Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.     

An Arabic language version of the health promotion lifestyle profile

BACKGROUND: Characteristic features of cholesteatoma of the middle ear are destruction of the bone and a high tendency for recurrent disease. The choice of surgical procedure is determined by audiological results and the rate of recurrent cholesteatoma. PATIENTS: One hundred fifty patients who underwent primary cholesteatoma surgery were investigated 3-5 years postoperatively. Preoperative and postoperative audiological results and rate of revision surgery were compared for the respective surgical procedures. All cholesteatomas were treated with an open surgical technique. The lateral attic walls and cholesteatomas were removed. RESULTS: Cholesteotoma recurred in 15 patients (10%). Primary reconstruction of the ossicular chain with a tympanoplasty (type III) was performed in 98 patients in the first operation. Approximately 80% of patients treated with a type III tympanoplasty had a maximum postoperative air-bone gap of 20 dB in the main speech range, depending on the frequency. In about 50% of patients, this value was 10 dB or less. Comparison of preoperative and postoperative conductive hearing loss between 250 Hz and 8000 Hz revealed an improvement (p < 0.05) of 10 dB (500 Hz, 3000 Hz, 4000 Hz) and 15 dB (250 Hz, 1500 Hz, 2000 Hz, 8000 Hz). CONCLUSIONS: In our opinion, a second look operation should be performed in cases where a large cholesteatoma cannot be removed with sufficient reliability. This applies especially to a cholesteatoma in the oval window. Here, we suggest second-look surgery after one year.     

Ventilating tubes in tympanoplasty

The successful surgical treatment of chronic otitis media or its sequela is frequently related to a ventilated tympanic cavity. Tubes at tympanoplasty have been recommended to assure ventilation until eustachian tube and middle ear mucosal functions have been restored and to prevent the complications of graft loss, atelectasis, cholesteatoma and ossicular destruction. This presentation reviews the literature on the subject and documents our results in 40 patients treated by tympanomastoid surgery with ventilating tubes. The types of tubes used, the surgical technique involved, and the selection of cases suitable for this method are described. Cholesteatoma was the primary disease in 32 patients, 6 had chronic otitis media, 1 cholesterol granuloma, and 1 eosinophilic granuloma. Complete healing of grafts following extrusion or removal of the tubes occurred in 34 patients, 2 tubes remain in place, 3 patients had persistent tube site perforations, and 1 was lost to follow-up. None of the patients had graft breakdown as a result of tube placement, and there has been no recurrence of cholesteatoma. In all cases, the follow-up period is a minimum of 18 months and extends to 92 months.     

Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy--changing trends in a developing country

OBJECTIVES: To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy. DESIGN: A prospective case series. SETTING: An academic tertiary referral center in India. PATIENTS: Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning. INTERVENTION: Concurrent craniotomy and mastoidectomy. RESULTS: Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery. CONCLUSIONS: In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.     

Ossicular coupling of an implantable hearing aid transducer using an Er:YAG laser

Special coupling devices made of pure gold or titanium have been developed to connect a new implantable hearing aid transducer (Tübingen implant) to the ossicular chain. They allow piezotransducer probe-tip connection to the long process of the incus or the stapedial head. Similar to the design of conventional PORPs (partial ossicular replacement prostheses), the coupling devices can be fixed at the ossicular chain, e.g., with the eye loop of stapedial piston prostheses or the bell element of golden wire PORPs. A crimp technique allows connection between coupling device and transducer probe tip [5]. The main disadvantage in connecting the long process of the incus or the stapes having is to drill a dorsal tympanotomy in the posterior wall of the ear canal during surgery. The short distance between tympanotomy and N. facialis contains serious surgical risks. To avoid the risk of facial paralysis, Fredrickson's alternative coupling technique for the body of the incus is investigated in this paper [2]. In this case, the transducer probe tip will be positioned to the incus body and placed on its surface with controlled elastic displacement of the ossicular chain. The simple direct attachment of the probe-tip end on the surface of the incus, however, will not guarantee a stable long-term connection. Thus, by creating a conical, 0.5-to 0.7-mm-deep hole in the incus, the probe tip will be fitted much better. With a novel surgical Erbium-YAG laser this can be done in a contactless procedure. In this paper, first results of microsurgical laser applications with human temporal bones will be shown.     

