The role of allergic and nonallergic rhinitis on success of type 1 cartilage tympanoplasty

OBJECTIVE

To investigate the role of allergic rhinitis (AR) and non-allergic rhinitis (NAR) on success of type 1 cartilage tympanoplasty.

METHODS

This prospective study was conducted on 60 patients who had type 1 cartilage tympanoplasty. The patients were divided into three groups as no-rhinitis (n = 28), NAR (n = 18) and AR (n = 14) groups, based on their symptoms, skin prick tests and/or serum specific IgE levels. AR and NAR groups were treated for their rhinitis symptoms both pre- and postoperatively. The patients were followed up for a minimum of 6 months and compared for graft success rates and audiological outcomes.

RESULTS

Three study groups were similar for age, gender distributions and preoperative air-bone gaps (p = 0.780, p = 0.167 and p = 0.676, respectively). Postoperative graft perforation rate was 0% in no-rhinitis and AR groups while it was 16.7% in NAR group, with a significant difference among three groups (p = 0.034). The comparison of three study groups for change in the postoperative air bone gaps in comparison with preoperative air bone gaps did not yield any statistically significant result (p = 0.729).

CONCLUSION

Although AR does not result in failure of type 1 cartilage tympanoplasty in patients treated for rhinitis compared to the control group, NAR does. Pre- and postoperative treatment of patients for rhinitis and employment of cartilage graft may be the key factors for success of surgery in patients with AR. Further studies with a larger sample size are needed.

Clinical diagnoses of patients showing caloric inversion

OBJECTIVES

When air irrigation is used for caloric stimulation in patients with a perforated ear, warm irrigation may elicit a nystagmus that initially beats in the opposite direction of what is expected for warm irrigations, which is referred to as "caloric inversion". This study aimed to investigate the disease group in which caloric inversion appeared in patients who underwent caloric testing and to classify the patterns of caloric inversion.

METHODS

We conducted a retrospective review of bithermal caloric test results that were collected in our dizziness clinic between 2005 and 2022. Caloric inversion was defined when nystagmus induced by caloric stimulation appeared in the opposite direction to that expected. The incidence of caloric inversion among all patients who underwent bithermal caloric tests was calculated. To confirm the clinical diagnoses of the patients with caloric inversion, their clinical records were reviewed.

RESULTS

Out of 9923 patients who underwent bithermal caloric tests, 29 patients (0.29%) showed a caloric inversion. The most common clinical diagnosis was chronic otitis media (21 of 29, 72%). Of the 21 patients with chronic otitis media, 20 patients showed a caloric inversion by warm air irrigation and one patient showed caloric inversion by cold air stimulation. Patients with clinical diagnoses other than chronic otitis media such as sudden sensorineural hearing loss, benign paroxysmal vertigo of childhood and recurrent vestibulopathy showed caloric inversion by warm air irrigation. Caloric inversion by warm water irrigation was observed in patients with lateral semicircular canal cupulopathy and recurrent vestibulopathy. Two patients (one with Meniere's disease and one with age-related dizziness) showed caloric inversion by cold water irrigation.

CONCLUSION

Caloric inversion can be observed in various diseases other than chronic otitis media with tympanic membrane perforation. Special care should be taken in the interpretation of caloric test results.

LEVEL OF EVIDENCE

Level 4.

Bone cement in ossicular chain reconstruction: systematic review and meta-analysis

OBJECTIVES

To compare the hearing outcomes of ossicular chain reconstruction using bone cement versus other materials such as prostheses and autografts.

METHODS

This study included articles that compared hearing outcomes in patients with conductive hearing loss who underwent stapes revision surgery or chronic otitis media surgery. A systematic search for articles from January 2000 to February 2022 was conducted in Medline, Embase, and Cochrane Library databases. Only articles in English were included. An effective postoperative air-bone gap (ABG) was defined as ≤20 dB. A bias assessment tool was developed according to Cochrane guidelines, and the chi-square test was used to evaluate the mean age of the samples.

RESULTS

Of the 418 studies that met the selection criteria, only seven were eligible for this study, consisting of 187 patients in the bone cement group and 173 in the non-bone cement group. Ossiculoplasty using bone cement yielded significantly better results, with a combined odds ratio (OR) of 2.03 (95% CI: 1.16-3.55, p = 0.01).

CONCLUSIONS

The results of this study suggest that the effectiveness of bone cement in ossiculoplasty was greater than that of other materials in chronic otitis media surgery or stapes revision surgery, with a higher number of patients achieving ABG ≤20 dB.

Our Experience of Comparison of Hearing Outcomes in Patients Undergoing Type-1 Tympanoplasty with Different Graft Materials

The present study was undertaken to compare the results of various autogenous tissues: temporalis fascia, sliced tragal cartilage and fascia lata as graft materials for type I tympanoplasty in terms of hearing improvement in safe type of chronic suppurative otitis media. A total of 75 cases with central perforation were considered in the study. Of the 75 cases, temporalis fascia graft was used in 25 cases (Group-A), fascia lata graft in 25 cases (Group-B), and sliced tragal cartilage graft in 25 cases (Group-C). The results were evaluated in the form of hearing improvement with respect to the graft materials. A significant association was observed between the groups, that is, temporalis fascia (Group-A), fascia lata (Group-B), and sliced tragal cartilage (Group-C) in terms of improvement in AB gap (P = 0.047). Improvement in AB gap was statistically significant between groups B and A, but not between the other groups. In the present study, fascia lata showed better graft uptake as compared to temporalis fascia and sliced tragal cartilage. The hearing assessment at post-operative 3rd month showed statistically significant hearing improvement with fascia lata when compared to temporalis fascia.

