatoma were studied. All patients had undergone prior surgical management at our institution from January 2006 to April 2012. The incidence of fallopian canal dehiscence and its location were compared between pars flaccida and pars tensa cholesteatomas. Intraoperative findings of coexistent pathologies, including destruction of the stapes superstructure, labyrinthine fistula, and dural exposure, were compared between the dehiscence and no-dehiscence groups for the two types of cholesteatomas. The incidence of dehiscence was significantly higher in patients with pars tensa cholesteatoma (55.6 %) than in patients with pars flaccida cholesteatoma (26.5 %). Dehiscence located posterior to the cochleariform process occurred slightly more frequently in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. In patients with pars flaccida cholesteatoma, labyrinthine fistulas and dural exposure were significantly more frequent in the dehiscence group than in the no-dehiscence group. Fallopian canal dehiscence is more frequent in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. Especially in patients with pars flaccida cholesteatoma, paying special attention to these coexisting pathologies is important to increase preoperative detectability of dehiscence.

Is the Bone-Conduction Headband Test Useful for Predicting the Functional Outcome of a Round Window Active Middle Ear Implant?

To estimate the reliability of the Bone Conduction-HeadBand (BC-HB) test for predicting the postoperative functional outcome of a round-window (RW) vibroplasty. Within-subject comparison of the functional results of the BC-HB test, which is routinely used for the preoperative evaluation of a bone-conduction transducer, with an active middle ear implant (AMEI) placed onto the round window. Tertiary referral university hospital center. Seven patients with similar anatomic (absent stapes superstructure) and functional (moderate, mixed hearing loss) sequelae from open tympanoplasty technique. All subjects underwent preoperative audiologic assessment with the BC-HB. Subsequently, all subjects underwent surgical placement of an AMEI onto the round window. Pure tone and speech audiometry in quiet and noise were assessed. Additionally, evaluation of specific satisfactory targets was performed using the Client Oriented Scale of Improvement. Pure tone and speech audiometry in quiet established that both devices had very similar performance and provided remarkable improvement compared with the unaided condition. However, high-frequency gain and speech audiometry in noise demonstrated better performance with RW-AMEI. In patients presenting with mixed hearing loss as a sequela from middle ear surgery, the preoperative BC-HB test may be helpful in predicting the final functional outcome and patient satisfaction with RW-AMEI.

Evaluation of Postoperative Hearing Outcome and Recurrence for Pars Flaccida Cholesteatoma

Objectives: Find out which factors affect postoperative hearing outcomes and those which affect recurrence rate in cases of pars flaccida cholesteatoma. Methods: Fifty-six ears of 54 patients who underwent tympanoplasty for pars flaccida cholesteatoma for the first time at our hospital between 2006 and 2011 were enrolled. Progression of cholesteatoma, results of postoperative hearing, and the incidence of recurrence were compared. To define the progression of cholesteatoma, we used components of the classification proposed by American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) and the Japan Otological Society. Results: Cholesteatoma was present in eustachian tube, protympanum, or both in 13 cases, in the mesotympanum in 36, and in the mastoid cavity in 39. The stapes was intact in 47 cases, in which mucosa surrounding the stapes was normal in 15 and granulation tissue and/or cholesteatoma were present adjacent to the stapes in 32. Stapes superstructures were (nearly) completely destroyed in 8, and the stapes was not observed in one. Hearing was improved in 39 cases, with no significant difference in postoperative hearing among the regions involved by cholesteatoma. The cholesteatoma recurred in 5 cases. Recurrence was significantly more frequent when cholesteatoma involved the eustachian tube and/or protympanum ( P = 0.041) and also when the stapes was destroyed ( P = 0.043). Conclusions: Progression into the eustachian tube and/or protympanum and the destruction of the stapes superstructure are considered important factors to predict postoperative recurrence of pars flaccid cholesteatoma.

