Incidence of dehiscence of the facial nerve in 416 cases of cholesteatoma

There Is No Relation between Epitympanic Recess Volume and Chronic Otitis Media

BACKGROUND

Chronic otitis media is recurrent infection of the middle ear and mastoid air cells in the setting of perforation of the tympanic membrane. Risk factors for chronic otitis media include predisposing characteristics such as gender, allergies, Eustachian tube dysfunction, history of acute otitis media, and upper respiratory tract infection. The purpose of this study was to evaluate the potential relationship between chronic otitis media and epitympanic recess volume.

MATERIALS AND METHODS

A total of 197 patients with chronic otitis media had their epitympanic recess volume compared to the epitympanic volume of 99 healthy controls. The epitympanic recess volume was measured via the 3D volumetric measurement tool of the local PACS. Epitympanic recess volume measurement was performed using axial sections in a plane starting from the level of the malleus head-anvil body in the craniocaudal direction to the tegmen tympanum.

RESULTS

It was shown that patients with bilateral involvement had an epitympanic recess volume of 75.00 mm³, compared to 72.30 mm³ in those with unilateral chronic otitis media. The healthy control group's median value for the epitympanic recess was 74.73 mm³.

CONCLUSIONS

Epitympanic volume values did not differ substantially between patients with chronic otitis media and healthy persons, and epitympanic volume was not recognized as a predisposing factor (p = 0.686).

A novel imaging scoring method for identifying facial canal dehiscence: an ultra-high-resolution CT study

OBJECTIVES

Facial canal dehiscence (FCD), typically found in the tympanic segment, is a risk factor for facial nerve injury. An imaging scoring method was proposed to identify FCD based on ultra-high-resolution CT.

METHODS

Forty patients (21 females and 19 males, mean age 44.3 ± 17.4 years), whose tympanic facial canal (FC) was examined during otological surgery, were divided into the FCD group (n = 29) and the control group (n = 11) based on surgical findings. Imaging appearance of tympanic FC was scored 0-3: 0 = no evident bony covering, 1 = discontinuous bony covering with linear deficiency, 2 = discontinuous bony covering with dotted deficiency, and 3 = continuous bony covering. Both lateral and inferior walls were assigned a score as L_FCD and I_FCD, respectively. An FCD score was calculated as L_FCD + I_FCD. The diagnostic value of the FCD score was tested using the ROC curve.

RESULTS

The inter-observer agreement was moderate for the lateral wall (Cohen's κ coefficient 0.416, 95% CI 0.193-0.639), and good for the inferior wall (Cohen's κ coefficient 0.702, 95% CI 0.516-0.888). In the FCD group, the most common appearance for both walls was discontinuous bony covering with linear deficiency (L_FCD = 1, 22/29, 75.9%; I_FCD = 1, 15/29, 51.7%). An FCD score of less than 4 was associated with high sensitivity (0.82) and specificity (0.93) for identifying FCD, with an AUC of 0.928.

CONCLUSIONS

Using the proposed scoring method, FCD score < 4 could identify FCD of the tympanic segment with high concordance with surgical findings.

KEY POINTS

• Imaging appearance of the tympanic facial canal (FC) is divided into four types based on ultra-high-resolution CT images. • The most common appearance of FC with facial canal dehiscence (FCD) is discontinuous bony covering with linear deficiency. • An FCD score, consisting of scores of the lateral and inferior walls, less than 4 is highly indicative of FCD.

Facial Palsy Secondary to Cholesteatoma: A Case-Series of 14 Patients

BACKGROUND

To evaluate patients with middle ear cholesteatoma presenting with facial palsy (FP).

MATERIAL-METHODS

A total of 14 subjects (10 males and 4 females), with a mean age of 42.5 years, were included in our study. The majority of patients presented with incomplete FP (House-Brackmann HB II-IV, 11 cases) and the remaining 3 patients had complete facial paralysis (HB V-VI). A canal wall down mastoidectomy was performed in all the patients, followed by partial facial nerve decompression.

RESULTS

At the one-year follow-up, eleven (78.5%) patients demonstrated satisfactory recovery to HB I-II. Facial function recovered to HB grade I-II in 9 (100%) patients who were surgically treated within one month, and in 2 (40%) patients who underwent surgery after one month. The tympanic segment of facial nerve was the most common site of involvement (8 patients). The multiple regression analysis showed that a higher preoperative HB grade combined with a gradual than sudden onset of FP more likely resulted in worse postoperative HB grade.

CONCLUSION

Early surgical removal of cholesteatoma associated with FP is more likely to result in good facial nerve recovery (78.5% of cases), when it is performed within one month from the onset of FP. According to the literature, the tympanic segment of the facial nerve was more frequently damaged (77.7%), followed by the mastoid segment (22.9%), labyrinthine segment (11.1%), and geniculate ganglion (11.1%). Labyrinthine fistula, mainly of the lateral semicircular canal, can be expected in cases of facial nerve dehiscence. The canal wall down mastoidectomy combined with partial decompression surgery was the most preferred surgical treatment for the FP secondary to cholesteatoma.

