Unilateral Middle Ear Effusion Research Articles

Post-radiation middle ear effusion in NPC patients: Analysis of patient, tumour, and radiation factors.

The purpose of this study was to investigate whether patient, tumour and radiation therapy factors are associated with development of middle ear effusion (MEE) in nasopharyngeal carcinoma (NPC) patients. A retrospective review of NPC patients treated between January 2000 and June 2018 at Rabin Medical Center. Patient factors, tumour factors, radiation doses, and radiation fields were collected and outlined if needed (middle ear, eustachian tube [ET], tensor veli palatini [TVP], and levator palatini [LVP] muscles), then analysed and compared between patients with MEE and those without and between sides in patients with unilateral MEE. Seventy-three patients were enrolled. Most were males (71.2%) with advanced-stage diseases (78%). At the time of diagnosis 14 patients (19.2%) presented with MEE. Following radiation, 18 patients, with no evidence of MEE at presentation, developed MEE. Tumour stage, histology, and laterality were not associated with development of MEE. Comparison of mean radiation field dosages including-gross target volume, clinical target volume, and patient target volume showed no association with post-radiation MEE. In addition, no difference was found in the radiation doses to the middle ear, ET or the LVP nor the TVP between ears with and without MEE. Post-irradiation MEE remains a common adverse effect in NPC patients. Surprisingly, tumour stage, tumour laterality, and histology were not associated with MEE. Similar findings were observed for total radiation doses and specific doses to the middle ear, ET, and ET muscles.

Spontaneous cerebrospinal fluid leaks of the temporal bone – clinical features and management outcomes

Objective:1.To characterise the clinical profile, symptoms and examination findings of patients with spontaneous cerebrospinal fluid otorrhoea.2.To evaluate the management outcomes of patients with spontaneous cerebrospinal fluid otorrhoea. MethodsA retrospective cohort study over seven-years from 2013 to 2020 was conducted at five tertiary referral centres. Patients identified with biochemically confirmed spontaneous cerebrospinal fluid leaks of the temporal bone manifesting as middle ear fluid with no other obvious cause were included. Demographics (age, gender, body-mass-index), symptomatology, past medical history, examination, investigation (biochemical and radiological), management and outcomes were recorded. Results90 adult patients with spontaneous cerebrospinal fluid otorrhoea were identified. Right sided leaks were most common (58%), and a majority of the cohort overweight (mean body-mass-index = 29.2 kg/m2). Unilateral hearing loss was the commonest presenting symptom (81%). Two patients presented to hospital with meningitis presumed secondary to spontaneous cerebrospinal fluid otorrhoea. Over half (54%) of patients were observed who tended to be older (mean age of 71 years vs 62 years) whilst the remainder underwent surgical repair with middle-fossa craniotomy the most common approach (87%). Eight patients managed surgically had recurrent leaks (21%). ConclusionsThis is one of the largest cohorts of spontaneous cerebrospinal fluid otorrhoea reported in the literature and reiterates the importance for clinicians to have a high index of suspicion for this condition in patients presenting with a unilateral middle ear effusion, especially in those who are overweight. Surgical intervention carries a risk of recurrence and further studies are needed to determine the risk of intra-cranial infection in order to guide management.

Spontaneous cerebrospinal fluid (CSF) otorrhoea in Western Australia—an emerging entity?

Background: Spontaneous cerebrospinal fluid (CSF) otorrhea appears to be an emerging clinical entity. The aetiology, characteristics and treatment outcomes of these group of patients are poorly described so we aimed to further investigate this growing cohort. Methods: A retrospective review across the three largest tertiary hospitals in Western Australia (WA) over a 5-year period was conducted. Twenty-eight patients with non-iatrogenic, and non-traumatic spontaneous CSF otorrhea were included. Baseline demographics, presenting symptoms, past medical history, clinical examination, investigation (biochemical and radiological), management and outcomes were analysed. The study was approved by the South Metropolitan Health Services Ethics Committee (approval number RG001008). Results: The majority of patients were female (61%), obese (mean BMI =29.5 kg/m 2 ) and presented with a unilateral middle ear effusion and conductive hearing loss. Beta-trace protein sampling of the fluid was positive for CSF in 26 of the 28 patients. The most frequent site of leak was at the tegmen mastoideum and middle cranial fossa repair was the most commonly performed procedure with excellent outcomes. Only one patient had confirmed benign intracranial hypertension and two patients presented emergently to hospital with meningitis thought to be due to the CSF leak. Conclusions: Spontaneous CSF otorrhea should be suspected in unilateral middle ear effusion of unknown cause, especially occurring in at-risk individuals including those whom are obese and of female gender. Clinical or radiological diagnosis alone appears inadequate in diagnosing a spontaneous CSF leak unless clinicians have a high index of suspicion. This emerging entity does not appear to be solely a consequence of raised intracranial pressure and further studies to elucidate the cause are required.