Outcomes of Palisade Cartilage Tympanoplasty in Chronic Otitis Media: Our Experience at a Tertiary Care Centre

To evaluate the anatomical and functional success rates of palisade cartilage tympanoplasty in chronic otitis media. Thirty patients with chronic otitis media with subtotal perforation underwent palisade cartilage tympanoplasty and were assessed prospectively. The outcomes evaluated were graft uptake and hearing gain. Overall graft uptake was 90% with failure in 3 cases. The preoperative mean air conduction threshold was 22.087 ± 6.120 dB which was improved to 13.387 ± 5.253 dB postoperatively at 12 weeks which was statistically significant. The mean postoperative ABG closure was 8.700 dB with a p value of 0.001 which was statistically significant. Palisade cartilage tympanoplasty demonstrates that subtotal perforations, which are at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the tympanic membrane with reasonable hearing can be achieved.

Tympanomastoidectomy versus parenteral antibiotic therapy for pediatric otorrhea

OBJECTIVE

To evaluate the efficacy of tympanomastoidectomy versus parenteral antibiotic therapy for otorrhea as a result of chronic suppurative otitis media (CSOM) without cholesteatoma in the pediatric population.

METHODS

A retrospective review of 221 patients treated for otorrhea at a tertiary academic pediatric hospital was performed to evaluate the impact of tympanomastoidectomy versus parenteral antibiotic therapy on resolution of otorrhea. Inclusion criteria were age 0-18 years, prior treatment with otic and/or oral antibiotic, prior history of tympanostomy tube placement for recurrent otitis media, history of otorrhea, treatment with tympanomastoidectomy or parenteral antibiotic therapy, and follow-up of at least 1 month after intervention. Time to resolution was compared between the two modalities adjusting for age, bilateral ear disease status, and comorbidities using a Cox proportional hazard model.

RESULTS

Eighty-three ears from 58 children met the inclusion criteria. Ears that initially underwent tympanomastoidectomy had a significantly shorter time to resolution of symptoms (median time to resolution) 9 months (95 % confidence interval CI: 6.2-14.8) vs. 48.5 months (95 % lower CI 9.4, p = 0.006). On multivariate analysis, however, only bilateral ear disease status was independently associated with time to resolution of symptoms (hazard ratio 0.4, 95 % CI 0.2-0.9, p = 0.03). There was no statistically significant difference in the rate of treatment-related complications when comparing tympanomastoidectomy to parenteral antibiotic therapy (p = 0.37).

CONCLUSION

When adjusting for age, bilateral ear disease status, and comorbidities, there does not appear to be a significant difference in time to resolution of symptoms when comparing parenteral antibiotic therapy to tympanomastoidectomy. An informed discussion regarding risks and benefits of each approach should be employed when deciding on the next step in management for patients with CSOM who have failed more conservative therapies.

Determinants of Cochlear Dysfunction in Chronic Otitis Media: Mucosal Disease

The nature of association between chronic otitis media (COM)-mucosal disease and sensorineural hearing loss is controversial. Identifying the risk factors which influence the bone conduction threshold in these patients can help the clinician in counselling the patients for surgery at the earliest to achieve optimum hearing outcomes. The present study was undertaken to determine the association between COM-mucosal disease and cochlear dysfunction. The study also aimed at identifying the determinants and their influence on the bone conduction thresholds of the diseased ear. In this study, 72 patients with unilateral chronic otitis media-mucosal disease were enrolled consecutively. All patients were enquired in detail about their presenting ear symptoms. All the patients underwent a pure tone audiogram in a sound treated room. Patients were categorised into two groups according to the presence of conductive hearing loss only or with a sensorineural component. The bone conduction thresholds were calculated and compared for frequencies at 0.5, 1, 2 and 4 kHz. The average hearing threshold for air conduction and bone conduction were calculated across 0.5, 1 and 2 kHz. Bone conduction threshold more than 20 decibels (dB) in any of the frequencies were considered significant and indicative of having sensorineural hearing loss component. The contralateral healthy ear served as control to cancel out the confounding factors such as presbyacusis, noise induced hearing loss, congenital hearing loss, etc. Multivariate linear regression models were used to evaluate the relationships between bone conduction thresholds and chronic otitis media-mucosal disease. In the present study, 18.05% of participants had a sensorineural component. The difference between the bone conduction threshold in the diseased ear and normal ear ranged from 5.41 dB at 0.5 kHz to 3.77 dB at 4 kHz (p < 0.001). Bone conduction thresholds at 4 kHz were greater than that for speech frequencies (p < 0.5). 84.6% of participants with sensorineural component had a disease duration of less than 5 years and the remaining 15.4% had a duration of greater than 15 years. There was no statistically significant difference in the incidence of sensorineural component based on the site of the perforation (p = 0.341). 21.9% of participants who used topical antibiotic drops developed a sensorineural component, while 15% of participants who did not use antibiotic ear drop preparation developed a sensorineural component. Multivariate linear regression analysis revealed that increasing age was the only factor associated with increase in bone conduction thresholds of the diseased ear (p = 0.002). Chronic otitis media- mucosal disease appears to be associated with higher bone conduction thresholds, signifying cochlear dysfunction. A statistically significant higher bone conduction thresholds are seen across 0.5 to 4 kHz in the diseased ears compared to the normal ears, signifying the vulnerability of the inner ear against chronic otitis media. In our analysis increasing age is the most significant predisposing factor associated with higher bone conduction thresholds. Higher frequencies are more affected than lower speech frequencies. Sensorineural hearing loss can occur early in the disease process and early surgical intervention in COM-mucosal disease is recommended to prevent increase in bone conduction thresholds and achieve optimum hearing outcomes.