Comparative study of cholesteatoma in paediatric and adult patients

Background

The aggressiveness of paediatric cholesteatoma has long been a matter of debate. While much of the evidence is substantiated by data from the Western world, it is further limited by the retrospective nature of most studies. Therefore, this paper presents a comparative analysis of various characteristics of cholesteatoma between paediatric and adult populations seen at our centre.

Methods

A total of 50 patients (25 adults and 25 paediatric) with clinical diagnosis of chronic suppurative otitis media with cholesteatoma underwent canal wall down mastoidectomy over a period of two years. The intra-operative findings were noted and patients were followed up for six months.

Results

There was more extensive spread and ossicular erosion in paediatric cases. However, complications such as facial canal dehiscence and lateral semicircular canal dehiscence were more common in adults.

Conclusion

Paediatric cholesteatoma is more aggressive and invasive than adult cholesteatoma, and the clinical behaviour is consistent with findings from other parts of the world.

Facial nerve dehiscence and cholesteatoma: Pediatrics vs adults

OBJECTIVES

the aim of this paper is to study the incidence of facial canal dehiscence (FCD) in pediatric and non-pediatric patients, analyzing eventual differences in frequency, localization, primary or revision surgery and duration of the disease.

METHODS

527 patients suffering from chronic otitis media with acquired cholesteatoma, divided into two groups, those aged 18 years or over (470 patients), and those aged below 18 years (57 patients).

RESULTS

Total incidence of FCD in adult population was 25,7% (121/470) and 7% (4/57) in pediatric one. Globally higher values were found in revision surgery, 43,5% (40/92) in adults and 16,7% (1/7) in children. Diseases longer than 5 years have been correlated to higher incidence of FCD in adults, 29,9% (109/364), than in pediatrics, 7,3% (3/41). No statistical significant difference has been found in those with a disease shorter than 5 years: 11,3% in adults (12/106) and 6,2% in children (1/16). The majority of patients, both adults and pediatrics, had a dehiscence in the tympanic tract of facial nerve. No statistical correlation regarding concomitant semicircular canal fistula and FCD has been found due to the absence of data in children.

CONCLUSIONS

Incidence of FCD is higher in adult population than in pediatric. Adults have a higher incidence in primary surgery than children. No statistical significant difference has been found in adults and pediatrics with a less than 5 years disease, while diseases longer than 5 years expose adults to higher risk of FCD. Middle tract of tympanic segment is the most involved site of dehiscence in both populations.

Facial Nerve Dehiscence and Cholesteatoma: A Comparison between Decades

OBJECTIVES

To evaluate the incidence of facial canal dehiscence (FCD) and other intraoperative findings over the last 20 years as well as correlation with the Japanese Otological Society/European Academy of Otology and Neurotology classification in patients with cholesteatoma.

MATERIALS AND METHODS

A total of 469 patients operated from 1998 to 2018 were selected and divided into 2 groups of 10 years each.

RESULTS

Dehiscence was significantly higher in patients with a history of pathology longer than 5 years (22.7%). Higher values were observed in revision surgery, 44.4% in the first period and 41.7% in the second. The tympanic segment was the one most frequently involved, affecting 92% of patients in the first period and 97% of patients in the second. Dehiscence occurred significantly more often in patients with a semicircular canal fistula, 14.8% in the first decade and 8.8% in the second. The incidence of FCD was significantly higher in patients with primary cholesteatoma (especially in those with combined pars tensa-flaccida) than in those with a secondary acquired one, 31.5% vs 7.4% in the first period, 21.1% vs 7.4% in the second, and in those with a stage III disease, 42% in the first period, 33.3% in the second.

CONCLUSION

Patients with a shorter history of cholesteatoma as well as those not previously operated had a lower incidence of FCD. The tympanic tract of the facial nerve remains the most frequent site of dehiscence, while the association between dehiscence and fistula of the semicircular canal remains strong. Patients with combined pars tensa-pars flaccida and stage III cholesteatoma have a higher incidence of FCD.

Prevalence of facial canal dehiscence and other bone defects by computed tomography

INTRODUCTION

The facial nerve is the most vulnerable structure during otological surgeries. Facial canal dehiscence (FCD) is the main risk factor for iatrogenic injuries. Its prevalence in clinical studies ranges between 6 and 33.3%, while anatomical studies report 25-57%. The objective was to determine the prevalence of FCD stratified by age and gender in a healthy population.

MATERIALS AND METHODS

Temporal bones from high-resolution computed tomography (CT) were analyzed. Patients with a history of trauma or tumors of the temporal bone, cholesteatomas, chronic middle ear disease, and any pathology that could modify the bone's anatomy, were excluded.