Ossicular discontinuity

Because of the numerous and varied surgical approaches to ear pathology devised and expanded in the past two decades, we are destined to be confronted with increasingly frequent cases of ossicular defects behind an intact eardrum. Using a technique which is the converse of the established "patch" test a simple office procedure is described which may help establish the diagnosis of ossicular discontinuity in the adult with an intact eardrum. An audiogram is obtained and then a myringotomy performed with insertion of a large ventilation tube. A second audiogram is then done. A rise in the air conduction level, in the absence of fluid, is suggestive of ossicular discontinuity.     

Improvement of the surgical technique of anterior tympanoplasty in cholesteatoma

Technical improvements in anterior tympanotomy with a transmastoid approach in cholesteatoma surgery are reported. Mastoidectomy must be extended to the root of the zygoma and the space anterior to the malleus head must be opened. For this purpose, the visual axis must coincide with the external meatal axis. In this head position, complete removal of the anterior attic bony plate becomes possible only through the transmastoid approach, without touching the ossicular chain. In the case of the pyramidal type bony plate with a normal ossicular chain, the incudo-malleal joint is temporary subluxated, as this is more convenient for access and removal of pathology than incudostapedial joint subluxation. Our clinical results on postoperative hearing showed no damage to the inner ear by the improved technique.     

Chronic otitis media in children

There are two main types of chronic otitis media in children. The "benign" type with a central tympanic membrane perforation may heal spontaneously with conservative management. However, if the central tympanic membrane perforation fails to heal, it should be closed surgically--preferably at the age when the incidence of ear disease in children is lowest. Chronic otitis media with cholesteatoma usually has an attic or marginal perforation and requires surgical treatment to prevent serious complications. The incidence of this disease has been decreasing because of awareness by primary physicians of the importance of prompt treatment and the increase in the practice of inserting ventilation tubes.     

Controllable graded cerebral ischaemia in the gerbil: studies of cerebral blood flow and energy metabolism by hydrogen clearance and 31P NMR spectroscopy

Patent ductus arteriosus is an uncommon anomaly in adult patients. Surgical closure of patent ductus arteriosus in this age group presents difficult problems to the surgeon. We report our experience of 21 adult patients (19-62 years of age, mean 40 years) who underwent closure of the ductus by transfemoral implantation of a Rashkind double umbrella device. The patients came to light because of atrial fibrillation, congestive heart failure, residual flow after surgical ligation of the duct or because of incidental diagnosis made during physical examination or chest X-ray. In ten patients the pulmonary arterial pressure was normal (systolic pressure < 30 mmHg), in eleven it was elevated (systolic pressure from 30 to 100 mmHg, mean 50 mmHg). In seven patients the duct was clearly calcified and the size of the duct varied from 3 to 9 mm (mean 4.3 mm). In 16 patients the ductus resulted perfectly closed after implantation of the first double umbrella device, two patients had minimal residual aortopulmonary flow, whereas in three patients the residual shunt was significant; two of these also developed haemolysis and went to surgery, in the latter the shunt was completely abolished after implantation of a second 17-mm device 16 months later. In conclusion transcatheter closure of patent ductus arteriosus in adults is feasible, even in the presence of calcifications and/or pulmonary hypertension; taking into account the significant surgical risk, PDA umbrella closure should be considered the first choice procedure in this group of patients.     

A novel k-space trajectory measurement technique

OBJECTIVE: To report our experience with erosion of permanent suture or mesh material after abdominal sacrocolpopexy. METHODS: A retrospective chart review was performed to identify patients who underwent sacrocolpopexy by the same surgeon over 8 years. Demographic data, operative notes, hospital records, and office charts were reviewed after sacrocolpopexy. Patients with erosion of either suture or mesh were treated initially with conservative therapy followed by surgical intervention as required. RESULTS: Fifty-seven patients underwent sacrocolpopexy using synthetic mesh during the study period. The mean (range) postoperative follow-up was 19.9 (1.3-50) months. Seven patients (12%) had erosions after abdominal sacrocolpopexy with two suture erosions and five mesh erosions. Patients with suture erosion were asymptomatic compared with patients with mesh erosion, who presented with vaginal bleeding or discharge. The mean (+/-standard deviation) time to erosion was 14.0+/-7.7 (range 4-24) months. Both patients with suture erosion were treated conservatively with estrogen cream. All five patients with mesh erosion required transvaginal removal of the mesh. CONCLUSION: Mesh erosion can follow abdominal sacrocolpopexy over a long time, and usually presents as vaginal bleeding or discharge. Although patients with suture erosion can be managed successfully with conservative treatment, patients with mesh erosion require surgical intervention. Transvaginal removal of the mesh with vaginal advancement appears to be an effective treatment in patients failing conservative management.     

