Interaction between bile salts and beta-adrenoceptor antagonists

Chronic suppurative otitis media (CSOM) in profoundly deaf patients is a contraindication for cochlear implantation. Eight (6%) of the 126 patients referred to cochlear implantation at this center between 1986 and 1992 became deafened as a result of bilateral CSOM but were otherwise suitable candidates. This study details the methods used in four patients to prepare the septic ear for a sterile device. Two patients had wet radical cavities with residual cholesteatoma, and two had discharging safe perforations resistant to surgical repair. Obliteration of the middle ear cleft with blind pit closure of the ear canal was attempted in all four patients, and cochlear implants were installed at a second operation 3 to 6 months later. The hearing results were as good as in implanted patients without CSOM, and the only complication has been the finding of a cholesteatoma pearl at the second operation in one patient. Fat obliteration of the mastoid and middle ear with blind pit closure of the ear canal can be adapted to make most chronic ears fit for implantation, if the patient is prepared to undergo two operations.     

Influence of the concentration of ions and foramen diameter on the accuracy of electronic root canal length measurement--an experimental study

The controversy regarding the best procedure for treating middle ear cholesteatoma has lasted over 100 years. This paper discusses our current methods for dealing with cholesteatoma, always through external ear or transmeatal mastoidectomy. We present the results of three years of follow-up. MATERIAL AND METHODS: A prospective study was made of 215 ears operated for cholesteatoma using a transcanal approach with one of three techniques: "on demand" DAA mastoidectomy, modified radical mastoidectomy, and radical mastoidectomy with obliteration. Three parameters were used to evaluate results: stability of the mastoid cavity, integrity of the neotympanum, and evolution of hearing. RESULTS: The rate of cholesteatoma recurrence in ears operated with these techniques was much lower than that found in canal-wall-up techniques. Only 3 of the 215 cases (1.4%) remained unstable due to different causes three years after surgery. DISCUSSION AND CONCLUSIONS: Due to the high rate of cholesteatoma recurrence, canal-wall-up mastoidectomy has been abandoned in our clinic. Open techniques using a transmeatal approach, with or without obliteration, and the so-called "on demand" mastoidectomy, have yielded more stable results, although postoperative care is more critical.     

Cochlear implantation in children with inner ear malformations

We performed a case study and intervention study, with follow-up of 1 to 5 years, in 4 children with inner ear malformations who underwent implantation of a multichannel cochlear implant (Nucleus, Cochlear Corporation) at ages 3 to 12 years. Malformations included a common cavity deformity, 2 incomplete partitions, and 1 case of isolated bilateral vestibular aqueduct enlargement. One child had a single-channel implant placed at 3 years of age, and this was exchanged for a 22-channel implant at age 9. One child had her implant placed at age 4.5 years, but due to complications from a cerebrospinal fluid (CSF) leak had the initial implant removed and replaced at age 5 years during repair of the CSF leak. Intraoperative findings included a CSF leak at the time of surgery in 3 patients. One patient contracted bacterial meningitis 7 months postimplantation that was thought to be secondary to acute otitis media in the unoperated ear. Bilateral CSF leaks were noted in the middle ear by a lumbar puncture radionuclide and fluorescein dye study. Successful repair of the CSF leaks and reimplantation of the cochlear implant was carried out in this patient. Mapping and programming of the implant was found to be challenging in each of these patients. All patients demonstrated improved performance after implantation. Two patients demonstrated some open-set speech perception. One patient demonstrates improved use of temporal cues in a structured closed set. One patient has achieved no significant speech recognition at this time, but does have improved sound detection and awareness. Cochlear implantation in children with congenital inner ear abnormalities can be a successful method of rehabilitation. It should be recognized that the postoperative speech perception results may be highly variable among patients, and that intraoperative complications may occur.     