RESULTS

A total of 184 temporal bones were included. FCD was observed in 94 (51.2%) of the analyzed bones. The tympanic portion was the most frequently affected site with 91 (49.5%), followed by the mastoid segment with 3 (1.6%). No dehiscence was found in the labyrinth portion. We observed 30 (31.9%) of the FCD involved the oval window. Other bone defects identified with the FCD included: 11 (11.7%) with a lateral semicircular canal fistula and 7 (7.4%) with tegmen tympani erosions.

CONCLUSION

FCD has a high prevalence among healthy patients. A pre-surgical otological evaluation using high-resolution CT should be indicated to properly assess the patient and reduce the risk of injury.

Cautionary High-resolution Computed Tomography Findings for the Presence of Facial Canal Dehiscence in Patients with Cholesteatoma

Objective

This study aimed to investigate the abnormal high-resolution computed tomography (HRCT) findings in cholesteatomatous chronic otitis media (CCOM) patients preoperatively and the coexistence of abnormal HRCT findings with facial canal dehiscence (FCD) observed intraoperatively to identify the predictive factors associated with FCD.

Methods

The medical records of 151 CCOM patients who had undergone tympanomastoidectomy at our center were retrospectively examined in terms of the patients’ age and gender, preoperative HRCT findings [scutum defect, posterior wall of external auditory canal (PWEAC) defect, lateral semicircular canal (LSSC) defect, tegmen defect, and sigmoid plate erosion]. Operation records containing information about FCD were also analyzed.

Results

The prevalence of FCD was found to be 33.8% (51/151). There was a significant correlation between the presence of scutum, PWEAC, LSSC, and tegmen defects and the presence of FCD. However, no statistically significant correlation was found between the presence of sigmoid plate erosion and the presence of FCD. The results of regression analysis of the coexisting pathologic findings for FCD showed that the risk of FCD was highest in patients with LSSC + scutum defects (34.3-fold increase), followed by LSSC + PWEAC defects (31.6-fold increase).

Conclusion

Our study revealed that the presence of scutum, PWEAC, LSSC, and tegmen defects on HRCT indicates a higher risk of FCD preoperatively. This risk is even greater when multiple abnormal findings coexist.

Imaging anatomy of the retrotympanum: variants and their surgical implications

The retrotympanic anatomy is complex and variable but has received little attention in the radiological literature. With advances in CT technology and the application of cone beam CT to temporal bone imaging, there is now a detailed depiction of the retrotympanic bony structures.With the increasing use of endoscopes in middle ear surgery, it is important for the radiologist to appreciate the nomenclature of the retrotympanic compartments in order to aid communication with the surgeon. For instance, in the context of cholesteatoma, clear imaging descriptions of retrotympanic variability and pathological involvement are valuable in pre-operative planning.The endoscopic anatomy has recently been described and the variants classified. The retrotympanum is divided into medial and lateral compartments with multiple described potential sinuses separated by bony crests.This pictorial review will describe the complex anatomy and variants of the retrotympanum. We will describe optimum reformatting techniques to demonstrate the structures of the retrotympanum and illustrate the associated anatomical landmarks and variants with CT. The implications of anatomical variants with regards to otologic surgery will be discussed.

Can MDCT Scan of the Temporal Bone Looking at Pneumatization Predict Surgical Vulnerability of the Facial Nerve?

OBJECTIVES

The aim of this study is to investigate the scutum-cochleariform process (CP) and scutum-promontorium distances according to the mastoid pneumatization condition.

METHODS

Two hundred temporal multidetector computed tomography scans (90 males and 110 females) were evaluated retrospectively. The scutum-CP and scutum-promontorium distances were measured. Facial canal dehiscence (FCD) in the tympanic segment and mastoid pneumatization were also evaluated.

RESULTS

The distances between scutum-CP and scutum-promontorium were not different between males and females and between right and left sides. Facial canal dehiscence in the tympanic segment was detected: 5.6% (right) and 7.8% (left) in males and 5.5% (right) and 10.0% (left) in females. Grade 4 (100%) pneumatization was detected mainly in 55.6% to 57.8% of the patients in both genders. Grade 0 (0%) pneumatization (sclerosis) was detected in 22.2% to 28.2% of both males and females. In more pneumatized mastoids, the scutum-CP and scutum-promontorium distances increased. In sclerotic mastoids, the scutum-CP and scutum-promontorium distances decreased. Facial canal dehiscence rates were not related to the mastoid pneumatization levels.

CONCLUSION

Cochleariform process is an important landmark to localize the tympanic segment of the facial canal. In sclerosed mastoids, scutum-CP and scutum-promontorium distances decreased. There was no relationship between FCD rates and mastoid pneumatization levels. It may be due to the development of FCD that occurs during the intrauterine period. In endoscopic and classic ear surgeries, mastoid pneumatization must be evaluated preoperatively to avoid facial nerve injuries.

