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PubMed1998

Mastoid pneumatization in children with congenital cholesteatoma: an aspect of the formation of open-type and closed-type cholesteatoma.

OBJECTIVES: To clarify mastoid pneumatization in children with congenital cholesteatoma and compare their clinical characteristics. STUDY DESIGN: The mastoid pneumatization of 34 children with congenital middle ear cholesteatoma, of 34 age-matched children with unilateral acquired cholesteatoma, and of 17 age-matched control children without middle ear diseases was studied. METHODS: The sizes of the mastoid cells were measured from 1.5-mm sliced semiaxial sections of a temporal bone computed tomography scan. The sum of the two areas from the two images, one showing the lateral semicircular canal and the other, 3 mm below this, was defined as the area of the pneumatized mastoid cells. RESULTS: The mastoid cells in ears of children with congenital cholesteatoma were poorly pneumatized compared with those of control children without middle ear diseases, but were better pneumatized compared with those of children with acquired cholesteatoma. In children with congenital cholesteatoma, the degree of pneumatization in the cholesteatoma side was significantly poorer than that in the opposite side. A well-pneumatized mastoid was seen in ears with no episode of otitis media, in ears with the open-type cholesteatoma, and in ears with ossicular anomalies. CONCLUSIONS: The presence of cholesteatoma matrix accelerates the inflammatory response when middle ear infections occur, and this probably leads to the suppression of mastoid pneumatization. The authors also propose the hypothesis that cholesteatoma in most congenital cases is the open type, and that middle ear inflammation may contribute to the formation of cystic and closed-type cholesteatoma.

Adolescent↗

PubMed2000

Structural changes and protein expression in the mastoid bone adjacent to cholesteatoma.

OBJECTIVE: Cholesteatoma of the mastoid and middle ear causes erosion of nearby bone. In this study we examined the mastoid bone adjacent to cholesteatoma and compared it with normal mastoid bone. In particular, noncollagenous proteins, which have a special structural and functional role in bone, were addressed. STUDY DESIGN: Nine mastoid specimens with cholesteatoma and four normal specimens obtained at surgery were examined. METHODS: Histological and immunohistochemical methods were employed to evaluate the nature of structure and noncollagenous protein content changes in the mastoid bone affected by cholesteatoma. RESULTS: The bone associated with cholesteatoma had structural changes as a noncontinuous periosteum, empty lacunae, irregular cement lines, and, specifically, the appearance of eosinophilic vesicles at the interface between the bone and cholesteatoma Immunohistochemistry demonstrated that noncollagenous proteins were apparently absent in the affected mastoid bone. Bone remote from the cholesteatoma seemed normal. CONCLUSIONS: These findings demonstrate for the first time the changes in the noncollagenous protein content in the mastoid bone affected directly by cholesteatoma These changes could be a result of a direct influence of cholesteatoma-derived products on the osteoblast.

Adolescent↗

PubMed2001

Acute mastoiditis in children: a seventeen-year experience in Dallas, Texas.

BACKGROUND: In the preantibiotic era acute mastoiditis was the most common complication of acute otitis media, often resulting in substantial morbidity and mortality. Since 1989 several investigators have documented an increased frequency of acute mastoiditis in children. METHODS: The medical records of all children with a discharge diagnosis of acute mastoiditis, managed at Children's Medical Center, Dallas, TX, from 1983 through 1999 were reviewed. RESULTS: There were 57 cases of acute mastoiditis during the 17-year period of 1983 through 1999 compared with 57 cases in a 25-year period of 1955 through 1979 reported previously at the same institution. The number of cases of acute mastoiditis per 10,000 hospital admissions increased significantly (regression analysis P = 0.003) during the more recent 17 years. From 1993 through 1999 there were 4.5 cases or more per 10,000 admissions each year, whereas from 1983 through 1992, the incidence never exceeded 4.3 cases per 10,000 admissions (P = 0.018). The median age of the patients was 48 months. Twenty-two patients (38.5%) were younger than 24 months; 17 of these were 12 months of age or younger. Twenty-two (38.5%) patients had no history of previous episodes of acute otitis media. Streptococcus pneumoniae was the pathogen most often isolated from the cultures. Complications of mastoiditis occurred in 20 children (35%). CONCLUSIONS: We conclude that acute mastoiditis continues to be a problem in the post antibiotic era. It occurs mainly in young children and can be the first evidence of ear disease.

