Oval window perilymph fistula in child with recurrent meningitis and unilateral hearing loss

A 2-year-old boy presented to Ears, Nose and Throat (ENT) surgeons with unilateral hearing loss. Following a prodrome of upper respiratory tract infection (URTI), he developed two episodes of pneumococcal meningitis in quick succession. This case demonstrates an unusual cause of perilymph fistula diagnosed on imaging and confirmed surgically. He had failed the Newborn Hearing Screening Programme and was therefore referred to audiology, who confirmed profound sensorineural hearing loss in the right ear. MRI showed incomplete partitioning (type 1) of the right cochlea, suggesting cerebrospinal fluid (CSF) leak from the region of the stapes. Exploratory tympanotomy confirmed this, and proceeded to CSF leak repair, obliteration of the Eustachian tube, subtotal petrosectomy, abdominal fat grafting and blind sac closure. Although middle ear effusions are common; particularly in children with recent URTI, the possibility of otogenic CSF leak needs to be considered, especially in cases of recurrent meningitis.

Surgical management of Tympanomastoid Paraganglioma: Experience in BSMMU, Dhaka

Objective: To characterize the clinical presentation, surgical management, and outcomes of a consecutive cases of patients with tympanomastoid paraganglioma (TMP) tumors managed at a single tertiary referral center with 5 years’ experience. Study Design: Retrospective review. Setting: Bangabandhu Sheikh Mujib Medical University, a tertiary referral center in Bangaldesh. Methods: Between November 2014 and May 2019, 10 patients with histologically confirmed TMP tumor underwent surgical treatment. Tumor stage was described using the Sanna modified Fisch and Mattox’s classification system. Results: Distribution of tumors according to modified Fisch and Mattox classification was as follows: type A2 1 case (10%); B1 2 cases (20%), B2 6 cases (60%) and B3 1 case (10%). Class A2 tumour was safely removed via postauricular-transcanal approach. Two patients with Class B1 tumors were operated on through canal wall up mastoidectomy approach. Six patients including five Class B2 and one Class B3 tumors were managed by canal wall down mastoidectomy approach. One Class B2 underwent a subtotal petrosectomy with blind sac closure of the external auditory canal and middle ear obliteration. Gross total tumor removal was achieved in 9 cases (90%). One patient developed facial weakness (HB grade III) after one week of postoperative period which recovered completely by conservative treatment. No recurrence was noted in follow-up period. Conclusion: Early diagnosis of tympanomastoid paragangliomas are very rare because of its benign and slow-growing nature. Clinical differentiation between tympanojugular and tympanomastoid paragangliomas are difficult. Surgery is the recommended primary modality of treatment for tympanomastoid paragangliomas with minimum morbidity and recurrence rate. Bangladesh J Otorhinolaryngol; October 2019; 25(2): 66-75

Single stage cochlear implantation in radical mastoid cavity- a surgical dilemma

Objective: To describe the potential problems of cochlear implantation in mastoid cavity with possibilities of extrusion of electrode array by breakdown of epithelial lining or flap cover recurrent cholesteatoma and spread of infection to the implant. The issues with surgical management and subsequent follow up is discussed. Methods: In a Series of 170 Cochlear Implantations at our centre, four patients had Cochlear Implantation with Blind sac closure, complete removal of epithelium from the radical mastoid cavity, obliteration of the cavity with temporoparietal fascia flap and electrode insertion. Follow up ranging from 21 months up to 84 months is available. One patient during follow up had to undergo re implantation due to extrusion of the electrodes. Results: All the patients had good outcome regarding hearing improvement. One of the patients had to undergo exploration and re implantation of electrodes due to extrusion of electrodes through the external auditory canal. This patient had a canal cholesteatoma. Discussion: An important issue in single stage procedure is ensuring complete removal of fibro epithelial lining of the cavity. The advantage is cost reduction and minimizes the need for multiple general anesthesia. A follow up CT scan at regular intervals is required to detect recurrence. Conclusions: The patients undergoing cochlear implantation in a radical mastoid cavity require intensive follow up with computerized tomography to detect recidivism, Single stage cochlear implantation in radical mastoid cavity is an appropriate therapeutic decision by the cochlear implant surgeon.

Evaluation of Subtotal Petrosectomy Technique in Difficult Cases of Cochlear Implantation

<b><i>Objectives:</i></b> To assess the validity of the subtotal petrosectomy (STP) technique in problematic cases of cochlear implant (CI) surgery, and review indications, outcomes, and related controversies. <b><i>Study Design:</i></b> This is a retrospective review of data from a private quaternary referral center of otology and skull base surgery. <b><i>Patients and Methods:</i></b> A review of patients who underwent CI with STP (STP-CI) as the leading approach was performed. Demographics, indications, surgical details, and main outcomes were evaluated. The surgeries performed were usually single-stage procedures encompassing a comprehensive mastoidectomy, blind sac closure of the external auditory canal (EAC), and mastoid obliteration with autologous fat. <b><i>Results:</i></b> A total of 107 cases were included. Mean follow-up was 7.1 years (range 1–13 years). The most frequent indication for STP-CI was chronic otitis media with/without cholesteatoma (32.7%), followed by open mastoid cavity (26.1%), and cochlear ossification (17.7%). Other difficult conditions where STP facilitates successful implantation include inner-ear malformations, temporal-bone trauma, unfavorable anatomic conditions, and revision surgery. A planned staged procedure was performed in 3 cases. The rate of major complications was 5.6% (<i>n</i> = 6). Three patients developed postauricular wound dehiscence which eventually resulted in device extrusion. No cases of recurrent/entrapped cholesteatoma, EAC breakdown, or meningitis were encountered. This is the largest single-center series of STP-CI reported in the literature. <b><i>Conclusions:</i></b> When CI is intended in technically challenging cases or associated with a high risk of complications, STP is effective and reliable. Safe implantation and excellent long-term outcomes can be achieved provided surgical steps are properly followed. Single-stage procedures can be performed in most cases, even when there is active middle-ear disease.

The importance of petrous apex and peri-carotid pneumatisation in subtotal petrosectomy and blind sac closure: a radiological study

ObjectiveTo ascertain in what proportion the vertical segment of the intratemporal carotid artery on its medial aspect anatomically separates the peri-tubal cells and Eustachian tube from the remainder of the pneumatised spaces of the temporal bone.MethodA retrospective review was conducted of 222 adult and 29 paediatric consecutive computed tomography scans of petrous temporal bones from a single tertiary referral centre.ResultsIn 96 per cent of temporal bones, the carotid artery formed a lateral barrier (with no communication pathway medially) between air spaces anterior and posterior to it. This equated to 94 per cent when chronic otitis media cases were excluded.ConclusionThe degree of separation of middle-ear air cells from the Eustachian tube or nasopharynx, and the relevant anatomy, are reviewed. This knowledge helps to optimise the outcome of subtotal petrosectomy and blind sac closure. The frequency and process of pneumatisation of the petrous apex, and its connections with the middle ear, have been radiologically confirmed.

Middle Ear Obliteration with Blind-Sac Closure of the External Auditory Canal for Spontaneous CSF Otorrhea

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.