Spontaneous Middle Fossa Encephalocele

A 48-year old man presented with a unilateral right hearing loss of four months’ duration. A right middle ear effusion was noted on physical examination. Endoscopic examination of the nasopharynx was unremarkable. Due to the duration of the symptoms, myringotomy with ventilation tube insertion was offered as a treatment option. Upon myringotomy, clear pulsatile liquid flowed out of the incision. More than 5 cc of liquid was collected which continued to flow out despite active suctioning. Due to the realization that the liquid most likely represented cerebrospinal fluid, insertion of a ventilation tube was not performed. The ear canal was packed with sterile cotton, and the patient was given a short course of acetazolamide to decrease CSF production. Upon further questioning, the patient did not have any prior head trauma. The patient then underwent both computerized tomographic (CT) imaging and magnetic resonance imaging (MRI) of the temporal bone to look specifically for evidence of a dehiscence in the middle fossa plate (tegmen) or posterior fossa plate, as well as the presence of a meningoencephalocele.
 
 Computerized tomographic imaging of the temporal bone in the axial plane showed a soft tissue density completely occupying the air-containing spaces of the middle ear, epitypanum and mastoid air cells, without any evidence of bony erosion of the scutum, the ossicles, or the bony septations of the mastoid air cells. T2-weighted magnetic resonance imaging in the axial plane showed that the soft tissue densities in the middle ear, the epitympanum and mastoid air cells had a naturally high signal intensity characteristic of fluid. (Figure 1).
 On coronal CT imaging, a dehiscence of the middle fossa plate (tegmen) was noted lateral to the superior semicircular canal. Magnetic resonance imaging in the same plane revealed a soft tissue density in the region of the dehiscence that was contiguous with, and isointense with the temporal lobe. This soft tissue density appeared to originate from the temporal lobe, and extended downwards into the upper portion of the mastoid antrum. No enhancement was noted on gadolinium-enhanced T1-weighted imaging (Figure 2). With these imaging findings, a middle fossa encephalocele was considered. Exploratory mastoidectomy confirmed the diagnosis, and the patient subsequently underwent a transmastoid repair of the tegmen and dural dehiscence using both temporalis fascia and mastoid cortical bone, after the herniated brain tissue was amputated.
 A middle fossa encephalocele is a condition of the temporal bone that may arise as a complication of chronic otitis media, temporal bone fractures, or after surgery involving the temporal bone. Although rare, spontaneous middle fossa encephaloceles may also occur.1,2 One must maintain a high degree of clinical suspicion for this condition in an adult patient presenting with a unilateral middle ear effusion or watery otorrhea in the absence of an identifiable cause of otologic disease2 or nasopharyngeal pathology. It should definitely be highly considered if profuse, persistent clear otorrhea is encountered during a myringotomy for what may initially appear to be a chronic middle ear effusion. Surgical treatment of the encephalocele and repair of the skull base defect is generally recommended, as life threatening complications such as meningitis, brain abscess and temporal lobe seizures have been known to occur.2

A Study of Persistent Unilateral Middle Ear Effusion Caused by Occult Skull Base Lesions

The goal of this article is to review a series of patients with persistent unilateral middle ear effusion (MEE) and to suggest a more contemporary diagnostic algorithm. The author conducted a retrospective chart review of adults with persistent unilateral MEE and normal findings on physical and nasopharyngoscopic examinations whose MEE was eventually found to be caused by a variety of occult skull base lesions. The study population was made up of 79 patients—52 women and 27 men, aged 21 to 83 (mean: 54.8) at presentation—who had been referred to an academic tertiary care medical center between July 1, 1988, and June 30, 2008. Follow-up ranged from 9 months to 19.5 years (mean: 8.7 yr). Of this group, 50 patients (63.3%) had a malignant tumor, 26 (32.9%) had a benign tumor, and 3 (3.8%) had an internal carotid artery aneurysm. Eustachian tube occlusion had been caused by diffuse invasion in 33 patients (41.8%), by intracranial pathology in 24 (30.4%), and by extracranial-infratemporal lesions in 22 (27.8%). Nasopharyngoscopy cannot identify a variety of rare skull base lesions that cause eustachian tube compression or tissue invasion that ultimately leads to MEE. Therefore, patients with unexplained persistent unilateral MEE should undergo coronal magnetic resonance imaging or computed tomography to look for any intra- or extracranial lesions before undergoing ventilation tube placement.