Acute Disease↗

PubMed2004

The use of demineralized bone matrix for mastoid cavity obliteration.

OBJECTIVE: To evaluate the use of demineralized bone matrix as a graft material for mastoid cavity obliteration in the treatment and prevention of problematic mastoid cavities. STUDY DESIGN: The study is a retrospective review of patients identified using a computerized otology database. SETTING: Tertiary care referral center. PATIENTS: Patients were included in this study if they underwent mastoid obliteration using demineralized bone matrix. INTERVENTION: Mastoid obliteration was performed for revision of a problematic mastoid cavity (n = 8) or primarily after canal wall down mastoidectomy for recurrent cholesteatoma (n = 3). MAIN OUTCOME MEASURES: Data were collected to evaluate the ability to achieve a dry ear canal. Postoperative healing time and hearing results were also assessed. RESULTS: A dry ear canal was achieved in all patients with a follow-up of 6 to 20 months (average, 14.5 mo). Eight patients (73%) had a well-healed, dry ear canal by their first postoperative visit (9 wk). One patient required 12.5 weeks to heal. Two patients (18%) had more prolonged granulation at the ear canal incision, which resolved in 17 and 28 weeks, respectively. The average preoperative pure-tone average air-bone gap was 47 +/- 14.9 dB (mean +/- SD), compared with postoperative values of 27.6 +/- 12.8 dB (p = 0.0033; paired t test). This represents an average pure-tone average air-bone gap closure of 20 dB. CONCLUSION: The use of demineralized bone matrix as a graft extender in mastoid obliteration allowed creation of a dry, smooth-contoured canal in all patients studied. A significant improvement in hearing was also obtained. Demineralized bone matrix is an acceptable graft alternative for mastoid obliteration.

Adolescent↗

PubMed2004

Postauricular periosteal-pericranial flap for mastoid obliteration and canal wall down tympanomastoidectomy.

OBJECTIVE: To describe an effective technique for mastoid cavity obliteration in canal wall down tympanomastoidectomy for chronic otitis media and review its efficacy in producing a dry, low-maintenance, small mastoid cavity. DESIGN: : Retrospective clinical study of a consecutive series of procedures from 1995 to 2000. SETTING: Tertiary referral center and institutional academic practice in otology and neurotology. PATIENTS: Sixty consecutive procedures for active chronic otitis media with a minimum follow-up of 12 months (mean, 31 mo; range, 12-80 mo). INTERVENTION: All patients had canal wall down mastoidectomy with simultaneous tympanoplasty including split-thickness skin grafting. An inferiorly pedicled, periosteal-pericranial flap was used in conjunction with autologous bone pate to obliterate the mastoid cavity. The additional length provided by the pericranial extension of the flap permitted it to reach superior to the lateral canal and into the sinodural angle, with improved coverage of bone pate and better reduction of cavity size. OUTCOME MEASURES: The primary outcome measure was control of suppuration and creation of a dry, low-maintenance mastoid cavity, which was assessed using a previously developed semiquantitative scale. This scale includes a temporal dimension to assess control of infection. Secondary outcome measures included postoperative complications (i.e., hematoma, infection, flap necrosis, and meatal stenosis) and incidence of recurrent or residual cholesteatoma. RESULTS: Forty-nine ears (82%) maintained a small, dry, healthy mastoid cavity. Five ears (8%) had intermittent otorrhea easily controlled by topical treatment. Six ears (10%) had suboptimal control of otorrhea, of which four had meatal stenosis. There were no residual or recurrent cholesteatomas. Outcomes remained stable over progressively longer follow-up, up to 80 months. CONCLUSION: Obliteration of a canal wall down mastoid cavity by a postauricular periosteal-pericranial flap with autologous bone pate is a reliable and effective technique that results in a dry, trouble-free mastoid cavity in 90% of patients with active chronic otitis media.