Clinical and Radiographic Predictors of Lateral Semicircular Canal Fistula

Objectives: Lateral semicircular canal fistula (LSCCF) may occur in as many as 10% of patients with cholesteatoma. Despite improvements in diagnostic imaging, reliable preoperative identification of LSCC remains elusive. Our objective is to explore preoperative clinical variables and intraoperative findings in order to identify factors associated with the presence of LSCCF. Methods: A retrospective matched cohort study was conducted. All patients with LSCCF, determined by intraoperative diagnosis, that had preoperative temporal bone computed tomography (CT) available for review were identified. Subjects were matched to patients without LSCCF according to age, gender and year of surgery. Associations between LSCCF and preoperative vertigo, fistula test results, sensorineural hearing loss (SNHL), stapes superstructure erosion, facial nerve and dural dehiscence, and preoperative radiographic findings were evaluated. Results: Eighty-three patients with LSCCF met inclusion criteria and were matched to subjects without labyrinthine fistula. Patients with LSCCF more commonly had stapes superstructure erosion (34 vs 15, P &lt; .001), facial nerve dehiscence (55 vs 10, P &lt; .0001), and dural dehiscence (29 vs 4, P &lt; .0001) compared to subjects without LSCCF. The presence and severity of preoperative SNHL, vertigo, and fistula test results were unreliable predictors of LSCCF. Furthermore, of those patients with LSCCFs, only 28% were identified on pre-operative CT. Conclusions: Preoperative variables including SNHL, vertigo, fistula test results as well as preoperative temporal bone CT were not reliable predictors of LSCCF. However, intraoperative findings including stapes superstructure erosion, facial nerve and dural dehiscence were found to be associated with LSCCF and should raise suspicion of disease.

Outcome of Management of Otosclerosis by Stapedotomy Compared to Stapedectomy in a Jordanian Population

To study the success results rates and complications of stapedotomy compared to stapedectomy in the operative management of otosclerosis. This is a retrospective study of 50 patients who were treated surgically for otosclerosis. The medical records of these patients were reviewed for the type of operation performed, complications and the serial pure tune audiometries pre- and postoperatively for at least one year. Patients with conductive hearing loss not due to otosclerosis were excluded from this study. The medical records of equal number of patients (25 patients with stapedotomy and 25 patients with stapedectomy) were analyzed for hearing improvement or loss, postoperative nausea, vomiting, vertigo, nystagmus, perilymph fistula, reparative granuloma, labyrinthitis, tinnitus and perforation of the tympanic membrane. All operations were performed by the senior consultant-otologists of our department. Stapes superstructures were removed by crural scissors and stapes footplate was perforated by microdrill. Out of 25 patients with stapedotomy, 22 (88%) developed complete closure (≤10 dB) of the air-bone gap on pure tune audiometry; in two patients (8%), the air-bone gap improved to less 20 dB, and recurrent conductive hearing loss (due piston slipping) in one patient (4%). On the other hand, in patients with stapedectomy, only 16 patients (64%) developed complete closure of the air-bone gap (≤10 dB) on pure tune audiometry, and in four patients (16%) the air-bone gap improved to less 20 dB, while recurrent conductive hearing loss occured in three patients (12%), one patient developed complete sensorineural hearing loss (4%), there was one case of fluctuating hearing loss due to reparative granuloma (4%), perilymph fistula was reported in one case (4%) and no cases of facial palsy or perforation of the tympanic membrane were recorded. The results of this study clearly show that stapedotomy gives better hearing results and fewer complications than stapedectomy.