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.     

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HYPOTHESIS: Monoclonal antibodies directed against cytokeratin subtypes in cholesteatoma produce growth inhibition of keratinocytes. BACKGROUND: Despite elegant surgical procedures for cholesteatoma, residual disease is an important clinical problem. Although gross cholesteatoma removal usually is feasible, microscopic foci of residual keratinocytes may develop into clinically significant disease. This study was designed to evaluate the keratinocyte cytotoxicity of monoclonal antibodies directed against a cytokeratin subtype relatively unique to cholesteatoma. METHODS: Keratinocytes and skin fibroblasts were trypsinized, counted, and seeded in multiwell plates. The cells were exposed to mouse monoclonal antibody to cytokeratin 10 at dilutions of 1:10, 1:25, 1:50, 1:100, and 1:200 with six replicates. After 24-, 48-, and 96-hour incubations, cells that had been pulsed with 3H-thymidine were harvested. Cellular DNA was processed for quantification of 3H-thymidine incorporation with a beta scintillation counter. Cells exposed to antibody are reported as percent inhibition relative to controls. RESULTS: Inhibition ranged from 88.9% for the 1:10 concentration to 26.9% for the 1:200 concentration after 24 hours of incubation. Similar effects were noted at the 48- and 96-hour intervals. Overall, the effect was significantly more pronounced on the keratinocytes than inhibition on skin fibroblasts. CONCLUSIONS: These results suggest that monoclonal antibodies have in vitro activity against keratinocytes. Additional investigation of a possible role for cytokeratin monoclonal antibodies should be pursued with a goal of developing a clinically useful biologic adjunct for cholesteatoma management.     

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.     

Benign intracerebellar cyst without epithelial lining

Platelet-derived growth factor (PDGF) was localized in human middle ear cholesteatoma tissue by an immunoperoxidase technique using rabbit anti-human PDGF IgG. PDGF was found mainly in basal cells and in granulation tissue, and especially involved monocytes and fibroblast-like cells. The external ear canal epithelium was not significantly stained by anti-human PDGF. Findings demonstrate that the presence of PDGF in cholesteatoma is in response to inflammation and wound healing in the middle ear. PDGF in vitro was found to stimulate protein synthesis and cellular terminal differentiation of basal keratinocytes. PDGF also stimulated monocytes to form multinucleated osteoclast-like cells. These multinucleated cells, in turn, induced the resorption of devitalized bovine bone. This bone resorption was seen in co-cultures of osteoblasts and multinucleated osteoclast-like cells in the presence of PDGF, suggesting that cell-to-cell interaction plays a role in bone resorption. The present study suggests that PDGF takes part in the clinical development and the destructive effect of cholesteatoma.     

Traumatic brain injury in children and adolescents: psychiatric disorders at two years

OBJECTIVE: To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI. RESULTS: Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year. CONCLUSION: These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.     

An analysis of a behavioral intervention for children undergoing venipuncture.

An examination of factors was conducted to determine the effectiveness of the distraction component of a behavioral intervention (use of a party blower). In one condition, parents were instructed to coach children in the use of a party blower and to praise child cooperation. In a second condition, nurses were instructed to assist parents in coaching the child. Parents used the coaching skills they learned and got their children to use the distraction technique. Use of the distraction technique was associated with less crying. Encouragement from a health care professional and intervention early in the procedure did not enhance the intervention's effectiveness. Older children and children who were less distressed during the initial phase of the procedure were less likely to reject the intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toynbee Memorial Lecture 1997. Middle ear mechanics in normal, diseased and reconstructed ears