Adolescent↗

PubMed2005

Aural barotrauma in submarine escape: is mastoid pneumatization of significance?

OBJECTIVE: Submarine escape training is carried out by preselected, healthy young men under strictly controlled conditions regarding exposure to pressure and the rate of pressure change. This provides a unique opportunity to investigate the relations between middle ear characteristics and susceptibility to barotrauma while avoiding possible confounding parameters. We examined a possible association between mastoid pneumatization and middle ear barotrauma (MEB) in submarine escape trainees. STUDY DESIGN: Cross-sectional, parallel-group design. METHODS: Sixty-six subjects aged 19 to 28 participated in the study. The escape simulation included pressurization to 30 or 60 feet followed by a buoyant ascent to the surface. Subjects were evaluated for MEB after each ascent. A Schuller's mastoid radiograph was taken for the evaluation of mastoid pneumatization. RESULTS: Fifteen (23%) of the subjects suffered from MEB, and 6 (40%) of them had bilateral involvement. Repeated impedance audiometry after the completion of a successful ascent revealed a significant increase in middle ear compliance. Schuller's radiographs were obtained from 49 (74%) of the subjects. Of these radiographs, 16 (16%) were of ears that had suffered MEB. Mastoid pneumatization for all ears approached a normal Gaussian distribution, with a mean area of 9.58 cm. The mastoid areas and the proportion of ears with mastoid pneumatization at the extremes of the study population did not differ between barotrauma and no-barotrauma ears. CONCLUSION: In a population with no history of recurrent or chronic otitis media and normal tympanic membrane morphology and compliance, the amount of mastoid pneumatization probably represents merely the normal distribution of variation in organ size and is not related to the ability to equalize pressure in the middle ear.

Acoustic Impedance Tests↗

PubMedDate not supplied

Surgery of the mastoid in ears with middle ear effusion.

It has been demonstrated that in most ears with middle ear effusion the mastoid air cells may be involved as well. The mucosal changes and the secretion extends into all cavities of the ear including the mastoid air cells. In most ears insertin of a ventilating tube through the tympanic membrane is adequate for proper aeration of the middle ear as well as of the mastoid air cell system. The draining usually stops and the mucosa gradually changes into its normal condition. In a small percentage of these, the ear will continue to drain and the mastoid will not clear up. Antibiotics and decongestants fail to cure the ear. Surgical intervention of the mastoid may be indicated in the rare cases where conventional treatment fails to control the condition. The aim of this report is to 1) focus attention to the fact that the mastoid is an integral part of the middle ear cavity; 2) discuss the pathogenesis in stubborn ears with middle ear effusion; and 3) demonstrate the surgical procedure commonly used in our department in order to reestablish aeration of the mastoid air cell system. Early recognition and proper treatment of ears with middle ear effusion will hopefully reduce the incidence of stubborn cases and also decrease the number of those cases which end up with chronic otitis media and cholesteatoma. It is hoped that the screening programs involving school and even preschool children, as well as new preventative programs, will diminish the frequency of cases which need extensive surgery as discussed in this paper.

Ear, Middle↗

PubMedDate not supplied

Subperiosteal mastoid abscesses in chronic suppurative otitis media.