Validation of the heat treatment step used in the production of diaspirin crosslinked hemoglobin (DCLHb) for viral inactivation--effect of crosslinking

During the years 1979-81, three different surgical techniques were used in the treatment of 87 ears with extensive cholesteatoma. All procedures were performed in one stage by the same surgeon. Ten to 13 years after the operations about 70 per cent of ears operated on by the canal wall up technique had developed a new cholesteatoma, which in most cases was recurrent, or a deep retraction pocket. A modification of this technique with mastoid obliteration resulted in a similar failure rate. In contrast, ears operated on by the canal wall down technique (in most cases with mastoid obliteration) had acceptable stability with a long-term recurrence rate of about 15 per cent. Most patients in the canal wall down group had a dry ear without significant cavity problems. Hearing in these patients was as least as good as hearing in patients with a preserved canal wall. We conclude that a meticulous one-stage canal wall down technique in ears with extensive cholesteatoma results in a high percentage of unproblematic, stable ears with satisfactory function. In contrast, if the posterior canal wall is preserved, recurrent cholestealoma is the rule more than the exception.     

Mastoid obliteration in open cavities

The obliteration of a large or irregular mastoidectomy cavities with hard-to-control areas is a common problem for ENT surgeons. Numerous obliteration techniques have been proposed in the last 50 years. We report our experience of obliteration of mastoid cavities in 74 ears using autogenous mastoid cortical bone chips and rib cartilage. Our procedure, a partial obliteration with meatoplasty, has yielded good results. Almost 92% of these ears were dry three years after surgery. There were no cases of recurrent cholesteatoma between bone chips.     

The use of homograft stapes

Homograft stapes were used for ossicular reconstruction in 43 ears over a three-year period. The average hearing improvement was 7.9 db. These cases were divided into groups: those with an intact posterior canal wall and those with an open mastoid cavity. The latter group fared better, with an average improvement of 15 db. Fourteen of the 43 ears were subsequently re-explored. Satisfactory bony union between the homograft stapes and recipient footplate was found in eight cases, four cases showed poor bony union, and bony resorption of the homograft had occurred in two patiemise for reconstruction of the ear with a loss of the stapes arch, especially in the presence of an open mastoid cavity and thus a shallow middle ear.     

Bladder cancer in a patient on long-term haemodialysis

OBJECTIVE: The results of the first cohort of 60 cavity reconstructions with hydroxyapatite with a minimum follow-up period of 15 years were studied. STUDY DESIGN: The study design was a retrospective study. PATIENTS: A total of 60 patients had a follow-up period of >15 years. In four patients, not all data were available. Therefore, 56 patients were included in the study. They had a combination of cavity problems and hearing loss. INTERVENTION: The ear canal was reconstructed with a canal wall prosthesis of porous hydroxyapatite. The ossicular chain was reconstructed with an incus or incus-stapes prosthesis of dense hydroxyapatite. RESULTS: After 15 years, 42 patients (75%) had an intact reconstructed ear canal. The main problem for failure was the recurrent purulent middle ear infection and not cholesteatoma. The histology of the retrieved canal wall showed a good remodeling in living bone tissue. After 15 years, 34 patients had a normal ear canal and an ossicular chain. Of these patients, 7.05% had an air-bone gap closure within 20 dB. CONCLUSIONS: Long-term results of cavity reconstruction with hydroxyapatite are possible. The main problem is recurrent mucosal disease of the new middle ear-mastoid cleft.     

The problem mastoid cavity: medical and surgical management

The patient with persistent foul drainage from a previously operated-on mastoid cavity has a serious problem that requires aggressive attention from the otologic surgeon. The ear must be carefully evaluated in the office. Careful cleaning of the cavity and effective application of medication will dry up many of these cavities. Revision surgery of the ear requires a systematic approach using all the techniques of modern otologic surgery. This means the use of a post-auricular incision and wide bone removal combined with bone removal combined with obliteration techniques and grafting of the middle ear. This approach was used in 29 ears in 27 patients. Rapid healing and a trouble-free, dry ear was obtained in 26 patients or 90% of the operated-on cases.     

One year real world prospective follow-up study of a major depressive episode of patients treated with paroxetine and pindolol or paroxetine for 6 weeks

Among cochlear implant candidates there are patients who have abnormal middle and/or inner-ear conditions that make them unsuitable for implantation. Insertion of a foreign body may also be contraindicated in the setting of an existing or potential intracranial communication, or when the ear is prone to infection. Five patients presented with such unfavorable conditions. These included a Mondini dysplasia with persistent cerebrospinal fluid leak, an atretic mastoid with meningocele, chronic otitis media, a transverse petrous bone fracture, and a temporal bone adenoma. All patients underwent subtotal petrosectomies and cochlear implantations. In four cases implantation was performed concomitantly with subtotal petrosectomy, while the remaining case required a two-stage procedure. No complications occurred. The technique is described in detail, and the cases and the indications for surgery are discussed. By obliterating and isolating the tympanomastoid cleft from the outer environment and utilizing the technique of subtotal petrosectomy, a broader spectrum of patients can now be implanted safely.     