A Study of Persistent Unilateral Middle Ear Effusion Caused by Occult Skull Base Lesions

The goal of this article is to review a series of patients with persistent unilateral middle ear effusion (MEE) and to suggest a more contemporary diagnostic algorithm. The author conducted a retrospective chart review of adults with persistent unilateral MEE and normal findings on physical and nasopharyngoscopic examinations whose MEE was eventually found to be caused by a variety of occult skull base lesions. The study population was made up of 79 patients-52 women and 27 men, aged 21 to 83 (mean: 54.8) at presentation-who had been referred to an academic tertiary care medical center between July 1, 1988, and June 30, 2008. Follow-up ranged from 9 months to 19.5 years (mean: 8.7 yr). Of this group, 50 patients (63.3%) had a malignant tumor, 26 (32.9%) had a benign tumor, and 3 (3.8%) had an internal carotid artery aneurysm. Eustachian tube occlusion had been caused by diffuse invasion in 33 patients (41.8%), by intracranial pathology in 24 (30.4%), and by extracranial-infratemporal lesions in 22 (27.8%). Nasopharyngoscopy cannot identify a variety of rare skull base lesions that cause eustachian tube compression or tissue invasion that ultimately leads to MEE. Therefore, patients with unexplained persistent unilateral MEE should undergo coronal magnetic resonance imaging or computed tomography to look for any intra- or extracranial lesions before undergoing ventilation tube placement.

Inverted Papilloma Isolated in the Nasopharynx

Inverted Papilloma (IP) is an uncommon benign sinonasal neoplasm of a particular interest because of its capacity to recur and undergo malignant transformation. It affects usually the lateral nasal wall, but rarely develops in the nasopharynx. We report a case of a well-defined polypoidal lesion of the nasopharynx presented with decreased hearing secondary to unilateral middle ear effusion. It was completely excised through an endoscopic transnasal approach with no clinical evidence of recurrence. A minimally invasive endoscopic technique was deemed the appropriate surgical procedure for the resection of isolated nasopharyngeal benign lesions.

Synchronous spontaneous cerebrospinal fluid leaks in the nose and ear

The majority of spontaneous cerebrospinal fluid leaks occur at the anterior skull base; few cases at the temporal bone have been described. There have been no previous reports of synchronous leaks at the anterior skull base and temporal bone in the same patient. Case report and brief review of management of spontaneous cerebrospinal fluid leaks in the nose and ear. A 34-year-old, pregnant woman presented with watery nasal discharge and unilateral middle-ear effusion. The nasal and ear secretions both proved to be cerebrospinal fluid. Radiological imaging showed defects in both the ethmoid roof and the mastoid roof (middle cranial fossa). These defects were surgically closed using duraplasties. A literature review indicated that this is the first reported case of synchronous spontaneous cerebrospinal fluid leaks via the anterior skull base and temporal bone.

Challenging Problems in Clinical Otology

Program Description: Approximately 35% of office visits in a general otolaryngologic practice are otologic in nature. Simple diagnosis such as cerumen impaction, presbycusis, or acute otitis media are very straight forward and rather easily treated. Other ear-related issues can be more challenging and may require additional office time and resources to manage. This miniseminar will discuss the otologic evaluation and management of progressive SNHL, pulsatile tinnitus, referred otalgia, unilateral middle ear effusion, and osteoradionecrosis of the EAC. While the presentation of these issues may appear benign, they may represent a more serious underlying illness. Emphasis will be placed on a detailed differential diagnosis, and appropriate testing that should be considered by the general otolaryngologist. Audience participation will be encouraged through case presentations. Educational Objectives: 1) Recognize common patient presenting complaints that can be harbingers of a more serious problem. 2) Understand the basic workup that should be performed prior to referring the patient to a subspecialist. 3) Understand the essential treatment protocol that should be instituted prior to a referral.

