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We report a case of meningitis due to Neisseria meningitidis group 29E. The organism was serum-sensitive and therefore not expected to be encountered in an immunologically competent young man. Trauma sustained in a road traffic accident 18 months earlier had affected the tympanic membrane and middle ear, allowing direct infection of the meninges. Myringoplasty was performed to prevent recurrent infection.
A retrospective analysis of the medical records of all cases of cholesteatoma in children treated between 1981 and 1996 was performed. The charts of 59 children with cholesteatoma were reviewed. A total of 62 ears received surgery over 15 years. The median follow-up period was 5 years. There were 132 operations. An intact canal wall (ICW) procedure was performed in 29% of the ears in the first stage, a canal wall down (CWD) procedure in 37%, a transmeatal atticotomy (TA) in 21%, a tympanoplasty (T) in 6.5% and a myringoplasty (M) in 6.5% of the ears. The ICW procedure had a higher rate of residual/recurrent cholesteatoma than did CWD (P=0.8), TA (P=0.4), T (P=0.5), and M (P=0.05). The CWD procedure had a lower rate than TA (P=0.7), but a higher rate than T (P=0.6) and M (P=0.09). Lastly, TA had a higher rate than T (P=0.7) and M (P=0.1). Auditory results were similar for type II and type III reconstructions (P=0.5). An air-bone gap of less than 20 dB was achieved in 51% of the ears, and 80% had a gap of less than 40 dB. We found a clear difference, although not statistically significant, in the personal rate of recurrent cholesteatoma. It was 26% for surgeons who had performed more than 350 otological surgeries and fell to 15% for the most-experienced surgeon (1715 operations). It rose to 34% for the less experienced surgeons (P=0.8). We recommend that surgery for children with cholesteatoma be reserved for experienced surgeons.
Since 1981, we have used the stapes allograft, singly or in combination with homograft incus, in 20 cases of tympanoplasty and in 7 cases of fixed stapes. All of the allograft stapes discussed were procured, processed and stored in 1980 by the Hyogo Ear Bank, the first to be established in Japan. The stapes allograft was used in three situations: an intact posterior canal wall, an open mastoidectomy cavity, or a fixed stapes (postinflammatory, congenital or otosclerotic). Two modalities of positioning of the donor stapes were attempted: (1) the allograft stapes was placed in the normal position and a shaped incus or cortical bone or tragal cartilage was placed on the top of the stapedial head and connected and (2) the allograft stapes was placed in the upside-down position and the columella was placed on the stapes footplate. Better results were obtained with the allograft stapes placed in the normal position. A two-stage operation, first to place an allograft stapes in the normal position with myringoplasty and then ossiculoplasty, was preferable to one-stage middle ear surgery.
The external ear canal may be occluded by a rare tumor of the tympanic membrane. We reported herein a case of solid schwannoma arising from the tympanic membrane of a 29-year-old man. It presented as a circumscribed and encapsulated tumor of the external ear canal. The definite diagnosis was based on a careful microscopic examination and pathological findings. A precise excision of the tumor together with part of the tympanic membrane, followed by a myringoplasty was performed. To the best of our knowledge, our case should be the first reported case of this entity in the world literature.
The methods, results, and indications for operation on only hearing ears are discussed on the basis of 13 patients operated upon for chronic otitis media and its sequelae. Although good results were obtained, with an air-bone gas closure within 15 dB. in 77 per cent, this should not serve as propaganda for the general use of surgery on only hearing ears. On the other hand, they show that surgery on only hearing ears should not be rejected a priori and that on certain indications and under c ertain circumstanc es it may be carried out with minimal risk of aggravating the hearing loss. In most of the patients the indication for surgery was a progressing cholesteatoma, in some cases the sequelae of otitis, either in the form of myringoplasty or type II tympanoplasty, and one patient had the operation on a vital indication. To avoid postoperative exacerbation of the hearing, the patients must be strictly selected, the ears have to be pretreated conservatively, the Eustachian tube must be passable, the operation must be carried out by the most experienced otosurgeon, and thoroughly tested, very gentle operative methods must be used.