Multichannel cochlear implantation in obliterated cochleas using the Gantz procedure

Gantz, et al, reported two patients with extensive cochlear ossification in which cochlear implantation was done with a Nucleus 22-Channel Cochlear Implant after extensive cochlear drill-out. One of the patients did well with 20 functioning electrode pairs. We report an additional three patients with extensive cochlear ossification who received Nucleus 22-Channel Cochlear Implants. All three patients had extensive cochlear drill-out as described by Gantz, et al. All three patients have use of all 21 electrode pairs with amperages typical of conventional implantation in two of the three and slightly increased levels in the third. Extensive bilateral cochlear ossification does not seem to be an absolute contraindication for multi-channel cochlear implantation.     

Ear manifestations in adolescents after closure of lip-jaw-palate- or isolated palatal clefts

We examined two groups of teenagers who had been surgically treated as small children for cleft palate. Most patients were between 13 and 21 years of age. One group had been looked after by the Dept. of Orthodontics at the University of Erlangen-Nürnberg, the other by the Dept. of Orthodontics at the University of Rostock. There were differences in sequence and time of the surgical closure between the two departments. Additionally, 60% of the people treated in Rostock had a velopharyngoplastic, which was rarely the case in Erlangen. In both groups only a few patients had been seen by an ENT-doctor regularly. Only some patients had been previously treated with tubes. There was one patient in each group with a bilateral, most likely genetically determined, sensorineural hearing loss. In Erlangen we examined 66 teenagers (132 ears). Six ears had been previously treated with one or more tympanoplasties. 10 ears needed further treatment due to a seromucotympanon, adhesions, perforations of the ear drum, suspicion of cholesteatoma or insufficient improvement of hearing after previous tympanoplasty. Another 18 ears showed signs of former inflammations. The control group in Rostock included 63 patients (i.e. 126 ears). 14 of the ears examined had undergone one or more tympanoplasties previously. 13 other ears needed further treatment for seromucotympanon, adhesions, perforations of the ear drum, insufficient improvement of hearing after tympanoplasty or cholesteatoma. Residuals due to prior inflammations were found in another 26 ears. Possible reasons for the different occurrence of middle ear problems in both groups are discussed.     

Influence of the gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases

To investigate the influence of gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases, the authors examined the mastoid pneumatization among patients with sniffing habit using computed tomography, and also examined the change of negative middle ear pressure induced by sniffing using tympanogram. In 20 ears with cholesteatoma or adhesive otitis media, the areas of mastoid cavity measured at the level of the lateral semicircular canal were significantly smaller than those in 26 ears with otitis media with effusion (OME) or attic retraction and in eight normal ears with sniffing habit (P < .01 and P < .0001, respectively). In 26 ears with OME or attic retraction, the areas of mastoid cavity were significantly smaller than those in eight normal ears with sniffing habit (P < .0001). By contrast, in the four ears with sniff-induced middle ear disease, the recovery of negative middle ear pressure in 5 minutes without swallowing was less than 10 mm H2O, whereas in all seven ears with normal eardrum, negative middle ear pressure recovered by more than 20 mm H2O in 5 minutes. These findings suggested that impairment of gas exchange function through the middle ear mucosa, as well as eustachian tube dysfunction, might be closely related to the development of sniff-induced middle ear diseases.     

Results of cochlear implantation in patients with severe to profound hearing loss--implications for patient selection

In patients with some residual hearing and minor benefit from conventional hearing aids, the benefits of cochlear implantation have to be weighed carefully against eventual adverse effects. In this study, pre- and post-operative thresholds as well as functional results after cochlear implantation are reported; 17 of 44 implanted adults had residual hearing pre-operatively (mean threshold(250 to 4000 Hz): 106 dB HL) in the implanted ear. Residual hearing in the implanted ear could not, in general, be preserved post-operatively. Seventeen of 44 implanted children had some amount of residual hearing in the implanted ear pre-operatively (implanted ear: 114 dB HL; contralateral ear: 109.9 dB HL; mean thresholds(250 to 4000 Hz))). Contrary to the results in adults, residual hearing in the implanted ear remained statistically unchanged. Hearing in the contralateral ear increased significantly from 109.9 to 101.9 dB HL post-operatively. This increase was mainly attributed to maturation of the central auditory pathway. In adults with residual hearing, the monosyllable word recognition scores increased significantly from 9 per cent pre-operatively to 42 per cent post-operatively. Children with residual hearing tended to perform better on speech-related test material compared to children without prior auditory experience. Cochlear implantation is indicated in adults and children with residual hearing and minor benefit from conventional amplification. The contralateral ear in children should be considered for additional acoustical stimulation.     