A Study on the Outcome of Myringoplasty in Small to Medium Sized Perforations Using Collagen Sheet as Graft Material

Chronic Otitis Media is a global health problem causing significant morbidity of life. Various medical and surgical treatment modalities are being used for the treatment of Chronic Otitis Media. Surgical treatment is the definitive option which includes different surgical procedures, all of which have been designed to attain the same goals of eradicating disease and achieve a safe and dry ear with closure of tympanic membrane perforations. Various graft materials are being used for the closure of tympanic membrane perforations like autografts, isografts, allografts and xenografts, each having its own advantages and limitations. The trend towards increasingly less invasive medical procedures, with shorter hospitalisation stay has led to demand for materials to replace autologous grafts, one such material being the collagen. The purpose of this study is to evaluate the outcome of myringoplasty in small to medium sized perforations using collagen sheet as the graft material. In the period from November 2018 to May 2020, 50 patients after fulfilling the inclusion and exclusion criteria were taken up for myringoplasty. They underwent myringoplasty using transcanal approach and collagen sheet was used to close the tympanic membrane perforation. Post-operatively, patients were treated with antibiotics and regularly followed up. Otoendoscopy was done at the end of 1st month and 3rd month. At the end of 3 months, patients were evaluated for graft uptake and pure tone audiometry repeated to evaluate the post-operative hearing gain. In this study, we examined a total of 50 patients with 25 males and 25 females (50%). The mean age of our patients was 29.42 years, ranging from 18 to 60 years; with almost 66% between 21 and 40 years. Treatment was considered successful if there was complete closure of tympanic membrane perforations. Of the 50 patients that were included; graft uptake was noted in 46 patients i.e. in 92%, closure was achieved at the end of 3 months. Four failures in our study were due to infections. In this study, the graft uptake following myringoplasty was analyzed with statistically significant objective parameters like age, gender, size of perforation, laterality of disease, etiology of CSOM that affect the success of tympanoplasty. It was observed that small sized perforations had more chances of graft uptake. Post-operative hearing outcomes were also evaluated and was found to be statistically significant. Collagen sheet provided promising results as a graft material for myringoplasty and the graft uptake rates were comparable to the success rates of other conventional autologous grafts. Post operatively, significant improvement in hearing was also noted.

Comparison of temporalis muscle fascia and cartilage grafts for primary type 1 tympanoplasty: a meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of temporalis fascia (TF) with cartilage grafts for primary type 1 tympanoplasty in chronic otitis media (COM) patients.

METHODS

Computerized search was performed in MEDLINE, Embase, and CENTRAL. Eligible for inclusion were randomized controlled trials (RCTs) comparing TF and cartilage grafts in individuals with non-cholesteatoma COM and intact ossicles requiring type 1 tympanoplasty. Primary outcomes were graft success and hearing improvement, measured by the air-bone gap (ABG) closure. The secondary outcome was the occurrence of complications. Standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated.

RESULTS

Eighteen RCTs that enrolled 1273 participants were found eligible. Data were reported at follow-up periods ranging from 6 weeks to 24 months. The pooled effect estimate revealed a higher and statistically significant graft success favoring cartilage grafts at 12 months (OR = 2.24, 95% CI 1.33-3.78) and 24 months (OR = 2.96, 95% CI 1.18-7.43). There was no significant difference between both grafts in post-operative ABG closure across all follow-up periods (6 weeks to 12 months).

CONCLUSIONS

Compared to TF, primary type 1 cartilage tympanoplasty offers better graft uptake rates and comparable postoperative hearing outcomes for COM patients.

Surgical Outcomes of Type 1 Tympanoplasty in Chronic Otitis Media in Paediatric Patients: A Prospective Study

Objectives: To observe the surgical outcome of type 1 tympanoplasty in paediatric patients in the form of graft uptake and audiological improvement. Materials and methods: A prospective study was done in which 40 paediatric patients in age group 6-16 years, diagnosed of chronic otitis media, were taken up for tympanoplasty under general anaesthesia. Patients were followed in post operative period at 4, 6 and 12 weeks for assessment of graft status and audiological evaluation. Results: In this study, we found surgical success rate in the form of graft uptake in 80% of the cases and audiological improvement in 75% of the cases. Conclusion: Tympanoplasty is safe and effective in children with adequate graft uptake and audiological outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03965-1.

A Comparative Study to Determine Hearing Outcome in Type 1 Tympanoplasty With and Without Canaloplasty in Tubotympanic Type of Chronic Suppurative Otitis Media

Background

Chronic suppurative Otitis Media is a common ear infection in India. Canaloplasty done with tympanoplasty helps to remove bony overhangs and provide complete visibility of fibrous annulus of tympanic membrane.

Aim

1. To determine the hearing outcome in chronic otitis media (mucosal type) patients undergoing type 1 tympanoplasty with canaloplasty. 2. To determine the hearing outcome in chronic otitis media (mucosal type) patients undergoing type 1 tympanoplasty without canaloplasty. 3. To compare the hearing outcome in the above mentioned 2 groups of patients.

Materials and Methods

56 patients of 15-60 years of age with mucosal type of Chronic otitis media, with central dry perforation and intact ossicles were included in our study. They were divided into group 1 (type 1 tympanoplasty + canaloplasty) and group 2 (type 1 tympanoplasty without canaloplasty), on alternate basis. AC, BC, Air bone gap avg was assessed via pure tone audiometry at 4 frequencies preoperatively and postoperatively at 3rd and 6th month, % closure of ABG average was calculated.

Results

Type 1 tympanoplasty along with canaloplasty has better hearing improvement in pure tone audiometry compared to type 1 tympanoplasty alone, as % closure of ABG at postoperative 3rd and 6th month holds significant.

Conclusion

The canaloplasty provides better surgical exposure via removing bony overhangs, aids in excellent functional outcome in the form of % closure of ABG. Hence canaloplasty is added as an adjunct to routinely performed aural surgeries to enhance hearing outcome.

Middle cranial fossa tumor presenting as chronic otitis media: Rare case of aneurysmal bone cyst

INTRODUCTION

Aneurysmal bone cysts (ABCs) are a rare, vascular, rapidly growing, benign, osteolytic lesions. Most ABCs involve the metaphysis of long bones, vertebrae, or flat bones. In this study, we review the literature to better understand the natural history, clinical presentation, and treatments.

PRESENTATION OF CASE

A 34-year-old man who presented with left intermittent otorrhea for months. Yellowish, pus-like discharge was noted. Mild tinnitus, hearing loss, and occasional headache was also found. The initial impression was chronic otitis media and ear drops were prescribed. However, his symptoms did not improve in the following months. The brain MRI with gadolinium enhancement revealed an extra-axial mixed signal intensity lesion on the T2-weighted image, multiloculated cystic components and rim enhancement was noted over the left middle cranial fossa. Left fronto-temporal craniotomy for tumor removal was performed. The pathological reports revealed an aneurysmal bone cyst.