In Europe and America, acute mastoiditis usually appears as a complication of acute otitis media, and some patients develop subperiosteal mastoid abscesses. In Nigeria, however, most subperiosteal mastoid abscesses develop from chronic otitis media with cholesteatoma. Of the 16 patients with subperiosteal mastoid abscesses discussed, 11 (69%) had cholesteatoma and only five (31%) had granulation tissue in the mastoid cavity. The ideal treatment for these cases is modified radical mastoidectomy. Radiographic investigation of the mastoid can be useful in the diagnosis of cholesteatoma in the presence of a subperiosteal mastoid abscess.

Abscess↗

PubMed1994

[Mastoid pneumatization after blocking the aeration route through the eustachian tube].

In the mastoid air cell system, air has been thought to be supplied only through the eustachian tube and tympanic cavity to the cells, and to be absorbed continuously in one direction through the lining mucosa of the mastoid air cells. In the ear with a blocked air supply route to the mastoid air cell system, gas in the blocked mastoid air cells has been thought to be absorbed and to be replaced by exudate. Recently, several observations have supported the existence of gas exchange not only through the eustachian tube but through the lining mucosa in the mastoid. To clarify gas exchange in mastoid air cells, tympanic cavities of the infant piglet, the tympanic bullae of which is similar to the human mastoid air cell system, were filled with jellied adhesive, an alpha-cyanoacrylate monomer, to block the aeration route to the air cells, and tympanic bullae were examined histopathologically. Group 1: Injection of adhesive into the tympanic cavity 1 month after birth following glycerin injection at 1 week after birth. Group 2: Injection of adhesive 1 month after birth without any prior injection into the tympanic cavity. Group 3: Injection of adhesive 3 months after birth without prior injection. In group 1, remarkable inflammation was subsequently observed in the tympanic bullae, development of the air cell system was markedly inhibited and very few air cells remained intact. In groups 2 and 3, however, inflammatory reactions were relatively mild normal air cells remained on the periphery and development of the air cell system was not interrupted.(ABSTRACT TRUNCATED AT 250 WORDS)

Adhesives↗

PubMed2000

Mastoiditis: a disease often overlooked by pediatricians.

Although mastoiditis can be a life threatening disease, clinicians often overlook it because it is uncommon. We reviewed the presentation and management of all children younger than 15 years of age with the discharge diagnosis of mastoiditis in our hospital from January 1994 through December 1999. Nineteen patients that fulfilled the case definition were included. The most common clinical presentation in this series was fever. More specific findings, such as otorrhea, postauricular pain, swelling, and redness of mastoid could be found in less than half of these patients. Only two patients had characteristic physical findings, and mastoiditis was diagnosed in only three patients upon admission. Plain radiographic evidence of mastoiditis was usually not apparent early in the course. In this series, the majority of patients were diagnosed by computed tomography (CT) scans. The present study demonstrates that mastoiditis most commonly presents without a clearly diagnostic set of physical examination and laboratory findings. Mastoiditis should be considered in patients with otitis media or with fever of unknown origin (FUO). The empirical antibiotic treatment should cover organisms commonly found in acute otitis media (AOM), including Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.

Adolescent↗

PubMed1993

[Masked mastoiditis].

Masked mastoiditis defines a subclinical infectious inflammatory process of the mucosal lining and the bony structure of the mastoid air cells, with intact tympanic membrane. It follows an apparently well-treated recent acute otitis media. Because of obstruction of the tympanic diaphragm by mucosal swelling, polypoid mucosa or granulation tissue, a complete separation of the tubo-tympanic cavity from the mastoid air cell system results. The latter remains unaereated and the local infectious mucosal disease progresses to osteitis. Probably due to colonizing flora in this unventilated media, the developing bone infection is low-grade, without pus formation. The clinical features of the disease are not overt as those in coalescent mastoiditis. The intact ear drum does not reflect the severity of bone-eroding disease within the mastoid. Since this disease is characterized not by exudative but by proliferative changes, there is no pus formation. The incidence of complications is high. Plain x-ray and CT scan do not specifically define the disease process, but bone scan indicates the bone-invading nature of the mastoid infection. The osteoblastic reaction secondary to osteitis is demonstrated by high uptake of the isotope in the involved mastoid. Antibiotics may cure the disease, but in most cases surgery is unavoidable.