Cautionary Findings for the Presence of Facial Canal Dehiscence During Cholesteatoma Surgery

Our aim was to investigate the relationship between facial canal dehiscence (FCD) and surgical findings and procedures in patients with cholesteatoma. A total of 186 patients (118 males, 39.2 ± 15 years) who underwent surgery for advanced cholesteatoma between 2013 and 2018 were included in the study. The relationship between FCD and surgical findings was investigated via the surgical registries. The prevalence of FCD was 36.6% (68/186). The prevalence of FCD was 44%, and 13.2% for the patients who underwent canal wall down mastoidectomy (62/141) and canal wall up mastoidectomy (6/45), respectively (P < .001). Facial canal dehiscence was detected in 73.9% of the 23 patients who had a lateral semicircular canal (LSCC) defect (P < .001), in 61.9% of 21 patients who had a tegmen tympani defect, and in 58.1% of the 31 patients who had erosion on the posterior wall of the external auditory canal (EAC; P < .05). The prevalence of FCD was 3.1% in patients with isolated incus erosion, 59.1% in patients with erosion of malleus and incus, 60.7% in patients with erosion of stapes suprastructure and incus, and 43.2% in patients with whole ossicular chain deformation (P < .001). The defects on LSCC, EAC, tegmen tympani, and malleus and incus might be cautionary findings for the presence of FCD during cholesteatoma surgery.

Facial canal dehiscence rate: a retrospective analysis of 372 chronic otitis media cases

PURPOSE

This study aimed to investigate the rate and location of facial canal dehiscence (FCD) observed during surgery for chronic otitis media (COM) with or without cholesteatoma.

MATERIAL AND METHOD

Operative details of 1296 patients who underwent chronic otitis media surgery from January 2000 to January 2017 by the same surgeon were included in this retrospective study focusing on intraoperative observations of FCD.

RESULTS

Because of the type of the surgery, the Fallopian canal could not be seen completely, so 924 of the cases which only involved performing a tympanoplasty were not included in the study. A total of 372 patients (196 males and 176 females) who had a canal wall down (CWD) or canal wall up (CWU) mastoidectomy were included in the study. A CWD mastoidectomy was performed on 250 patients, while 122 patients underwent a CWU mastoidectomy. The prevalence of FCD was 11.29% (42/372 patients). The dehiscence was more common in patients with cholesteatoma (n = 37; 88.1%) than those with non-cholesteatoma (n = 5; 11.9%). The tympanic segment (n = 32; 76.19%) was the most common location for FCD. When we compared the ossicular erosion results of the cases that had FCD, erosion in three ossicles together was more statistically significantly frequent than the other possibilities.

CONCLUSION

It is possible to see FCD because of COM, especially with cholesteatoma. FCD is most commonly seen around the oval window. If stapes or all three ossicles are eroded, the surgeons must be more careful regarding FCD to be more effective in preventing facial nerve damage.

Endoscopic versus microscopic approach in attic cholesteatoma surgery

PURPOSE

Compare the outcomes of primary exclusive endoscopic ear surgery with those of the microscopic ear surgery in a group of patients affected by attic cholesteatoma.

MATERIALS AND METHODS

Eighty patients suffered from attic cholesteatoma. Forty patients surgical treated with endoscopic ear surgery and forty patients surgical treated with microscopic ear surgery.

RESULTS

No statistical differences were found in the parameters analysed (frequency of facial nerve dehiscence, age, disease duration, site of dehiscence) between the endoscopic and microscopic groups indicating a homogeneous selection thus providing a good comparison of the outcomes between the two groups. None of the patients in our survey developed postoperative iatrogenic facial palsy. Graft success rate was 100% in both groups. The overall operation time of endoscopic ear surgery presented a mean value of 87.8min, while in the group of patients treated via microscopic ear surgery a lower mean value of 69.9min was reported. The average healing time was 36.3days for the endoscopic subgroup and 47.8days for the microscopic subgroup.

CONCLUSION

The surgical outcomes of endoscopic ear surgery are comparable to those of the conventional approach in terms postoperative air-conduction, graft success rate and taste sensation. The analysis of postoperative pain and healing times showed better results for EES. The mean operative times of endoscopic ear surgery gradually shortened as the surgeons gained expertise in performing one-hand surgery.

Incidence of Facial Nerve Canal Dehiscence in Primary and Revision Cholesteatoma Surgery

The aim of this retrospective study was to determine the incidence of facial canal dehiscence (FCD) in primary and revision cholesteatoma surgery in a tertiary referral center. Moreover, our second goal was to identify association between FCD and other intra-operative pathological findings in a group of patients with cholesteatoma surgery. Inclusion criteria were primary and revision canal wall up and canal wall down tympanomastoidectomy in patients who suffers from chronic otitis media (COM) with cholesteatoma. An exclusion criterion was charts with in adequate documentation. In addition tympanoplasty cases were excluded due to evaluate both tympanic and mastoid segments of facial nerve canal. Preoperative clinical data and intra-operative findings were documented in a formatted questionnaire. We found the incidence of FCD in COM surgery was 18%. There was no difference between the primary and revision surgeries regarding its incidence. In addition, there was association between some preoperative or intra-operative findings of COM, such as middle fossa dural dehiscence, external auditory canal polyp, facial nerve paralysis, labyrinthine fistula, and FCD. In conclusions we found that there was no difference between primary and revision surgeries regarding the incidence of FCD. Surgeons should consider effective measures to prevent intra-operative facial nerve trauma in COM surgeries.