The use of bone cement for ossicular chain defects

Bone cement is a good and cheap option for some ossicular chain problems such as incudostapedial re-bridging. The purpose of this retrospective study is to evaluate the audiologic results after reconstruction of three different types of ossicular chain defects, using bone cement. Group 1 consists of 42 patients who underwent an ossiculoplasty using bone cement between the damaged long process of the incus and an intact stapes superstructure. Group 2 consists of 46 patients in which incus interposition between malleus and stapes superstructure was performed, using bone cement to fix the interposed incus. For group 3, consisting of 32 patients who had a present malleus, a defective long process of the incus and a missing stapes superstructure, a re-shaped incus was placed between the stapes footplate and the malleus and bone cement was again used as a fixator. Preoperative and postoperative pure-tone audiometric findings were obtained and hearing differences were assessed. The mean preoperative and postoperative air-bone gaps were 34.8 and 15.6, 35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3, respectively. There was a significant improvement in hearing outcomes in all the groups when comparing preoperative and postoperative mean air-bone gaps (p<0.001). The postoperative air-bone gap was ≤20dB in 76% of patients in group 1, 64% of patients in group 2, and 46% of patients in group 3. Bone cement is an effective and cheap option for some ossicular chain problems such as incudostapedial re-bridging. It may also be used to fix the interposed incus to the stapes superstructure and/or malleus to avert displacement.

Canal wall dow mastoidektomi ile birlikte tip III timpanoplasti ameliyatı geçiren hastalarda işitme sonuçları

Objective: Preoperative and postoperative hearing results were compared in patients undergoing hearing reconstruction through open mastoidectomy with type III tympanoplasty method in our center. Methods: A total of 46 patients with chronic suppurative otitis media, who had undergone ossicular chain reconstruction by type III tympanoplasty with canal wall down mastoidectomy (CWDM) operation between January 2005 and 2009 were enrolled in the trial. The preoperative status of ossicular chain, the reconstruction methods on the ossicles, as well as the materials used in the reconstruction and the presence of stapes superstructure were recorded. Postoperative hearing gain of patients was evaluated by pure tone audiometry on an average of 6th months following surgery. Results: Among enrolled patients, 18 were females (39%) and 28 were males (61%). In 30 patients (65%), cholesteatoma was seen to have extended to the attic, antrum, supratubal recess and sinus tympani, while in 16 cases, cholesteatoma was determined to have partly invaded the mastoid cavity and mesotympanum. A polypoid tissue, arising from mucosa of middle ear and sagging into the external ear canal was detected in 6 patients (13%). While the preoperative and postoperative mean air-bone gaps were determined as 33.96 dB and 28.21dB, respectively. Preoperative and postoperative audiological examinations revealed an air-bone gap of £25 dB in 26.1 and 47.8% of the cases respectively. Conclusion: Type III tympanoplasty operation with canal wall down mastoidectomy provides eradication of the disease with cholesteatoma and enables reconstruction of hearing.

Low-Frequency Sound Pressure and Transtympanic Endoscopy of the Middle Ear in Assessment of “Spontaneous” Perilymphatic Fistula

This study was designed to verify an eventual perilymphatic fistula (PLF) in 264 patients with sensorineural hearing loss (SNHL) and/or vertigo. The patients were exposed to a low-frequency sound stimulation (LFS) on posturography to objectively test Tullio's phenomenon and Hennebert's sign. Endoscopes with 5 degree and 25 degree of visual angle and an outer diameter of 1.7 mm were used. The round window niche, with its foldings, oval window with stapes superstructure, a part of the facial recess and the area in the fissula ante fenestram were examined and video recorded. In one patient, we endoscopically verified a fistula in the round window membrane (resulting from a diving accident) that was covered with a fibrinous layer. In 4 cases, there was abnormal mucosal shining in the round window but without PLF. In 7 cases, the tympanic cavity could not be visualized because of the adhesive middle ear process, the abnormal anatomy, or the prominent exostoses of the ear canal prohibited vision. In 34 patients, LFS provoked unsteadiness on posturography without PLF. In 6 cases, a postoperative middle ear infection was recorded. No permanent tympanic membrane perforation occurred. It is unlikely that disease entity of “spontaneous PLF” exists. Tympanoscopy should be regarded as the first choice when a PLF is suspected.