Adolescent↗

PubMedDate not supplied

[Influence of secretory otitis media on mastoid pneumatization. Multiple regression analysis].

The influence of secretory otitis media (SOM) on mastoid pneumatization was studied in 122 ears of 61 children under 15 who were seen at our clinic two times. Age, tympanometry, mastoid size, and time between visits were analyzed. Multiple regression analysis yielded and equation relating age and SOM with mastoid size at first examination. Another regression equation explained the contribution of SOM resolution or persistence and age on mastoid size at the time of the second examination. This equation explained 76.14% of the variability in mastoid size and showed that normal ears had better mastoid growth than children with SOM. Even thought inflammation resolved with medical or surgical treatment, mastoid pneumatization was more developed in normal subjects.

Acoustic Impedance Tests↗

PubMed1998

Cause of posterior canal wall retraction after surgery from the viewpoint of mastoid conditions.

OBJECTIVE: To determine the relationship between preservation of the mastoid mucosa during ear surgery and retraction of the attic or posterior wall of the external auditory canal (EAC) and mastoid aeration after surgery. METHODS AND DESIGN: Retraction of the posterior EAC wall and mastoid aeration were evaluated after surgery in 48 individuals (50 ears) with cholesteatoma, adhesive otitis media, or chronic suppurative otitis media, in whom the posterior bony EAC walls were removed with or without preservation of mucosa and reconstructed with soft tissues alone (EAC skin and temporal fascia) during surgery. RESULTS: Postoperative computed tomography showed that in ears with notable retraction of the posterior EAC wall appearing like an open mastoid cavity, there was no air in the mastoid, whereas in ears with no or only slight retraction there was computed tomographic evidence of mastoid aeration. Second, notable retraction of the posterior EAC wall occurred in a significantly smaller percentage of ears in which at least the epitympanic mucosa had been able to be preserved during surgery than in those that had undergone removal of all mucosa (mastoidectomy). CONCLUSIONS: These results indicate that 1) preservation of epitympanic mucosa during surgery is an important factor for prevention of retraction of the posterior EAC wall and for reaeration of the mastoid after surgery, and 2) the intact canal wall technique seems to be indicated whenever at least the epitympanic mucosa can be preserved, and when no mucosa can be preserved the canal wall down procedure seems to be indicated.

Adult↗

PubMed1995

Nontuberculous mycobacterial mastoiditis.

Although nontuberculous mycobacterial (NTM) infections are recognized as an important cause of cervicofacial lymphadenopathy in children, NTM mastoiditis is rare. Further, NTM mastoiditis may be difficult to distinguish clinically from tuberculous mastoiditis since both may present with chronic, painless otorrhea and exuberant middle ear granulation tissue. The treatment of tuberculous mastoiditis is antituberculosis chemotherapy; however, most NTM infections are resistant to antituberculous agents, and the preferred treatment of NTM mastoiditis is mastoidectomy. We report a recent case of mastoiditis caused by Mycobacterium avium complex in an infant who presented with a temporal bone mass.

Child↗

PubMed1999

Factors affecting recovery of mastoid aeration after ear surgery.

Fifty-six patients after tympanomastoid surgery were examined to determine recovery of mastoid aeration and various pre- and intraoperative factors such as eustachian tube (ET) function, how the mastoid mucosa had been treated during surgery and whether or not a large silastic sheet had been placed in the middle ear or a ventilation tube used. Mastoid aeration recovery was confirmed by computed tomography in 27 of the 57 cases (47%) within 12 months of surgery. Among the factors examined, preservation of the epitympanic mucosa was found to be most important in mastoid aeration recovery. Use of a large silastic sheet to cover the area from the bony ET and tympanic cavity to epitympanum, aditus ad antrum or antrum was found to be of some help in recovery mastoid aeration after complete resection of the mucosa and mastoid air cells. Preoperative ET function, anterior tympanotomy and use of a ventilation tube did not influence recovery.