CLINICAL DISCUSSION

Typically, ABCs present with localized swelling and pain due to their rapid growth and expansion, with concomitant signs corresponding with the anatomical location of the lesion. MRI studies can reveal the cystic components of the lesion and multiple fluid levels within multiloculated cysts resulting from unclotted blood, separated from the soft tissue and medullary bone. Histopathologic diagnosis of ABC is the presence of multiple blood-filled cystic spaces separated by fibrous septa. The fibrous septa are composed of spindle-celled fibroconnective tissue with occasional osteoclast-type giant cells.

CONCLUSION

ABCs are a rare, osteolytic lesions that rarely involve the skull. When the MRI shows a lesion with soap-bubble appearance in the calvaria, an aneurysmal bone cyst should be considered in the differential diagnosis, even if it is an extremely rare entity or the patient is relatively old. Surgical resection of the tumor is the first choice for treatment.

Sensorineural Hearing Loss in Unilateral Mucosal Type of Chronic Otitis Media

Sensorineural hearing loss is relatively well established in the squamosal chronic otitis media. However, its association with mucosal COM is still debated. The present study aimed at evaluating the prevalence of sensorineural hearing loss in unilateral mucosal COM. The study was conducted at a tertiary care hospital in New Delhi, and 60 patients with unilateral mucosal chronic otitis media were recruited. Pure tone thresholds were ascertained for air and bone conduction in an acoustically treated room and matched against certain patient and disease characteristics. In this study, the combined prevalence of SNHL/Mixed Hearing loss in mucosal COM was found to be 8.3%. A statistically significant association between SNHL/Mixed HL was seen in the 40-50-year age group (p-0.004). Prevalence with a disease duration of more than 10 years was 33% (p-0.019). All the patients who presented with SNHL/Mixed HL had an actively discharging ear. 80% of the patients who presented with SNHL/Mixed HL had large perforations. SNHL/Mixed HL prevalence of 28.6% was found in smokers, compared to 5.7% in non-smokers (p-0.039). The risk of developing SNHL/Mixed HL increased with increasing patients' age, disease duration, and size of the perforation and smokers.

Is pre-operative audiometry a reliable predictor of ossicular chain condition?

OBJECTIVE

Investigation of ossicular chain (OC) status before surgery is important for preoperative patient consultation. This research aimed to investigate the relationship between pre-operative audiometric values and intra-operative OC condition in a relatively large population of chronic otitis media (COM) surgeries.

METHODS

In this descriptive-analytic cross-sectional study, we evaluated 694 patients who underwent COM surgeries. We analyzed pre-operative audiometric data and intraoperative findings including ossicular anatomy, ossicular mobility, and the condition of middle ear mucosa.

RESULTS

The optimal cut-off values of pre-operative speech reception threshold (SRT), mean air-conduction (AC), and mean air-bone gap (ABG) for predicting OC discontinuity were 37.5 dB, 37.2 dB, and 28.4 dB, respectively. For the prediction of OC fixation, the optimal cut-off points of SRT, mean AC, and mean ABG were 37.5 dB, 40.3 dB, and 32.8 dB, respectively. The computing of Cohen's d (95 % confidence interval) demonstrated the greater mean ABG in ears with OC discontinuity in comparison with ears with normal ossicles in all types of pathologies. There was a descending trend of Cohen's d from cholesteatoma to tympanosclerosis and then to granulation tissue and hypertrophic mucosa. There was a substantial relation between the type of pathology and OC status (P < 0.001). Ears with tympanosclerosis plaque had the most fixed OC among all types of pathologies (40 ears, 30.8 %), and ears with no pathology had the most normal OC (135 ears, 83.3 %).

CONCLUSIONS

The results supported the view that pre-operative hearing is a key determining factor for the prediction of OC status.

Hearing Outcome After Incudo-stapedial Joint Reconstruction Using Conchal Cartilage Interposition Graft

Ossicular chain defects secondary to Chronic otitis media most frequently involves the incudo-stapedial joint. This study observes the effect of incudo-stapedial joint reconstruction using conchal cartilage interposition graft on hearing of the patient. Fifty-three patients with chronic otitis media of inactive mucosal type with incudostapedial necrosis of less than half of long process of incus were posted for tympanoplasty with incudostapedial joint reconstruction using autologus conchal cartilage. Their hearing outcome was analysed by comparing the pre-operative and 12 weeks post-operative Pure Tone Audiogram. A statistically significant improvement is seen in air conduction by 14.66 dB after incudo-stapedial joint reconstruction using conchal cartilage (p value 0.0001), whereas improvement seen in bone conduction was statistically insignificant. 52 (98.1%) patients had ≤ 40 dB post-op AC and 1 (1.9%) had > 40  dB.. Conchal cartilage is an easy-to-harvest, biocompatible and cost effective graft material. It gives hearing results comparable to other materials.

ABO blood type correlates with risk and protective factors for chronic suppurative otitis media

BACKGROUND

ABO blood type associated with differentiated onset of infectious diseases.

AIMS/OBJECTIVE

To investigate whether people with different blood types were vulnerable in developing chronic otitis media (CSOM) and if the risk and protective factors varied among them.

MATERIAL AND METHODS

The study was a case-control study that included 206 participants in the case group and 210 in the control group. Stratified analysis for blood type was adopted.

RESULTS

Patients with different blood types were insignificantly different in the incidence of CSOM. Upper respiratory tract infection (URTI, OR = 21.81, 95% CI: 4.80-99.06), socioeconomic status (OR = 3.02, 95% CI: 1.35-6.74), and were risk factors in blood type A. In blood type B, smoking and urban residence were risk factors. The OR (95% CI) were 11.42 (2.77-47.08), and 0.14 (0.03-0.65). Urban residence, BMI and blood calcium increase, male gender were protective factors for different blood types.

CONCLUSIONS AND SIGNIFICANCE

Our study identified the risk and protective factors for CSOM among different blood types. The findings might provide new insights into taking precautions against CSOM in people of different blood types.