The Tightrope Facial Nerve-An Unsupported Mastoid Segment After Resection of Recidivistic Cholesteatoma

OBJECTIVES/HYPOTHESIS

Cholesteatomas are epidermal inclusion cysts containing stratified squamous epithelium that arise in the middle ear and mastoid cavities resulting in a persistent inflammatory state. Complications include chronic otorrhea, granulation tissue, and bony erosion. Cholesteatoma growth patterns predict frequent involvement of the Fallopian canal of the facial nerve. Extensive disease may extend to the posterior and middle fossa dura, the otic capsule, the carotid artery, and the jugular bulb. Dehiscence of the Fallopian canal and direct involvement of the facial nerve epineurium by cholesteatoma are risk factors for intraoperative facial nerve injury during tympanomastoid surgery by exposing the facial nerve to mechanical trauma and inflammation during microdissection. We present two cases of recidivistic cholesteatoma with unusual medial involvement of the vertical segment of the facial nerve that resulted in an unsupported mastoid segment after resection. The outcomes from these two patients suggest that facial nerve function may be preserved despite circumferential exposure with appropriate preoperative planning and intra-operative techniques.

STUDY DESIGN

Case studies.

METHODS

Two patients undergoing revision tympanomastoidectomy for extensive recidivistic cholesteatoma with medial involvement of the facial nerve in the mastoid segment. In each case, the facial nerve was circumferentially exposed during the resection of the cholesteatoma.

RESULTS

Normal facial nerve function after surgery was confirmed in both patients at 18 months and 6 years, respectively.

CONCLUSIONS

Surgical resection of extensive cholesteatoma with medial involvement of the vertical segment of the facial nerve resulted in an unsupported mastoid segment in two patients with normal postoperative facial nerve function.

Chronic otitis media

Chronic otitis media (COM) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of COM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including "COM", "diagnosis", "incidence", "complications" and "management". Relevant articles were identified and examined for content. What is the "take-home" message for the clinician? COM is a common problem with various sub-categories according to the disease state. It most commonly presents with painless otorrhoea and hearing loss. Treatment options vary according to the activity and type of disease encountered. COM carries significant patient morbidity.

The intra-operative incidence of Fallopian canal dehiscence during surgery for cholesteatoma: a prospective case-control study and review of the literature

OBJECTIVE

To investigate Fallopian canal dehiscence (FCD) during cholesteatoma surgery.

STUDY DESIGN

Prospective case-control study.

PATIENTS

Four hundred and one patients with cholesteatoma and 172 with otosclerosis.

INTERVENTIONS

Therapeutic.

SETTING

District general hospital.

MAIN OUTCOME MEASURES

(i) Intra-operative incidence of FCD during (a) surgery for cholesteatoma versus a homogeneous control group (patients with otosclerosis); (b) revision surgery for cholesteatoma as compared to primary surgery. (ii) Intra-operative incidence of a fistula if FCD is present.

RESULTS

Data were prospectively collected and analysed using chi-square tests. FCD was found in 19% of cases versus 5.2% of controls. Intra-operative incidence of (i) FCD during cholesteatoma surgery versus otosclerosis surgery was statistically very highly significant (P < 0.0001, OR = 5.43); (ii) FCD during revision versus primary cholesteatoma surgery was not statistically significant (P = 0.83); and (iii) encountering a fistula in the presence of FCD during cholesteatoma surgery was statistically very highly significant (P < 0.0001, OR = 6.71).

CONCLUSIONS

A surgeon is more likely to encounter FCD during cholesteatoma surgery than in stapes surgery. If during cholesteatoma surgery FCD is found, then a fistula is also more likely to be present, mainly of the semicircular canal. The incidence of FCD is not increased in revision surgery. These findings are very relevant for any otologist undertaking cholesteatoma surgery.

Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma

OBJECTIVE

We investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for cholesteatoma.

METHODS

We examined retrospectively 334 patients who had been operated on for cholesteatoma in Izmir Katip Celebi University, Ataturk Research and Training Hospital, ENT Clinic, between April 1997 and April 2010. The patients were examined for facial canal dehiscence according to age, gender, side of the ear, surgery type, first or revision surgery, localization of the facial canal dehiscence, spread of the cholesteatoma, with the presence of lateral semi-circular canal (LSCC) fistula and any defect in the ossicle chain, and destruction in the posterior wall of the external auditory canal(EAC).