Cholesteatoma surgery today

Four present-day surgical techniques are reviewed to assess their respective merits in surgery for cholesteatoma. The oldest method with an open cavity in ears with mastoid extension of cholesteatoma if combined with partial obliteration is still suitable for less experienced surgeons. Transcanal atticotympanotomy is suitable for limited epitympanic and tympanic cholesteatomas as long as it provides a direct view of the operative field. In similar ears, canal wall up surgery is employed if, additionally, mastoidectomy is needed because of chronic inflammation. Canal wall down surgery with full cavity obliteration with a musculoperiosteal flap, bone chips and bone pate should be the method of choice for all cholesteatomas extending beyond the facial nerve canal. The canal skin is kept as an intact tube and provides quick healing. Open cavities should be revised using similar obliteration techniques but, because of the lack of an intact canal skin tube, making use of a large modified K?rner skin flap.     

Middle ear pressure and dysfunction of the labyrinth: is there a relationship?

Relationships between middle ear pressure and non-infection-related cochleovestibular dysfunction have been suggested by several authors. According to some data, vertiginous attacks can be prevented by the insertion of a ventilation tube in patients suffering from Meniere's syndrome. The aim of our study was to investigate if the incidence of eustachian tube malfunction and pathologic middle ear pressure is frequent, and if routine implantation of ventilation tubes is reasonable in ears with dysfunctions of the labyrinth, including clinical Meniere's syndrome. So, we determined in our pressure chamber all active and passive parameters of eustachian tube function in 40 patients suffering from Meniere's syndrome, sudden sensory hearing impairment (SSHI), or vestibular neuronitis. Our results disclosed no nonrandom incidence of impaired tubal function among our patients compared to healthy control subjects. Pressure equalization was sufficient in most patients suffering from clinical Meniere's syndrome, and only one patient with vestibular neuronitis presented with a patulous tube. Our results show that impairment of vestibular or cochlear function is not regularly accompanied by eustachian tube dysfunction. Furthermore, no patient reported symptoms while pressure variation was performed. We conclude that variation of middle ear pressure does not usually play a role in the genesis of Meniere's syndrome, vestibular neuronitis, or SSHI. Thus, from our data, we cannot recommend routine implantation of tympanic ventilation tubes in patients suffering from Meniere's syndrome, vestibular neuronitis, or sudden hearing loss.     

Echocardiographic spectrum of supracardiac total anomalous pulmonary venous connection

We report an unusual case of a 13-year-old girl with a benign osteoma associated with a cholesteatoma in the external auditory canal and serous otitis media. The osteoma was located in the antero-inferior wall of the right external auditory canal. A cholesteatoma was present between the osteoma and the tympanic membrane. Computed tomography revealed a soft tissue density within the external auditory canal and in the middle ear cleft. The shadow in the middle ear cleft was considered to represent the serous otitis media. Surgical removal of the osteoma and cholesteatoma proved successful, and no recurrences or complications have occurred in the first year postoperatively.     

Cochlear implants: selection criteria and shifting borders

Cochlear implants have proven to be effective and reliable in postlingually deaf adults. This is also true for congenitally deaf and perilingually deaf children up to the age of six years. Due to the increasing experience, the improvement of implant technology and the proven reliability the selection criteria are broadened with shifting borders. The main extensions are related to age, additional handicaps, residual hearing and special etiologies of deafness. Increasing evidence shows that very early implantation results in better performance and better hearing and speech development. Near-normal language acquisition can be achieved in children implanted under the age of four. Additional handicaps do not automatically exclude a candidate from cochlear implantation. A case-to-case decision has to be made based on additional diagnostics and the experience of the implant centre. A list of suitable handicaps is provided. Severely hearing impaired patients may also be considered for cochlear implantation if their residual hearing provides no benefit for speech discrimination. The same holds true for children. Cochlear implantation in obliterated cochleae and inner ear malformation requires a special surgical technique and special electrode arrays. In this way even difficult cases can be managed with remarkable outcome. Over all, the selection criteria have been broadened with increasing experience and technological improvement. This development may continue and the borderline between hearing aids and cochlear implants will shift further towards severe hearing loss. However, the basis for success still remains good rehabilitation, a team approach and the willingness of the patient to undergo the whole process of cochlear implantation.     