Impact of titanium-prepared platelet-rich fibrin in type 1 fascia graft tympanoplasty on graft survival and hearing outcomes

Background

Type 1 fascia graft tympanoplasty (T1FGT) is the mainstay surgical approach for the treatment of tympanic membrane perforations. The most widely used graft material is temporal muscle fascia, and graft take rates are reported differently. The methods to enhance graft take are still being investigated. Aim: The aim of our study was to investigate the effect of titanium-prepared platelet-rich fibrin (T-PRF) on graft take and hearing outcomes in T1FGT.

Materials and Methods

Fifty-seven ears eligible for T1FGT were involved in the study and prospectively evaluated. T-PRF was applied with T1FGT in 27 ears. Thirty ears in the other group underwent only T1FGT. The patients underwent an otomicroscopic and audiometric examination in preoperative and postoperative 2nd week, 1st month, and 6th month. Both groups were evaluated in terms of hearing levels, infection, and graft take rates.

Results

Two patients in the T1FGT + T-PRF group and seven patients in the T1FGT group had postoperative perforation (graft take rate: 92.6% versus 76.7%). The graft take rate was found to be increased in the T-PRF group although the difference was not statistically significant. In the T1FGT group, the percentage of infection was higher than in the T1FGT + T-PRF group. When the preoperative and postoperative 6th-month audiometry was compared, a statistically significant hearing gain was obtained for both groups.

Conclusion

In the treatment of tympanic membrane perforations, T-PRF applied over the fascia graft was shown to increase graft take rates and decrease the probability of infection. Further studies with larger samples are needed to demonstrate the effects of PRF.

[Actinomyces europaeus (Gleimia europaea) associated with brain abscess: A report of three cases]

A brain abscess is a focal infection characterized by a collection of pus in the brain parenchyma. It is a life-threatening condition that should be diagnosed and treated as soon as possible. We report here three cases of patients with otogenic brain abscesses of polymicrobial origin that had in common the isolation of Actinomyces europaeus, which has not been previously described in this location. A. europaeus was identified by the conventional methodology, matrix-associated laser deionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. Antibiotic susceptibility was evaluated by the epsilometric method, and all isolates showed sensitivity to penicillin, vancomycin and linezolid, whereas susceptibility to clindamycin and erythromycin was variable. MALDI-TOF MS identification allowed a quick and reliable species level identification in order to provide a rapid and effective response to avoid treatment delay that could lead to increased morbidity and even mortality.

Pathophysiological Link Between Chronic Rhinosinusitis and Ear Disease

PURPOSE OF REVIEW

In the clinical practice, patients affected by chronic rhinosinusitis (CRS) commonly complain of otologic symptoms. This review aims to describe the available literature evidence assessing the relationship between CRS and ear illnesses published in the last 5 years.

RECENT FINDINGS

Available evidence suggests a higher prevalence of otologic symptoms in patients suffering from CRS, affecting up to 87% of patients. These symptoms may be related to Eustachian tube dysfunction, which improves after treatment for CRS. A few studies suggested a potential but not confirmed role of CRS in cholesteatoma, chronic otitis media, and sensorineural hypoacusis. A special type of otitis media with effusion (OME) may occur in patients with CRS, which seems to respond well to new biologic therapy. Ear symptoms appear to be highly prevalent in patients with CRS. So far, the available evidence is robust only for Eustachian tube dysfunction, which has been shown to be particularly impaired in CRS patients. Additionally, the Eustachian tube function appears to improve after treatment for CRS. Finally, interesting preliminary data were described for eosinophilic otitis media, as it appears to respond well to the treatment with biologics.

Chronic otitis media and middle ear variants: Is there relation?

BACKGROUND

Chronic otitis media (COM) is an inflammatory disease that lasts for a long time. It is common in developing countries. Hearing loss can result from COM. The relationship between variations in middle ear anatomy and COM was investigated in our study.

AIM

To compare the prevalence of middle ear anatomic variations between the cases with COM and healthy individuals.

METHODS

This retrospective study included 500 patients with COM and 500 healthy controls. The presence of those variants was determined: Koerner’s septum, facial canal dehiscence, high jugular bulb, jugular bulb dehiscence, jugular bulb diverticulum, sigmoid sinus anterior location and deep tympanic recesses.

RESULTS

A total of 1000 temporal bones were examined. The incidences of these variants were respectively (15.4%-18.6%), (38.6%-41.2%), (18.2%-4.6%), (2.6%-1.2%), (1.2%-0%), (8.6%-0%), (0%-0%). It was observed that only high jugular bulb (P < 0.001) and anteriorly located sigmoid sinus frequencies (P = 0.002) in the case group were statistically significantly higher than the control groups.

CONCLUSION

COM is a multifactorial disease and variants of middle ear have always been important in terms of potential risk for complication during surgery but rarely associated with COM as an etiology or as a consequence of the disease. We didn't find a positive correlation between COM and Koerner’s septum and facial canal defect. We ended up with a significant conclusion with the variants of dural venous sinuses -high jugular bulb, dehiscence of jugular bulb, diverticulum of jugular bulb and anteriorly located sigmoid sinus- that have been studied less and frequently associated with inner ear illnesses.

Impact of Intraoperative Findings on Hearing in Revision Ear Surgery

Introduction

Hearing results after chronic ear surgery encompass recurrence, localization and extent of cholesteatoma, type of surgery, ossiculoplasty methods, but rarely interpret intraoperative findings. This study aimed to analyze the impact of intraoperative findings in revision tympanomastoidectomy in predicting postoperative hearing.

Materials and Methods

This was a retrospective non-randomized cohort of 101 patients treated for recurrent chronic otitis media by tympanomastoidectomy. The patients' demographics, localizations of disease recurrence and perioperative hearing results were analyzed.

Results

Logistic regression showed that presence of tympanic perforation (p=0.036), ossicular chain damage (p=0.006), were negatively associated with improved hearing postoperatively. Attic cholesteatoma was associated with better postoperative hearing (p=0.045). Presence of tympanic perforation (p=0.050), alongside perifacial localization of imflammation (p=0.021) and ossicle destruction (p=0.013) were associated with worse postoperative hearing results. Multivariate analysis confirmed that tympanic perforation (p=0.040, F=4.401), and ossicular chain involvement (p=0.025, F=5.249), were consistent negative predictors of hearing improvement, while postoperative deterioration of hearing was associated with tympanic perforation (p=0.038, F=4.465) and facial nerve dehiscence (p=0.045, F=4.160).

