Ultrastructure of eustachian tube mucosa in chronic otitis media with cholesteatoma

Evidence against the mucosal traction theory in cholesteatoma

OBJECTIVES

To investigate the distribution of ciliated epithelium in the human middle ear and its potential role in the formation of cholesteatoma.

STUDY DESIGN

Comparative human temporal bone study.

METHODS

We selected temporal bones from 14 donors with a diagnosis of cholesteatoma, 15 with chronic otitis media without retraction pockets, 14 with chronic otitis media with retraction pockets, 14 with cystic fibrosis (CF), and 16 controls. We mapped the distribution of the ciliated cells in the mucosal lining of the middle ear and tympanic membrane using three-dimensional reconstruction analysis, and counted the number of ciliated cells in the middle ear mucosa.

RESULTS

Ciliated cells are extremely sparse in the epithelial lining of the lateral surface of the ossicles in the epitympanum and the medial surface of the tympanic membrane. Furthermore, there is a significant decrease in the number of ciliated cells in these areas in temporal bones with cholesteatoma, chronic otitis media, chronic otitis media with retraction pockets, and CF compared to controls. Ciliated cells most commonly are located at the hypotympanum and the Eustachian tube opening but not the tympanic membrane or epitympanum.

CONCLUSION

The paucity of ciliated epithelial cells on the medial side of the tympanic membrane and the lateral surface of the ossicles in the epitympanum in cases with cholesteatoma and/or chronic otitis media do not support the mucosal migration theory of cholesteatoma formation.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1663-1667, 2018.

Condition of the anterior part of the middle ear cleft in acquired cholesteatoma

CONCLUSION

The high rate of flogistic suffering of the controlateral ear seems to suggest a correlation between tubal dysfunction and acquired cholesteatoma but the low rate of pathological reports regarding the anterior mesotympanic region exclude a eustachian tube dysfunction (EDT) at the time of surgery. These observations support the hypothesis that ETD is not a factor that may influence the evolution of the cholesteatoma.

OBJECTIVES

To evaluate the role of eustachian tube function in the middle ear secondary acquired cholesteatoma.

PATIENTS AND METHODS

This was a case series study. The study group consisted of 72 patients submitted to tympanoplasty for middle ear secondary acquired cholesteatoma.

RESULTS

The contralateral ear was normal in 37 subjects (51%) and affected by chronic otitis media in 35 (49%); the anterior part of middle ear cleft was normal in 53 patients (74%). There was no significant relationship between the contralateral ear condition and the status of the anterior region of middle ear (p>0.05). The site of retraction or the presence of tympanic perforation with skin migration was not related to the condition of the protympanum. Otorrhea, cholesteatoma extension, and ossicular chain lesions were not significantly related to the status of the anterior part of the middle ear cleft (p>0.05).

Fistula of the Cochlear Labyrinth in Noncholesteatomatous Chronic Otitis Media

OBJECTIVE

To discuss the clinical aspects and management of promontory fistula of the cochlear labyrinth.

STUDY DESIGN

Case report and review of the literature.

SETTING

University hospital, tertiary referral center.

PATIENT, INTERVENTION, AND RESULTS

The authors describe an unusual case of cochlear fistula localized to the promontory discovered during tympanoplasty for noncholesteatomatous chronic otitis media in a 59-year-old woman. Bone conduction was slightly impaired after operation and hearing improved after a revision myringoplasty performed for reperforation.

CONCLUSION

Erosion of the bone of the labyrinth can also be observed in noncholesteatomatous otitis media. The presence of a fistula is not always associated with profound hearing loss. Overlying pathologic tissue can be removed without damaging the membranous labyrinth.

Middle ear cholesteatoma: characteristic CT findings in 64 patients

BACKGROUND

High resolution computerized tomography (HRCT) is valuable for detection of early erosive changes suggestive of cholesteatoma. The aim of our study was to determine characteristic CT findings in patients with middle ear cholesteatoma.

METHODS

We conducted a retrospective review of CT scans and surgical and histopathological reports in 64 patients with middle ear cholesteatoma (35 male, 29 female; age range, 7-80 years, median age, 22 years). CT scans were evaluated for the presence of intra-tympanic non-dependent soft tissue density, the extent of middle ear involvement, bone expansion and thinning, and bone erosions involving the ossicles and adjacent structures.

RESULTS

Middle ear cholesteatoma was more common in male patients and in patients aged 20-35 years. All patients had soft tissue density in the middle ear. Fifty-nine (92%) had expansion of the aditus and mastoid antrum, 59 (92%) had erosions of the ossicles, with involvement of the long process of the incus in 48 (75%), 55 (86%) had an eroded scutum, 55 (86%) an eroded facial nerve canal, 57 (89%) an eroded Koerner's septum, which was totally destroyed in 19 (27%), 48 (75%) had tegmen erosion, and 63 (98%) had erosions of the antral walls. The correlation of pre-operative CT with surgical and histopathological findings was 97%.

CONCLUSION

Middle ear cholesteatoma is a distinct clinical entity with characteristic findings that may be suggested by CT imaging. These findings should alert the clinician to the possibility of cholesteatoma, which will guide in the surgical approach and treatment plan.

Percutaneous treatment of a pancreatic fistula after pancreaticoduodenectomy

Breakdown of the pancreaticojejunal anastomosis after a Whipple procedure is reported to occur in as many as 15% of cases. Intraoperative placement of a drain adjacent to the anastomosis is performed to allow the creation of a controlled pancreaticocutaneous fistula in the event of an anastomotic disruption. The authors present a case of successful percutaneous treatment of a disrupted pancreaticojejunal anastomosis. This was achieved with use of the resulting pancreaticocutaneous fistula for access to restore internal drainage, followed by fistula occlusion with use of gelatin pledgets.