RESULTS

Of the patients, 23.6% had facial canal dehiscence and detected most commonly in the right ear 28.9% and tympanic segment, 83.5%. Facial canal dehiscence was found to be 24.2-fold more common in patients with LSCC fistula and 4.1-fold more common in patients with destruction in the posterior wall of the (EAC). In patients located cholesteatoma in tympanic cavity+antrum and the tympanic cavity+all mastoid cells and with incus and stapes defect, increased incidence of dehiscence. Age, first or revision operation and canal wall down tympanoplasty (CWDT) or canal wall up tympanoplasty (CWUT) did not affect the incidence of dehiscence.

CONCLUSIONS

That the likelihood of facial canal dehiscence occurrence is increased in patients with LSSC fistulas, destruction in the posterior wall of the EAC, or a stapes defect is important information for surgeons.

Analysis of differences in facial nerve dehiscence and ossicular injury in chronic otitis media and cholesteatoma

CONCLUSION

Facial nerve dehiscence (FND) and ossicular injury occurred more frequently in patients with cholesteatomatous than non-cholesteatomatous otitis media.

OBJECTIVE

FND and ossicular injury commonly occur intraoperatively in patients with otitis media, both with and without cholesteatoma. This study was designed to analyze differences in FND and ossicular injury between patients with cholesteatomatous and non-cholesteatomatous otitis media.

METHODS

Patients who underwent tympanomastoidectomy due to otitis media from January 2010 to July 2012 were analyzed retrospectively. Clinical features (age, sex, bacteria, and severity of preoperative hearing loss) and intraoperative findings (FND and state of ossicular injury) were compared in patients with cholesteatomatous and non-cholesteatomatous otitis media.

RESULTS

Of 212 patients with otitis media, 148 (69.8%) had non-cholesteatomatous and 64 (30.2%) had cholesteatomatous otitis media. Of these groups, 88.6% and 88%, respectively, had positive bacterial cultures. Facial nerve dehiscence was detected in 41 patients (27.7%) with non-cholesteatomatous and 41 (64.0%) with cholesteatomatous otitis media. Dehiscence of the tympanic segment was most frequently observed in both groups. Ossicular injury was detected in 52 (35.1%) and 51 patients (78.1%), respectively. Erosion was most frequent in the incus, followed by the stapes and malleus.

Fallopian canal dehiscence at pediatric cholesteatoma surgery

The objectives of the study were to investigate the characteristics of ears with dehiscence of the fallopian canal at the time of cholesteatoma surgery and the relationship between dehiscence and age, and to consider the reasons why the fallopian canal tends to be preserved in pediatric patients. This study included 37 ears with cholesteatoma in pediatric patients (mean age 9.2 years, age range 4-14 years) and 273 ears with cholesteatoma in non-pediatric patients (mean age 45 years, age range 15-84 years). Patients were treated between January 2006 and April 2012. All patients had undergone prior tympanoplasty under general anesthesia at our institution. Facial canal dehiscence was evaluated by inspection and through palpation by blunt picking after the pathological tissues had been removed. The size of fallopian canal dehiscence was not investigated in this study. The frequency of dehiscence of the fallopian canal according to the type of cholesteatoma and coexisting pathological conditions, including destruction of the stapes, presence of a labyrinthine fistula, and dural exposure, were compared between the pediatric and non-pediatric groups. The frequency of dehiscence in cases with destruction of the stapes was also compared between the pediatric and non-pediatric groups. Dehiscence of the fallopian canal occurred in 6 of 37 ears (16.8 %) in the pediatric group and 91 of 273 ears (33.3 %) in the non-pediatric group (p < 0.05). In congenital cholesteatoma, the frequency of dehiscence was lower in the pediatric group than in the non-pediatric group (p < 0.05). However, in other types of cholesteatoma there was no statistically difference between the two types of cholesteatoma. The frequency of the destruction of the stapes was higher in the pediatric group than in the non-pediatric group (43.2 vs. 16.5 %, p < 0.001). In patients with severe destruction of the stapes, the fallopian canal was preserved more frequently in the pediatric group than in the non-pediatric group (p < 0.05). The frequency of dehiscence of the fallopian canal at the time of cholesteatoma surgery was lower in the ears of pediatric patients than in the ears of non-pediatric patients. This is probably due to the difference in types of cholesteatoma between the two groups and other unknown mechanisms.