Conclusions

Comparison of postoperative revision tympanomastoidectomy hearing outcomes revealed significant positive reductions in air-bone gap values, primarily at low and mid frequencies. Postoperative hearing results at high frequencies are not affected by revision surgery.

Bacterial diversity of middle ear cholesteatoma by 16S rRNA gene sequencing in China

In this study, the bacterial diversity of acquired middle ear cholesteatoma (MEC) was evaluated to reveal its pathogenesis and provides a guide for the use of antibiotics. Twenty-nine cases of acquired MEC and eight cases of healthy middle ears undergoing cochlear implantation (CI) were evaluated. Full-length 16S rRNA gene sequencing was performed to profile the bacterial communities in lesions and healthy tissues of the middle ear. ACE (P = 0.043) and Chao1 (P = 0.039) indices showed significant differences in alpha diversity (P < 0.05). Analysis of PERMANOVA/Anosim using the Bray-Curtis distance matrix results suggested that the between-group differences were greater than the within-group differences (R = 0.238, P < 0.05, R² = 0.066, P < 0.05). Bacterial community analysis revealed that Alphaproteobacteria at the class level and Caulobacterales and Sphingomonadales at the order level were significantly different (P < 0.05). In the LefSe (Linear discriminant analysis effect size) analysis, Porphyromonas bennonis was elevated, and Bryum argenteum and unclassified Cyanobacteriales were reduced at the species level in MEC (P < 0.05). Fifteen metabolic pathways were found to be significantly different between the two groups by analysing the abundance of metabolic pathways in level 2 of the Kyoto Encyclopaedia of Genes and Genomes (KEGG). Seven and eight metabolic pathways were significantly elevated in the MEC and control groups, respectively (P < 0.05). The role of bacteria in the pathogenesis of acquired MEC was further refined through analysis of metabolic pathways. These findings indicate that the acquired MEC and healthy middle ear contain more diverse microbial communities than previously thought.

Labyrinthine Fistula in Chronic Otitis Media Surgery: Management and Outcomes

The objective of this retrospective study was to present the experience on the management of labyrinthine fistula secondary to chronic otitis media in a tertiary center. 263 patients, who underwent tympanomastoidecomy, in Centro Hospitalar Universitário do Porto, between 2015 and 2020 were reviewed, to select only those with labyrinthine fistulas. 26 patients (9.89%) had cholesteatoma complicated by fistula of the lateral semicircular canal. Most frequent symptoms were unspecific, such as otorrhea, hearing loss and dizziness. Preoperative high-resolution computed tomography predicted fistula in 54%. Using the Dornhoffer and Milewski classification, 10 cases (38.46%) were identified as stage I, 15 (57.69%) at stage II, and 1 (3.85%) as stage III. The choice between open or closed surgical procedure was independent of the type of fistulae. The cholesteatoma matrix was completely removed from the fistula and immediately covered by autogenous material. In one patient matrix was left over the fistula. After surgery, hearing (bone conduction) was preserved or improved in 73% of the patients. There was no statistically significant relationship between the extent of the labyrinthine fistula, type of material used in fistula repair and the hearing outcome. Also, we didn't find a statistically significant relationship between extent of the labyrinthine fistula and the presence of facial nerve canal dehiscence, tegmen timpani erosion, sigmoid sinus exposure or ossicular bone erosions. In conclusion, a complete and nontraumatic removal of cholesteatoma matrix over the fistula in a single-staged procedure, is a safe and effective procedure, which achieves a hearing preservation or improvement in most cases.

Paediatric Type 1 Tympanoplasty: Comparison of Full Thickness Tragal Cartilage Versus Temporalis Fascia Graft-A Randomised Controlled Trial

Tympanic membrane perforation in children usually appears as a sequel of middle ear infection. This study was conducted to compare the anatomical and functional outcomes of cartilage and temporalis fascia graft in type 1 tympanoplasty in Paediatric population.

DESIGN

A hospital based randomized controlled trial.

SETTING

A tertiary care institute of central India.

SUBJECTS

All consecutive paediatric patients between 5 and 18 years of either sex attending ENT OPD and Paediatric OPD fulfilling inclusion criteria were included in the study. Anatomical and functional results of total 90 patients who underwent tympanoplasty were analyzed. These patients were divided into two groups depending on the graft material used. The cartilage group and the temporalis fascia group each comprising of 45 patients respectively.

METHODS

All patients underwent Type I tympanoplasty under general anaesthesia and with a post auricular approach. The surgeries were performed by senior surgeons. The graft success rate of the cartilage group (91.1%) was higher than the fascia group (84.44%) but the difference was not statistically significant (p = 0.449). The air bone gap closure was slightly better with temporalis fascia group than with cartilage group but the overall functional success rate in both the groups was not statistically significant.Cartilage and fascia grafts yield similar results for hearing gain and graft success rate in paediatric tympanoplasty.

A Study of Complications, Sinonasal Predispositions and Microbiological Profile of Chronic Otitis Media

Keeping in view the changing flora of chronic otitis media (COM), geographical variability of its complications and differential prevalence of sinonasal predisposing diseases in these patients, we studied the microbiological profile along with the complications and sino-nasal diseases in patients with COM. It was a Cross-sectional study conducted during Nov 2017 to Dec 2019 in department of Otorhinolaryngology, Jawaharlal Nehru Medical College, AMU, Aligarh. The study included 200 cases of chronic suppurative otitis media, both Mucosal (safe) and Squamous (unsafe) type, out of which 111 (55.5%) were males and 89 (44.5%) were females. The overall prevalence of complications in patients with COM in our study was high at 6.5% with 61.54% complications being extracranial and 38.46% were intracranial. DNS was the most common sino-nasal disease found in 22.5% of patients followed by Inferior turbinate hypertrophy, Adenoid hypertrophy and polyp in 6.5%, 5.5% and 4% of participants respectively. A culture positive result was found in 84.5% of the samples with 55.5% samples being monomicrobial and 29.0% being polymicrobial. COM like the other chronic diseases impacts quality of life. As long as health-care delivery fails to target high-risk groups in developing countries such as ours infections like CSOM will persist with its adverse consequences. With the development and widespread use of antibiotics, the types of pathogenic micro-organisms and their sensitivity to antibiotics have changed. Continuous evaluation of pattern and antibiotic sensitivity of isolates is necessary to decrease the potential risk of complications by early institution of appropriate treatment.