The late results of one stage operation for middle ear tymanosclerosis in 73 patients during the period January 1965 to December 1980 are presented. Mean observation time was 11.2 years (range 3-20.2 years), with a follow-up rate 86 per cent. Among 64 patients with stapes fixation, 59 had removal of tympanosclerotic masses and stapes mobilization, and five cases underwent stapedectomy. The series was divided into six groups and the results analyzed. The best and most stable results occurred in the group with stapes mobilization and an intact ossicular chain followed by the group with stapes mobilization and Type II tympanoplasty with incus interposition. The poorest late results were obtained in ears with lacking stapes crura and stapes mobilization, and in ears subjected to stapedectomy. No case of post-operative sensorineural hearing loss occurred. We recommend that care is taken to preserve an intact ossicular chain at stapes mobilization performed at the same stage as myringoplasty. Also in ears with a defective ossicular chain but intact stapes with tympanosclerotic fixation we recommend stapes mobilization in one stage. In ears with fixation of the stapes footplate and defective crura, we recommend stapedectomy or stapedotomy in two stages.
Since good ventilation of the middle ear is a pre-requisite for successful myringoplasty, it was our policy to investigate the tubal function in dry central perforation of the eardrum and to correlate the manometric and endoscopic findings. Nasal endoscopy proved to be indispensable in diagnosing mechanical tubal obstruction and in localizing and even treating 'hidden' lesions in key areas, with probable normalization of the tubal function. The correction of the mechanical tubal obstruction must precede ear surgery. Whenever tubal obstruction is diagnosed as functional or idiopathic, the ventilation of the middle ear should be guaranteed during ear surgery by addition of a tympanostomy tube to the graft or drum remnant, and a guarded prognosis given.
Thirty consecutive patients with permanent perforations of their tympanic membranes (TM) present from 2.5 to 50 years (mean 18.7 years) were admitted to a prospective study using two alternative methods of dressings for closure of the perforations. An adhesive-coated hydrocolloid material was compared with a conventional dressing of vaseline impregnated rice paper patch after de-epithelialization of the perforation border. Nine of the permanent TM perforations (30 per cent), five with the hydrocolloidal dressing and four with the rice paper patch had healed when followed-up after one year. The size of eight of the central perforations that had healed was equal to or less than 25 per cent of the TM. Also one perforation with a size of 65 per cent had healed. Seven perforations were located in the posterior part of the TM: four in the posterior-superior quadrant, one in the inferior quadrant, one had engulfed the posterior half of the TM and one included the anterior-inferior quadrant. Only two perforations out of 14, with a size of 25 per cent or less, located in the anterior-inferior quadrant, healed. No significant difference was demonstrated between the two types of dressings. Both groups noted an immediate improvement in hearing of 10.8 and 9.3 dB, respectively, after application of the dressing. The study demonstrates that application of an occlusive dressing or paper patch in 30 per cent of patients can promote the healing of long-standing perforations. The chances for healing are better if the perforation is located in the posterior part of the TM. This simple technique immediately improved hearing and should be tried before a patient is referred for myringoplasty surgery.
Schwannoma arising from the tympanic membrane is a rare neoplasm. This report describes an external ear canal mass obscuring the tympanic membrane. A transcanal approach identified a tumour adhered to the tympanic membrane. The tumour was excised without myringoplasty. Pathology confirmed the diagnosis of schwannoma. Clinical examination revealed no evidence of recurrence during a follow-up period of one year. The possible origins of schwannoma of the tympanic membrane and lesion management are also discussed.
BACKGROUND: This report presents the long-term results of a special surgical technique in cases of persistent severe dysfunction of the Eustachian tube. PATIENTS AND METHODS: We performed this operation on 16 patients (18 ears) between 1982 and 1997. Almost all patients had undergone previous surgery. This included myringotomies and tube insertions, adenoidectomies, tonsillectomies, myringoplasties and mastoidectomies, sinus surgeries, and an operation on a cleft palate. The concept developed by one coauthor (Draf) combines different methods to improve ventilation of the middle ear and protect the eardrum against partial vacuum. The concept combines mastoidectomy, posterior tympanotomy, and removal of the incus and the head of the malleus with an interposition of the incus. The tympanic membrane is then stabilized with a cartilage-perichondrium graft, and a tube is placed leading from the tympanic cavity to the nose (Wright-tube). A T tube may also be used. The procedure was varied slightly on occasion depending on intraoperative findings. RESULTS: Thirteen patients (15 ears) were available for audiometry at a minimum of 5 months after surgery until 14 years (mean duration of 6.2 years). We compared preoperative and postoperative air-bone gaps. They were measured for the three speech frequencies (500, 1000, and 2000 Hz) at 5 dB intervals. The average preoperative air-bone gap was 25.7 dB versus 18.2 dB postoperatively. This represents an improvement of 7.5 dB. Seven of fifteen ears required revision. Six ears required one revision procedure each (three for cholesteatoma, one for myringitis, one for discharge due to a narrow external auditory meatus, and one for mastoiditis). Another patient required three revision procedures (one for mastoiditis and the other two for cholesteatoma). CONCLUSION: This concept can help prevent cholesteatoma and improve hearing in more than 50 per cent of severe cases of dysfunction of the Eustachian tube.