Usefulness of ictal and interictal 99mTc ethyl cysteinate dimer single photon emission computed tomography in patients with refractory partial epilepsy

OBJECTIVE: The aim was to investigate the feasibility of recording the electrical auditory brain stem response (EABR) evoked by electrical stimulation at the promontory (Prom-EABR) as a tool to assist selection of the ear for cochlear implantation in young children. STUDY DESIGN: The study group consisted of young children for whom the decision to proceed with implantation with the Nucleus mini 22-channel cochlear implant (Cochlear (UK) Ltd., London, UK) had already been made. SETTING: The Prom-EABR was recorded after the children had been anesthetised, but before the start of surgery. PATIENTS: A group of 25 children (11 boys and 14 girls), whose age at implantation ranged from 2 years 11 months to 6 years 8 months (mean age, 4 years 5 months), were investigated. INTERVENTION: Recordings of the Prom-EABR were used to determine which ear would receive the cochlear implant, providing there were no preexisting contraindications regarding selection of the ear. MAIN OUTCOME MEASURE: It has been suggested from earlier studies that the characteristics of the amplitude input/output (I/O) function of the EABR are related to neuronal survival. If the ear with the "better" I/O function is chosen for implantation, it might be expected that these children will perform better on average than those in whom the ear has been selected at random. RESULTS: Reliable recordings of the Prom-EABR were achieved in 40 ears (80%) of the 50 ears in the study. In 20 of the 25 children the technique was actively employed for selection of the ear for implantation. CONCLUSIONS: Recording of the Prom-EABR in the operating theater is a viable technique. Future analysis of long-term outcome measures of performance with the implant will confirm or dispute the benefit of ear selection using the Prom-EABR.     

Ocular impairments in an impairment survey of leprosy-affected persons in Nepal

To date, there is no satisfactory treatment for persistent eustachian tube blockage or negative pressure in the middle ear. Conventional ventilation tubes are usually either occluded or extruded with time. A new treatment of percutaneous mastoid vent provides permanent ventilation to the middle ear cleft without putting a tube through the eardrum. A titanium tube is inserted through the skin into the mastoid antrum using the established technique of osseo-integration and hence becomes truly permanent. It can also be connected to a CPAP machine to re-inflate a collapsed eardrum. Initial trials consist of six vents inserted and followed up for 6-16 months. There was no sign of extrusion or a foreign body reaction. However, an inner Teflon tube is essential to keep the vent patent for permanent ventilation to the middle ear cleft.     

Circadian rhythm in toxic effects of cystemustine in mice: relevance for chronomodulated delivery

We present a 76-year-old male patient with adhesive-type cholesteatoma and with metal foreign bodies which were shown to be located in the bony eustachian tube by computed tomography. He sustained a burn injury of the left tympanic membrane when he was struck by a bomb 52 years ago, during World War II. The cannonball fragments that entered the tympanic cavity were apparently transported to and stuck in the eustachian tube isthmus by mucociliary action after spontaneous closure of the tympanic membrane perforation. Persistent tubal obstruction due to the impacted foreign bodies and surrounding granulation tissue seems to have caused chronic adhesive otitis, leading to cholesteatoma which developed in the attic and mastoid antrum. No foreign bodies became visible after cholesteatoma removal by an intact canal wall technique in conjunction with anterior tympanotomy for wide exposure of the supratubal recess and the tympanic osteum of the eustachian tube. Therefore, anterior tympanotomy was further extended anteriorly to open the enlarged bony eustachian tube, allowing visualization and safe removal of two cannonball-fragments firmly impacted within it. We call this surgical approach to the bony eustachian tube "extended anterior tympanotomy". The transmastoidal accessibility of the bony eustachian tube produced by this technique should be assessed by preoperative computed tomography.