A Randomised Controlled Trial on the Efficacy of Topical Application of Autologous Platelet Rich Plasma (PRP) on Graft Uptake Rate in Adults Undergoing Type 1 Tympanoplasty for Inactive COM Mucosal Disease

To assess the efficacy of topical use of autologous platelet rich plasma (PRP) as a packing material in type 1 tympanoplasty in Mucosal Inactive COM disease by conducting a Randomized Controlled Trial in 80 patients. Prospective Randomized Controlled Trial. Total 80 patients were enrolled for the study after fulfilling the inclusion and exclusion criterion. Written and informed consent was taken from all patients. After taking detailed clinical history, the patients were divided in to two groups of 40 patients each by block randomization. Group A was the interventional group where topical autologous platelet rich plasma was applied on the graft during type1 tympanoplasty. In Group B, PRP not applied. Graft uptake rate was observed postoperatively after 1 month and 6 months. Successful graft uptake at 1st month was noted in 97.5% patients in Group A and 92.5% in Group B with a corresponding failure rate of 2.5% and 7.5% respectively. Successful graft uptake at 6th month was noted in 95% patients in Group A and 90% in Group B with a corresponding failure rate of 5% and 10% respectively. As observed from our study status of graft uptake and reperforations at 1st and 6th months subsequent to surgery and rate of post-operative infections were similar in both the groups irrespective of the status of receiving autologous platelet rich plasma. Trial registration Trial registered with CTRI (Clinical Trial Registry -India) (Reg. no CTRI/2019/02/017468 dated 05/02/2019).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03681-w.

Contemporary Plural Deliberations and Perspectives in Revision Middle Ear Surgery. Causes, Outcomes and Lessons Learned

The indications for revision middle ear surgery are inter-linked to the objectives of surgery and needs of the patient. Revision middle ear surgery is often challengingly arduous not only for the patient but for the surgeon as well. This study concentrates on the causes of failures of primary ear surgery, indications, techniques, outcomes and lessons learned in revision ear surgery. This retrospectivedescriptive study included 22 cases (12.29%) of revision surgery,with a follow up of at least one year, out of total 179 cases of middle ear surgeries performed over a period of 5 years.These revision cases included tympanoplasty, cortical mastoidectomy and modified radical mastoidectomy alongwith ossiculoplasty and scutumplasty, wherever required. Hearing improvement, closure of perforation, and prevention of recrudescence were the main outcome parameters. The overall morphologic success of revision surgery in our series was 90.90%.There was one graft failure, one attic retraction and the main complication observed was post-operative worsening of hearing.Mean postoperative pure-tone average air -bone gap (ABG) was 20.86 ± 11.29 dB compared with preoperative ABG of 29.64 ± 10.63 dB and the difference was statistically significant ( p < 0.05) with p value 0.0112 on paired t-test. Detailed knowledge and anticipation of the cause of failure is a must in preventing another failure in revision ear surgeries. Hearing preservation must be considered in a pragmatic perspective and accordingly surgical indications must complement the realistic and reasonable expectations of the patients.

Surgery for chronic otitis media in the elderly

PURPOSE

To evaluate the effectiveness and safety of surgery for chronic otitis media in elderly patients, compared to younger adults and children.

METHODS

Patients with chronic otitis media with and without cholesteatoma formation were assessed. Patients aged 65 years and older were included and compared to adults aged 35-55 and to children. Effectiveness was evaluated by comparing postoperative dry and safe ears in ages groups, safety was assessed by comparing postoperative adverse events.

RESULTS

Postoperative success and adverse events did not differ between age groups. Children had more recurrent cholesteatoma than adults. No difference in recurrent cholesteatoma between adults was observed.

CONCLUSION

Surgical treatment for chronic otitis media with and without cholesteatoma in elderly patients is safe and effective. Age has no influence on postoperative adverse events and treatment outcomes in chronic otitis media. Cholesteatoma recurrence was not different between adult age groups.

Facial canal dehiscence, dural exposure, and labyrinthine fistula in middle ear cholesteatoma and mastoiditis

PURPOSE

To analyze the prevalence and associations of facial canal dehiscence (FCD), dural exposure, and labyrinthine fistula in chronic otitis media (COM) with and without cholesteatoma.

METHODS

This was a retrospective study performed in an academic medical center. Patients who received tympanoplasty with mastoidectomy for COM with and without cholesteatoma were included. The prevalence of FCD, dural exposure, and labyrinthine fistula in COM with and without cholesteatoma (mastoiditis) and their relationships were analyzed.

RESULTS

A total of 189 patients, including 107 (56.6%) females and 82 (43.4%) males, with 191 ears were included. There were 149 cases (78.0%) of cholesteatoma and 42 patients (22.0%) with mastoiditis. FCD was noted in 27.5% of patients with cholesteatoma and 9.5% of patients with mastoiditis. Dural exposure was found in 21 patients (14.1%) with cholesteatoma and 4 patients (9.5%) with mastoiditis. Eleven patients (7.4%) with cholesteatoma and 1 patient (2.4%) with mastoiditis had labyrinthine fistula. Patients with a labyrinthine fistula had nearly a fivefold greater chance (OR = 4.924, 95% CI = 1.355-17.896, p = 0.015) of having FCD than those without a fistula. There was a positive correlation between dural exposure and labyrinthine fistula (P = 0.011, Fisher's exact test).

