Patterns of middle-ear cholesteatoma and implications for surgical approach

ObjectivesUnderstanding the pattern of middle-ear cholesteatoma becomes pertinent with the rise of endoscopic surgery as surgeons decide on the optimal approach to visualise and extirpate disease. With modifications to the Telmesani attic–tympanum–mastoid staging system, this study aimed to evaluate the commonest patterns of middle-ear cholesteatoma and their implications for surgical approach.MethodsA retrospective study was conducted in a single tertiary institution in Singapore. All patients undergoing cholesteatoma surgery between January 2012 and June 2015 were included. Staging of cholesteatoma was based on clinical assessment corroborated by radiological findings.ResultsOut of the 55 ears included, 98.2 per cent had cholesteatoma involving the attic. The disease extended into the mastoid antrum and beyond in 43 cases (78.2 per cent). The facial recess and/or sinus tympanum was affected in 26 cases (47.3 per cent).ConclusionThe majority of cholesteatoma cases present with extensive attic disease and significant mastoid involvement. In these cases, endoscopes may be best suited to adjunctive rather than exclusive use in surgery.

Study of outcome of tympanoplasty with and without mastoid antrum exploration in patients with mucosal CSOM

<p class="abstract"><strong>Background:</strong> Chronic suppurative otitis media (CSOM) is a major cause of acquired hearing impairment in children. Standard medical treatment of tubotympanic CSOM is aural toilet, topical antibiotics, systemic antibiotics and dry ear precautions. Surgical intervention for safe / tubotympanic CSOM is tympanoplasty. Otologists currently remain divided as to the importance of antrum exploration in the treatment of tubotympanic CSOM. The aim of the study was to evaluate the outcomes of tympanoplasties with and without antrum exploration in cases of tubotympanic CSOM in terms of graft uptake rate and hearing improvement.</p><p class="abstract"><strong>Methods:</strong> The present study included 60 patients of CSOM with central perforation who underwent surgery at JNU IMSRC from January 2016 to July 2016. Detailed history, clinical examination including tuning fork test, pure tone audiometry was done. All patients were followed up for a period of 3 months. </p><p class="abstract"><strong>Results:</strong> Out of the 60 cases of tubotympanic CSOM graft uptake was seen in 53 cases (88.33%). Graft uptake rate was 96.6% in patients who underwent tympanoplasty with antrum exploration which was significantly higher than those who underwent tympanoplasty alone (80%). Hearing improvement was seen in 93.10% of patients who underwent tympanoplasty with antrum exploration as compared to 83.33% of patients of tympanoplasty which was not statistically significant (p=0.263).</p><strong>Conclusions:</strong>Tympanoplasty with antrum exploration is recommended in all patients of CSOM as it inhances the chances of graft uptake. <p> </p>

Analysis of various tracts of mastoid air cells related to CSF leak after the anterior transpetrosal approach

OBJECTIVEThe anterior transpetrosal approach (ATPA) was established in 1984 and has been particularly effective for petroclival tumors. Although some complications associated with this approach, such as venous hemorrhage in the temporal lobe and nervous disturbances, have been resolved over the years, the incidence rate of CSF leaks has not greatly improved. In this study, some varieties of air cell tracts that are strongly related to CSF leaks are demonstrated. In addition, other pre- and postoperative risk factors for CSF leakage after ATPA are discussed.METHODSPreoperative and postoperative target imaging of the temporal bone was performed in a total of 117 patients who underwent ATPA, and various surgery-related parameters were analyzed.RESULTSThe existence of air cells at the petrous apex, as well as fluid collection in the mastoid antrum detected by a postoperative CT scan, were possible risk factors for CSF leakage. Tracts that directly connected to the antrum from the squamous part of the temporal bone and petrous apex, rather than through numerous air cells, were significantly related to CSF leak and were defined as “direct tract.” All patients with a refractory CSF leak possessed “unusual tracts” that connected to the attic, tympanic cavity, or eustachian tube, rather than through the mastoid antrum.CONCLUSIONSPreoperative assessment of petrous pneumatization types is necessary to prevent CSF leaks. Direct and unusual tracts are particularly strong risk factors for CSF leaks.

Cholesteatoma in children and adults: are there really any differences?