BACKGROUND: In myringoplasty or tympanoplasty, fascia of the temporalis muscle and perichondrium or cartilage-perichondrium composite grafts are most commonly used to reconstruct the tympanic membrane (TM). Primary failures or recurrent perforations in the anterior part of the TM frequently occur in cases of eustachian tube dysfunction or total perforations of the TM. The purpose of this paper is to introduce a perichondrium-cartilage composite graft for closure of total perforations of the TM. Twenty-one patients (17 adults, 4 children) were included in this study, all of whom had a total perforation of the TM. METHODS: An oval shaped piece of cartilage with perichondrium on one side was harvested from the cavum conchae. The cartilage was cut in the shape of a U without removing the inner layer of perichondrium. The inner diameter of the cartilage ring should be nearly the same as the diameter of the tympanic ring. This cartilage framework stabilizes and fixes the perichondrium and prevents the perichondrium from subsiding into the middle ear cavity. Shrinking of the perichondrium is also reduced by the cartilage ring. In all patients introduced in this study, the TM was closed and no residual perforation occurred. The hearing results in tympanoplasty were the same as in other techniques with a residual air-bone gap of about 20 dB. CONCLUSIONS: This technique seems to be a valuable method for the closure of total perforations of the TM. Especially in perforations near the anterior anular region the underlay technique with fascia or perichondrium is an uncertain method. The soft material which is only fixed by adhesion can easily be displaced during wound healing. The hearing results are comparable to that achieved in other techniques. Further studies with greater number of patients are necessary to assess long term results.
OBJECTIVES: The study goal was to assess the success rate and efficacy of a myringoplasty (tympanoplasty type I) technique using a composite chondroperichondrial graft in a combined overlay-underlay fashion. STUDY DESIGN: A retrospective analysis of patients subjected to the technique was conducted. METHODS: A sample of 15 patients who met the inclusion criteria were reviewed for surgical results. All patients were treated by a single surgeon. RESULTS: This transcanal technique provides minimal morbidity and excellent results in selected patients. CONCLUSIONS: The described technique provides an effective method of closing nonmarginal perforations of the tympanic membrane.
OBJECTIVE: Because it is necessary to maintain controlled hypotension during middle ear surgery in order to avoid bleeding and as it is known that cochlear blood flow (CBF) is related to blood pressure (BP), it is useful to evaluate CBF modifications induced by anaesthetics in order to prevent cochlear damage. The aim of this paper is to evaluate, using laser Doppler flowmetry, which anaesthetic drug, out of sevoflurane and propofol, has the smallest effect on CBF. MATERIAL AND METHODS: Twenty consenting adult patients scheduled for myringoplasty under general anaesthesia for simple tympanic membrane perforation were studied. Patients were divided into two groups: the first group was treated with sevoflurane and the second with propofol. For the first group, CBF measurement was carried out on three different occasions: (i) at a basal low drug dosage; (ii) having increased the drug dosage to a higher level; and (iii) having reduced the drug dosage to the basal low level again. For the second group, CBF measurement was carried out on three different occasions: (i) 10 min after injecting a bolus of propofol; (ii) immediately after a second propofol injection; and (iii) 10 min after a third injection of propofol. A probe was placed over the promontory in order to measure CBF levels. RESULTS: In the subjects treated with sevoflurane, after having increased the drug dosage, BP decreased significantly while CBF did not change significantly. In the subjects treated with propofol we recorded a significant reduction in BP, as well as a decrease in CBF. CONCLUSION: The results obtained show that sevoflurane has a hypotensive effect without modifying CBF, while propofol, although having a similar effect on BP to sevoflurane, has less of a protective effect on inner ear microcirculation.