Adolescent↗

PubMed2000

Experimental results do not support a gas reserve function for the mastoid.

The mastoid is an aerated extension of the middle ear gas pocket whose state of development was shown to be an indicator of past and future otitis media experience. While the function(s) of the mastoid is not known, a number of hypotheses has been advanced to explain the reported association between mastoid size and middle ear disease. These include the hypotheses that, with respect to the middle ear, the mastoid functions as a pressure buffer, a gas reserve, and/or a pressure regulator. In this paper, a physical model of the mastoid is presented that makes specific predictions against which the validity of the hypothesized gas reserve function could be tested. Data from three published clinical experiments were evaluated for consistency with the predictions of the model, and the hypothesis was rejected. Also, when reinterpreted within the context of the model, the published data do not support a pressure-regulating function for the mastoid.

Ear, Middle↗

PubMed2003

Day-case paediatric mastoid surgery.

OBJECTIVE: Children have traditionally been kept in hospital overnight after mastoid surgery, but evidence from the US in adults suggests that a substantial number of patients may be suitable for discharge on the day of surgery. We sought to ascertain the proportion of our children having mastoid operations between February 1994 and December 2000 who were suitable for same-day discharge. We also evaluated some of the factors that prevented discharge the same day. METHODS: A standard proforma was used to record relevant data in 35 children (mean age 10 years 6 months) undergoing consecutive mastoid operations at Mayday University Hospital, London, UK. Operative findings, duration of anaesthesia and time back on ward were recorded as well as details regarding admission, follow-up findings and complications. A bed was booked preoperatively but there was intent to discharge the patient if feasible. RESULTS: Nine out of twelve patients (75%) operated between 1998 and 2000 were suitable for discharge on the day of surgery. The pre-1998 discharge rate was 20%. Only one of the former group of patients underwent a modified radical mastoidectomy in comparison with ten such procedures pre-1998. There was a significant relationship between extent of surgery and in-patient admission. The outcomes of day-case mastoid surgery, in terms of complications rates and overall success rates, were comparable with surgery performed on an in-patient basis. Using correlation analysis, no relationship could be found between duration of anaesthesia and time of arrival back on the ward and in-patient admission. CONCLUSION: Children can undergo mastoid procedures safely and effectively on a day-case basis but should still have a bed booked pre-operatively as the majority will require admission. The main factor related to admission was the mastoid procedure performed. With improvements in surgical and anaesthetic techniques and other advances, operations such as atticotomy may become standard day-case procedures in paediatric patients.

Ambulatory Surgical Procedures↗

PubMed2003

Rate of nitrous oxide exchange across the middle ear mucosa in monkeys before and after blockage of the mastoid antrum.

OBJECTIVES: We tested the hypothesis that mastoid volume buffers the rate of change in middle ear pressure caused by transmucosal, inert gas exchange. STUDY DESIGN: Twelve monkeys were randomly assigned to group 1 or group 2. Right ears of group 1 had sham surgery and of group 2 had obstruction of the mastoid antrum. Before and after surgery, the time constant for transmucosal N(2)O exchange was estimated from N(2)O breathing experiments. The hypothesis predicts that the postoperative time constant measured for right ears of group 2 but not group 1 is greater than that measured before surgery. RESULTS: Mastoid antrum block significantly decreased right middle ear volume but did not affect the time constant for transmucosal N(2)O exchange. CONCLUSION: A mastoid gas-reserve function is not supported by the experimental data. SIGNIFICANCE: These results for monkeys and the theory developed to explain the effect of mastoid volume on transmucosal inert gas exchange suggest that the results for previous experiments in humans interpreted as evidencing a mastoid gas-reserve function are consistent with alternative explanations.

Animals↗