Differences in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas

This study investigated the difference in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas for the purpose of increasing the preoperative detectability of dehiscence. A total of 189 ears of patients 7-80 years of age (mean 42 years) with pars flaccida cholesteatoma and 63 ears of patients 9-84 years of age (mean 50 years) with pars tensa cholesteatoma were studied. All patients had undergone prior surgical management at our institution from January 2006 to April 2012. The incidence of fallopian canal dehiscence and its location were compared between pars flaccida and pars tensa cholesteatomas. Intraoperative findings of coexistent pathologies, including destruction of the stapes superstructure, labyrinthine fistula, and dural exposure, were compared between the dehiscence and no-dehiscence groups for the two types of cholesteatomas. The incidence of dehiscence was significantly higher in patients with pars tensa cholesteatoma (55.6 %) than in patients with pars flaccida cholesteatoma (26.5 %). Dehiscence located posterior to the cochleariform process occurred slightly more frequently in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. In patients with pars flaccida cholesteatoma, labyrinthine fistulas and dural exposure were significantly more frequent in the dehiscence group than in the no-dehiscence group. Fallopian canal dehiscence is more frequent in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. Especially in patients with pars flaccida cholesteatoma, paying special attention to these coexisting pathologies is important to increase preoperative detectability of dehiscence.

Aggressiveness of pediatric cholesteatoma. Do we have an evidence?

To compare pediatric and adult patients, affected by cholesteatoma for the clinical presentation, disease extent and final outcome. This is a prospective study in which 60 cases of unsafe chronic suppurative otitis media with cholesteatoma were included. These cases were divided into two groups of 30 cases each on the basis of age. All patients were subjected to detailed clinical examination. A high resolution computed tomography of the temporal bone was done in all the cases. An innovative grading system was devised to grade the disease. The patients were subjected to canal wall down mastoidectomy and were evaluated postoperatively for resolution of the symptoms, hearing and cavity problems. Granulation tissue along with cholesteatoma was more common among children (p < 0.01), whereas cholesteatoma alone was more common among adults. There was excellent correlation between the radiological and surgical findings. It was seen that higher the grade of the disease, the greater was the risk of complications and recidivism (p < 0.05). Recidivism was significantly higher in children (p < 0.05) whereas complications were equally common in both the groups. Hearing improvement was equivocal in both groups. Presence of granulation tissue along with cholesteatoma in children causes more aggressive disease with higher recidivism rate.

Facial nerve canal dehiscence in chronic otitis media without cholesteatoma

The information on incidence of the facial nerve canal dehiscence in chronic otitis media is important for surgeons. The purpose of this study is to disclose the histopathologic findings of facial nerve canal dehiscence in human temporal bones with chronic otitis media. We divided the human temporal bones into two groups (age 4 years, and under 4 years of age). We evaluated the incidence and the area of the facial nerve canal dehiscence in chronic otitis media under light microscopy. Age-matched normal control temporal bones were also examined. In the age group of 4 years, 68.9 % of temporal bones with chronic otitis media and 71.9 % of controls had the facial nerve canal dehiscence. There was no significant difference between them (P = 0.61). The area of the dehiscence in temporal bones with chronic otitis media was not statistically different from controls (P = 0.53). In the age group under 4 years, 88.2 % of temporal bones with chronic otitis media and 76.5 % of controls had the dehiscence. No significant difference was found between them (P = 0.66). The area of the dehiscence in temporal bones with chronic otitis media was not statistically different from controls in the age group under 4 years (P = 0.43). In chronic otitis media, the incidence of facial nerve canal dehiscence was high and was not statistically different from controls. These results suggest that there is no association between chronic otitis media and the presence of facial nerve canal dehiscence.

The dehiscent facial nerve canal

Accidental injury to the facial nerve where the bony canal defects are present may result with facial nerve dysfunction during otological surgery. Therefore, it is critical to know the incidence and the type of facial nerve dehiscences in the presence of normal development of the facial canal. The aim of this study is to review the site and the type of such bony defects in 144 patients operated for facial paralysis, myringoplasty, stapedotomy, middle ear exploration for sudden hearing loss, and so forth, other than chronic suppurative otitis media with or without cholesteatoma, middle ear tumors, and anomaly. Correlation of intraoperative findings with preoperative computerized tomography was also analyzed in 35 patients. Conclusively, one out of every 10 surgical cases may have dehiscence of the facial canal which has to be always borne in mind during surgical manipulation of the middle ear. Computerized tomography has some limitations to evaluate the dehiscent facial canal due to high false negative and positive rates.

Facial nerve dehiscence and cholesteatoma

OBJECTIVES

We evaluated the incidence of facial nerve dehiscence in a group of patients with cholesteatoma who underwent otologic surgery.

METHODS

We performed a retrospective study in a tertiary referral hospital of 336 patients (298 adults, 38 children) with cholesteatoma who underwent surgery in the years 1998 to 2008. Using intraoperative findings, we assessed the incidence of facial nerve dehiscence in a group of patients with cholesteatoma. We quantified, in adult versus pediatric patients and in primary versus revision surgeries, the occurrence of facial nerve dehiscence, the predisposed anatomic sites, and the coexistence of semicircular canal fistula. In a selected group of 67 patients, preoperative 0.55-mm collimation computed tomography (CT) scans were compared with the intraoperative findings.