In the present structural study the authors investigated the border of permanent tympanic membrane (TM) perforations in patients selected for myringoplasty. Furthermore, a panel of monoclonal antibody markers that recognize different epitopes within glycosaminoglycans as well as antibodies to epidermal growth factor and fibronectin were applied to the sections. In half of the specimens the epithelial junction ended at the inside of the perforation border, whereas in the other half it was located at the perforation border itself. In the junctional area the keratinocytes were covered by a thick keratin layer which protruded as a spur centripetally in order to bridge the perforation. Epidermal cells formed papillae and contained remnants of keratinocyte nuclei that showed similarities to those of the skin in inflammatory conditions. The connective tissue layer was fibrous and showed areas containing sclerotic plaques. The inner epithelium of the TM had abundant ciliae, thus supporting the concept that cells of the mucosal lining of the TM are able to differentiate in inflammatory conditions into ciliated cells and secretory cells. The immunoreactivity of hyaluronan and other glycosaminoglycans, the immunoreactivity of epidermal growth factor, and immunoreactivity of fibronectin, all of which are known to occur in healing wounds, were only scantily demonstrated; this could be one reason for the arrested healing and a reason why the natural drive to complete a mature closure is abandoned.
Management of the chronically draining ear requires careful assessment as to the source and predisposing factors leading to recurrent infections. Surgery should be planned to remove all irreversible disease and to seal the middle ear in a single operation, whether this requires a simple myringoplasty or extensive mastoidectomy, ossicular chain reconstruction, and tympanoplasty. Before surgery, every effort should be made to control the infection medically. After surgery, periodic irrigation with acetic acid alcohol will help to keep the ear clean and trouble-free. This paper will describe an approach to the assessment and management of the chronically draining ear in a single operation.
HYPOTHESIS: The goal of this study was to evaluate the effects of hyaluronic acid, epidermal growth factor, and mitomycin C on the healing of acute experimental traumatic perforations of the tympanic membrane. BACKGROUND: Most acute perforations of the tympanic membrane heal spontaneously. However, some form of surgical treatment (i.e., myringoplasty) is needed for nonhealing perforations. Because the closure occurs by squamous epithelial migration, drugs that stimulate this regenerative process may aid in the closure of the perforation, obviating the need for more extensive treatments. METHODS: Bilateral perforations of the tympanic membrane were created in 30 rats, divided into three groups (A, B, C). The perforations in the right ears were treated with hyaluronic acid, epidermal growth factor, or mitomycin C. Those in the left ears were left untreated for comparison. To examine the healing process in different periods, 5 animals were killed in each group at days 3, 5, 7, 9 and 14. The other 5 animals in each group were observed daily to determine the duration of perforation closures. Thirty surgical specimens (5 right sides from each group and all 15 left sides in all groups) were histopathologically examined for tympanic membrane thickness, fibroblastic reaction, neovascularization, and crust morphology. RESULTS: Hyaluronic acid and epidermal growth factor applications significantly shortened the healing in acute experimental traumatic perforations of the tympanic membrane (p = 0.0432); however, the difference between them was not significant (p = 0.3160). On the other side, tympanic membrane perforations treated with topical mitomycin C showed no evidence of closure. There were no significant differences in the histologic parameters between the treated groups and their contralateral control ears. CONCLUSION: Hyaluronic acid and epidermal growth factor accelerated the closure of acute tympanic membrane perforations in rats. This may make them clinically useful in augmenting the efficiency of conservative treatments of acute perforations of the tympanic membrane.
OBJECTIVE: To discuss the clinical aspects and management of promontory fistula of the cochlear labyrinth. STUDY DESIGN: Case report and review of the literature. SETTING: University hospital, tertiary referral center. PATIENT, INTERVENTION, AND RESULTS: The authors describe an unusual case of cochlear fistula localized to the promontory discovered during tympanoplasty for noncholesteatomatous chronic otitis media in a 59-year-old woman. Bone conduction was slightly impaired after operation and hearing improved after a revision myringoplasty performed for reperforation. CONCLUSION: Erosion of the bone of the labyrinth can also be observed in noncholesteatomatous otitis media. The presence of a fistula is not always associated with profound hearing loss. Overlying pathologic tissue can be removed without damaging the membranous labyrinth.
A new method is presented for the measurement of ear canal pressure changes in response to tympanic membrane volume displacements, i.e. the pressure-volume relationship (PVR) of the middle ear system. This method has several advantages when compared to tympanometry; for example, it avoids phase delay and hysteresis can be used as a variable thanks to bidirectional recordings. Moreover, dynamic compliance is registered physically as changes in volume relative to pressure. Normative data for 39 subjects are summarized along with preliminary data from patients exhibiting various clinical conditions. The major findings are that secretory otitis media with middle ear effusion results in significantly increased hysteresis (leading to large errors when middle ear pressure is determined by tympanometry), two types of ossicular discontinuity may be distinguished by this method and that myringoplasty leads to a linear PVR in contrast to the nonlinearity found in normal subjects.