BackgroundCholesteatoma is widely considered to be more aggressive in children than adults, yet few studies have directly compared the operative findings and surgical outcomes between these two groups. This study aimed to assess differences between childhood and adult cholesteatoma.MethodsThe operative caseload of a single consultant surgeon was reviewed between January 2006 and May 2017 using the online Common Otology Audit database. Extracted data were categorised according to patient age (children, aged below 16 years, and adults, aged 16 years or over) and compared.ResultsThis study included data from 71 operations on children and 281 operations on adults, performed for cholesteatoma. Childhood cholesteatoma demonstrated significantly more extension (into the sinus tympani, mastoid antrum and mastoid air cells) and ossicular erosion (of the malleus, incus and stapes superstructure) compared to adults. No significant differences were seen in revision rates, post-operative complications or hearing gain.ConclusionChildhood cholesteatoma was more extensive and destructive compared to adults, representing a more aggressive disease in this cohort.

The Petrosquamous Stalactite: Anatomic Characterization and Mastoid Surgical Implications

Objective To define the presence and relationship of the petrosquamous stalactite (PsS)—a condensation of the trabecular Korner’s septum into a bony plate of the petrosquamous suture—to surrounding structures and understand its surgical implications. Study Design Series of cadaver dissections. Setting University of Missouri Alumni Temporal Bone and Microvascular Laboratory. Subjects and Methods Anatomic dissections were conducted on 15 consecutive formalin-preserved and frozen adult human temporal bones. A calibrated Dino-Lite Premier Digital Microscope was used to photograph dissections of each bone. Measurements were conducted with DinoCapture 2.0 software, with measurement agreement between 2 authors. Results The PsS was present in all specimens. A conserved vascular structure courses within the structure, and the superior malleolar ligament inserts on it. The mean ± SEM distances from the PsS to the tegmen tympani and incus buttress were 2 ± 0.24 mm and 4.23 ± 0.14 mm, respectively. The shortest distance from the PsS to the posterior body of the incus was 1.25 ± 0.13 mm, while the greatest distance from the posterior prominence of the PsS to the posterior body of the incus was 4.58 ± 0.25 mm. Conclusion The PsS is a consistently identifiable structure that may facilitate identification of the tegmen tympani and guide the otologic surgeon from the mastoid antrum to the incus. It is important to recognize the contribution of the PsS to the division of the epitympanic space when cholesteatoma involves the region, to avoid leaving a nidus for future disease.

Status of contralateral ear in unilateral chronic otitis media

<ul><li><p class="abstract"><strong>Background:</strong> The aim of this study was to clinically, audiologically and radiologically examine the contralateral ear, and compare the findings with squamous and mucosal type of chronic otitis media<span lang="EN-IN">. </span></p><p class="abstract"><strong>Methods:</strong> A prospective study of 15 months between April 2015 to July 2016 was conducted in the Otorhinolaryngology department, enrolling 80 patients with unilateral chronic otitis media. The contralateral ear was defined as the ear with no tympanic membrane perforation. Otoscopy, pure tone audiometry and X-ray mastoid or HRCT temporal bone were done on the patients. The results were recorded and analysed<span lang="EN-IN">. </span></p><p class="abstract"><strong>Results:</strong> Descriptive statistical analysis was done using SPSS software version 22 in Windows 7. It was seen that most of the Tympanic membranes were abnormal, with contralateral ear of squamous disease showing more abnormality. Retraction and thinning were the most common abnormalities. And 14.3% cases of pars tensa retractions in squamous cases were grade 4 retractions. Mastoids were mostly sclerosed or diploeic, and soft tissue was present in the mastoid antrum in a few cases. Hearing loss was seen in contralateral ear of 47% of squamosal disease and in 30.5 % of mucosal disease<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> The contralateral ear is now, what the diseased ear was yesterday. The contralateral ear shows unmistakable predilection towards developing chronic otitis media in the future<span lang="EN-IN">.</span></p></li></ul>

Embryonal Rhabdomyosarcoma: A Case Report

Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood and adolescence. There are four histological types and among them the embryonic types are the most common. It can occur in any anatomic location, although when occurring in the head and neck region, it has an affinity to invade the cranial cavity. Patient was a 5 years old boy who was admitted with the complaints of pain and discharge from the ear, swelling on left side of the upper neck, and mastoid region and a fleshy mass protruding from the ear canal. The mass was confirmed to be Embryonal Rhabdomyosarcoma on histopathology. CT scan of the Head-Neck region, showed extension of the mass into infra-temporal fossa and in the mastoid antrum. After complete excision, the patient was referred to oncology deptt for consultation. The chemotherapy schedule comprised of Vincristine and Dactinomycine for 9-12 cycles. Otolaryngologists need to be aware of this rare condition as it may mimic the symptoms of CSOM or nasal polyp. And also long term followup is needed since recurrence can present several years after initial treatment.Bangladesh J Otorhinolaryngol; October 2015; 21(2): 127-131