RESULTS

The frequency of facial nerve dehiscence in this group of patients was 27.1%. The dehiscence was detected in 29.5% of the adults, but in only 7.8% of the patients 16 years and younger. Dehiscence was present in 42.3% of the patients who underwent revision surgery. The most common site of dehiscence (92.3%) was the tympanic segment. The sensitivity and specificity of CT were 69% and 87%, respectively.

CONCLUSIONS

Dehiscence of the facial nerve was found in 27.1% of patients with cholesteatoma, with a significant difference between patients of pediatric and adult ages. A dehiscent facial nerve was more commonly seen during revision surgery and more frequent in patients older than 16 years. The site of dehiscence most frequently involved by cholesteatoma was the tympanic segment. The presence of a semicircular canal fistula increases the risk of facial nerve dehiscence. Finally, the results of preoperative CT scans are encouraging for the use of CT in predicting facial nerve dehiscence.

Rehabilitation of canal wall down mastoidectomy using a titanium ear canal implant

OBJECTIVE

To describe the rehabilitation of canal wall down mastoidectomy cavities using a custom-made titanium wall implant and to analyze the benefits and the long-term functional results.

STUDY DESIGN

Retrospective analysis.

SETTING

Tertiary care center.

PATIENTS AND METHODS

We have reviewed the data of 113 consecutive operated ears from 106 patients during a 9-year period (1993-2002). The following preoperative and postoperative criteria were compared: the persistence or resolution of otorrhea, cholesteatoma, and vertigo; external auditory canal healing, position of the titanium prosthesis, and tympanic membrane findings. In addition, the hearing status was evaluated by comparing the preoperative data with the 6-month and last follow-up postoperative data to deduce the air-bone gap (ABG) and the auditory gains.

RESULTS

Operated ears (88.5%) were dry after the initial rehabilitation, and 97.3% were dry after a revision surgery for defective canal healing. Most patients (96.5%) were free of vertigo. The external auditory canal wall was in a good position in all cases and allowed for a primary skin healing process in 84% of cases; the remaining patients underwent revision surgery under local anesthesia to complete the healing. The reconstructed drum was stable and anatomic in 73% of the cases (n = 83) after the first surgery. Thirty-six patients (32%) underwent various revision procedures: aeration tube placement for 16 patients with mesotympanic retraction and/or serous effusion, revision surgery for 12 patients with attic retraction or evidence of cholesteatoma, and revision for 5 patients with perforation. At last follow-up, 100% of the ear canals were healed, and 85% of patients had a normal tympanic membrane. No residual cholesteatoma was found at last follow-up. Thirty-six percent of patients had an ABG within 20 dB at last follow-up, and 69% within 30 dB.

CONCLUSION

The rehabilitation of canal wall down mastoidectomies improves the quality of life of patients regarding cholesteatoma recurrence, otorrhea, and vertigo in more than 95% of cases and stabilizes the hearing loss to less than 30 dB of ABG for more than two thirds of patients. The main unresolved problem is the persistent dysfunction of the middle ear cavity, with unsatisfactory auditory improvements. Middle ear implants represent in selected cases a new solution to rehabilitate the refractory hearing losses.

Incidence of fallopian canal dehiscence at surgery for chronic otitis media

The objectives of this study were to determine the incidence and locations of dehiscence of the fallopian canal (FC) in patients undergoing surgery for different middle ear pathologies and to describe the findings that will aid in pre-operative prediction of dehiscence. Charts and operative details of the 118 ears managed with canal wall-down and 147 ears managed with canal wall-up tympanomastoidectomy performed by a single surgeon were retrospectively reviewed. The distribution of the diagnoses for ears that were operated was as follows: 118 ears cholesteatoma, 42 ears adhesive otitis, 23 ears tympanosclerosis, and 82 ears chronic otitis media. The presence and the location of facial nerve dehiscence after exenteration of the disease as well as the presence of any coexisting inner ear fistula and dural defect were noted. FC dehiscence was observed in 56 of the cases. The incidence of dehiscence was highest among ears with cholesteatoma (n = 44, P < 0.05). Adults and also male patients in the study had significantly higher incidence of dehiscence compared to pediatric (P < 0.05) and female (P < 0.01) patients. The most common location for dehiscence was the tympanic segment which was significantly higher than the other locations (P < 0.01). Among the ears with FC dehiscence, labyrinthine fistula presence was seen in ten ears which was also significant (P < 0.001). Patients with dural exposure were 12.06 times more likely to have FC dehiscence than those without dural exposure. The incidence of FC dehiscence was 1.26 times higher in revision operations, but the difference was not significant (P > 0.05). An otologic surgeon should be more careful while performing operation for cholesteatoma in an adult and male patient because of the high incidence of dehiscence observed in these ears. Presence of lateral semicircular canal fistula and erosion of the bony tegmen should also be considered as a clue for the presence of dehiscence before surgery. Operation of these ears should be performed by experienced surgeons in otology.