A review of the structure-function relationships in normal, diseased and reconstructed middle ears is presented. Variables used to describe the system are sound pressure, volume velocity and acoustic impedance. We discuss the following: (1) Sound can be transmitted from the ear canal to the cochlea via two mechanisms: the tympanoossicular system (ossicular coupling) and direct acoustic stimulation of the oval and round windows (acoustic coupling). In the normal ear, middle-ear pressure gain, which is the result of ossicular coupling, is frequency-dependent and smaller than generally believed. Acoustic coupling is negligibly small in normal ears, but can play a significant role in some diseased and reconstructed ears. (2) The severity of conductive hearing loss due to middle-ear disease or after tympanoplasty surgery can be predicted by the degree to which ossicular coupling, acoustic coupling, and stapes-cochlear input impedance are compromised. Such analyses are used to explain the air-bone gaps associated with lesions such as ossicular interruption, ossicular fixation and tympanic membrane perforation. (3) With type IV and V tympanoplasty, hearing is determined solely by acoustic coupling. A quantitative analysis of structure-function relationships can both explain the wide range of observed post-operative hearing results and suggest surgical guidelines in order to optimize the post-operative results. (4) In tympanoplasty types I, II and III, the hearing result depends on the efficacy of the reconstructed tympanic membrane, the efficacy of the reconstructed ossicular chain and adequacy of middle-ear aeration. Currently, our knowledge of the mechanics of these three factors is incomplete. The mechanics of mastoidectomy and stapedectomy are also discussed.     

Interleukin 1 (IL-1) and IL-1-receptor antagonist (IL-1-RA) in middle ear cholesteatoma: an analysis of protein production and biological activity

Cytokine networks are now presumed to play an essential role in the pathogenesis of middle ear cholesteatoma. Of the factors identified in cholesteatoma, interleukin-I (IL-1)-alpha appears to be especially important because of its stimulation of keratinocyte proliferation as well induction of bone resorption. To further characterize the possible role of IL-1 in the pathogenesis of cholesteatoma, we quantified the levels of IL-1 and IL-1-receptor antagonist (IL-1-RA) present using the bicinchonic acid protein assay and enzyme-linked immunosorbent assay (ELISA) on tissue extracts from 20 cholesteatoma specimens. The presence of biologically active IL-1 was also analyzed, using the cell line LBRM-33 and an ELISA for the detection of interleukin-2 (IL-2). Human skin obtained from the external ear canal was used as control. The amounts of IL-1-alpha in cholesteatoma (34.9 +/- 19.5) were higher than in human skin (6.7 +/- 2.8). The observed differences were statistically significant by Student's t-test (P < 0.01). Skin samples showed elevated concentrations of IL-1-RA (248.3 +/- 30.2) in comparison to that in the cholesteatoma (80.8 +/- 13.5). This was also statistically significant (P < 0.01). Whereas IL-1 activity was not detected in skin samples, all cholesteatoma specimens studied showed a stimulation effect on the production of IL-2 when incubated with the cell line LBRM-33. The results point to an over-expression of IL-1 concurrent with a decreased secretion of IL-1-RA in middle ear cholesteatoma. Furthermore IL-1-RA production is deficient relative to total IL-1 production, resulting in the presence of active IL-1.     

Tragus perichondrium-cartilage island transplant in middle ear surgery. Method and results after 5 years

Temporalis fascia remains the most widespread material for reconstructing the tympanic membrane in tympanomastoid surgery. If total or partial ossicular replacement prostheses are needed or pathology of the eustachian tube causes ventilation impairment, a more rigid transplant material is required. Between 1989 and 1994 perichondrium-cartilage composite grafts were used in a series of 597 cases of tympanomastoid surgery performed at the University ENT Clinic of Würzburg. The graft was taken from the tragus and prepared as a cartilage island with perichondrium attached to one side, the perichondrium-cartilage island transplant (PCI). If reconstruction of the ossicular chain was necessary, glass ionomer cement protheses (IONOS) were used. Closure of the tympanic membrane could be achieved in 90% of all cases. In those cases where ossicular chain reconstruction was postponed to a second procedure, closure of the drum was achieved in 96%. The audiological results of the different type III procedures were evaluated. By using the PCI technique a favorable closure of the air-bone gap to 10-25 dB was achieved, even in cases with advanced ear pathology technique and results are presented in detail.     

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.