Unilateral Middle Ear Effusion: An Early Indication of Occult Skull Base Tumors

Unilateral Middle Ear Effusion: An Early Indication of Occult Skull Base Tumors

Hearing levels in infants and young children in relation to testing technique, age group, and the presence or absence of middle-ear effusion.

As part of a prospective study of possible effects of early-life otitis media on speech, language, cognition, and psychosocial development, we evaluated hearing both during episodes of middle-ear effusion (MEE) and when MEE was not present. The objective of this report is to describe age-specific hearing threshold levels in relation to the presence or absence of MEE in a large sample of young children. Participants were 1,055 children drawn from a sample of 6,350 children who were enrolled in the larger study by 2 mo of age. Otologic evaluation of each child was conducted at least monthly. The protocol of the larger study called for hearing evaluations 1) after 8 wk of continuous unilateral or bilateral MEE and every 4 wk thereafter until one test had been conducted when MEE was no longer present; 2) immediately before developmental testing; and 3) in a sample of children without MEE to obtain age-specific normative data. Results are presented by testing technique, age group, and middle-ear condition. In general, hearing threshold levels were highest in the youngest children tested with visual reinforcement audiometry and lowest in the oldest children tested with conventional audiometry. In general also, thresholds were lowest in children with normal middle-ear status, intermediate in children with unilateral MEE, and highest in children with bilateral MEE. On average, the presence of bilateral MEE was associated with hearing threshold levels 10 to 15 dB higher than the normative values for the corresponding age group. In infants and young children, audiometric results are influenced by testing technique, age group, and the presence or absence of effusion in each ear.

Auswirkungen der Therapie von Larynx- und Hypopharynxkarzinomen auf die Funktion der Tuba Eustachii*

In a prospective investigation Eustachian tube function was tested before and after surgery and irradiation of patients suffering from carcinoma of the larynx or hypopharynx. Passive and active tubal parameters were determined using the dual-impedance method in a pressure chamber. In this test, passive tubal function is described by the spontaneous opening and closing characteristics of the tube by an overpressure in the middle ear. Active tubal parameters are determined by the facility of the tube to equalize an over- and underpressure in the middle ear by swallowing. Statistic evaluation was performed with Student's t-test. There were no significant alterations of passive or active tubal function after neck dissection with or without surgery of the primary tumour. On the other hand we observed significant deterioration of all tubal parameters immediately after a series of fractionated percutaneous telecobalt therapy (60 Gy). 2 out of 18 patients developed unilateral middle ear effusion during irradiation which was reversible within 6 months. In most patients we observed a total or at least partial restitution of passive tubal parameters during this time, which was statistically significant. The active tubal function was of minor reversibility. Whereas the facility to equalize a positive pressure in the middle ear was quite good after 6 months, only few patients were able to equalize a negative pressure. The temporary deterioration of passive tubal function may be caused by a marginal implication of the tube at the edge of the irradiation field and by increased lymphatic pressure in tubal tissue following a radiogenic swelling of the lymphatic vessels of the neck.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenoid cystic carcinoma: a comparison between CT, MR and Gd MR imaging techniques

Nasopharyngeal carcinoma continues to be a difficult diagnostic problem in many patients. It is well known that amongst the many and varied manifestations of this disease, a unilateral middle ear effusion in an adult should be regarded with suspicion. Such a case in a 42-year-old patient is presented. In this case the benefit of Gadolinium enhanced magnetic resonance imaging over and above computerized tomography is demonstrated.

The interaction of noise and aspirin in the chick basilar papilla. Noise and aspirin toxicity.

The possible synergism between noise and aspirin for causing cochlear damage was examined histologically. Six chicks fed aspirin for five days and five chicks fed a normal diet only were paired and placed in sound chambers. They were exposed to a 1500-Hz tone at 115 dB sound pressure level for eight hours. The mean serum salicylate level just before noise exposure was 24 mg/dL (1.74 mmol/L). Ten days later they were killed, and the temporal bones were processed. Hair cell counts were made at 100-microns intervals throughout the length of the basilar papilla (cochlea). The noise produced a discrete cochlear lesion centered about 30% of the distance from the base to apex. The addition of aspirin did not significantly alter the extent or location of this lesion. One aspirin-fed chick had a unilateral middle ear effusion, and a striking shift in the center of damage toward the apex was noted in this cochlea.