CONCLUSION

FCD, dural exposure, and labyrinthine fistula are common complications in COM. These complications are more frequently observed in patients with cholesteatoma than in patients with mastoiditis. Surgeons should pay more attention to the treatment of COM.

Disease recidivism after subtotal petrosectomy and ear canal closure

PURPOSE

To describe the presentation, diagnosis, and management of chronic otitis media recidivism after subtotal petrosectomy and ear canal closure (STP).

MATERIALS AND METHODS

Patients with temporal bone pathology detected during follow-up after STP were identified in the electronic medical record. Pertinent clinical details regarding surveillance plan, presentation, imaging findings, and revision surgery were collected and analyzed.

RESULTS

A total of 10 patients were identified with recurrent or persistent pathology after STP. The median time to detection was 46 months (IQR 24-84). Five patients (50 %) had non-specific symptomatology, 4 patients (40 %) were completely asymptomatic, and 1 patient (10 %) was asymptomatic outside of two instances of mastoiditis with cochlear implant device infection treated with incision and drainage. One patient (10 %) was noted to have proptosis on examination, but no other patients had objective signs of disease at detection of disease recidivism. Nine (90 %) patients had pathology identified on preoperative imaging. All patients underwent revision surgery, with identification of cholesteatoma in 8 cases (80 %) and cholesterol granuloma in 2 cases (20 %). Extensive disease was noted in 6 patients (60 %), all of whom followed-up greater than 3 years from surgery. All patients tolerated revision surgery without complication.

CONCLUSIONS

Recidivistic disease often remains clinically silent for extended periods of time after STP. Planned follow-up - with imaging or second look surgery - to facilitate early detection should be considered. Undetected disease recurrence or development may result in morbidity in a proportion of patients if surveillance is not performed.

Comparison of partial vs. total ossicular chain reconstruction using titanium prosthesis: a retrospective cohort study

PURPOSE

Comparison of the hearing outcomes of titanium partial ossicular replacement prosthesis (PORP) vs. titanium total ossicular replacement prosthesis (TORP) with footplate shoe (Omega Connector) in second stage ossicular chain reconstruction surgeries.

METHODS

In this retrospective cohort study in a tertiary hospital, we compared the hearing outcomes in 248 patients who had undergone ossicular chain reconstruction with titanium prostheses PORP (n = 115) vs. TORP (n = 133) from August 2017 to June 2021. Pre-and post-operative audiometric data were assessed.

RESULTS

In general, we found that there were no significant differences between PORP and TORP groups in gains of BC (P = 0.080), AC (P = 0.454), ABG (P = 0.928), SRT (P = 0.065), and SDS (P = 0.363). There were no significant differences in terms of ABG gain between the two groups. Regarding ABG gains frequency-specific analysis in the ears with pre-operative conductive hearing loss, there were no significant differences between low-frequencies (P = 0.260) and high-frequencies (P = 0.973) between the two groups.

CONCLUSION

To sum up, this research provided additional evidence with respect to hearing outcomes after staged ossicular chain reconstruction with PORP and TORP. The practical application of our study is that TORP with footplate shoe (Omega Connector) is comparable with PORP in staged ossiculoplasty.

Changes in Coagulation Study and Risk of Developing Cholesteatoma: Is There a Link?

BACKGROUND AND OBJECTIVES

The etiopathogenesis of acquired pediatric cholesteatoma has not yet been fully clarified. Recent studies and modern technologies have led researchers to look for explanations at a molecular level. This study aims to understand if the origins of cholesteatoma could be related to dysfunctions in coagulation factors, thereby emphasizing its role in angiogenesis. Subjects and.

METHODS

This was a retrospective case-control study carried out at a tertiary hospital center between January 2010 and December 2020. The study included 92 children. The variables of the summary coagulation study (partial thromboplastin time, prothrombin time, and international normalized ratio) were compared among children with and without development of chronic otitis media with cholesteatoma.

RESULTS

The cases and controls were comparable in terms of age, type, and number of times that ventilation tubes were placed. Partial thromboplastin times tended to be higher in children who developed cholesteatoma, with a statistically significant difference between the two groups in terms of normal and abnormal partial thromboplastin times (p=0.029).

CONCLUSIONS

The results of this case control study indicate that slight extension of partial thromboplastin times in the coagulation study may not meet the criteria for diagnosis of certain hematological pathologies or clinical significance, but at a molecular level may already have implications for activation of angiogenesis and other growth factors involved in the onset, growth, and expansion of acquired pediatric cholesteatoma.

Prognostic Parameters and Their Relevance in Outcome of Middle Ear Surgeries

To study various parameters, including Middle ear risk index (MERI) and their correlation with outcome of middle ear surgery. The study was conducted from September 2015 to May 2017 in Department of Otolaryngology at our institute. It included 185 cases of safe type of chronic suppurative otitis media. These patients were admitted and treated surgically and record was kept for at least 3 months follow-up in postoperated period. The study concluded that a good correlation exist between MERI and result of tympanoplasty.

The Wheel-Shaped Composite Cartilage Graft for Type 1 Tympanoplasty: Comparison with Palisade and Island Cartilage Graft

This study aims to compare the graft success and hearing results of the palisade and island cartilage graft, with wheel-shaped composite cartilage graft (WsCCG) for type 1 tympanoplasty. The study was designed retrospectively. Only patients with conductive hearing loss and simple pars tensa perforation of the tympanic membrane were included in the study. Pure tone average (PTA), air-bone gap gain (ABG), word recognition score (WRS), ABG closure and grafts success were compared between the graft groups. Records of 111 patients were analyzed. The graft success rate was 89.7% for palisade cartilage graft (PCG, n = 39), 86.1% for island cartilage graft (ICG, n = 36), and 97.2% for wheel-shaped composite cartilage graft (WsCCG, n = 36) (p = 0.244). Average postoperative PTA and ABG values were significantly affected by the cartilage graft type, but WRS was not affected. (p = 0.005, 0.019, 0.306, respectively, One Way-Anova test). Post-Hoc LSD test showed a statistically significant decrease in PTA and ABG averages for WsCCG group compared to the ICG group (p = 0.004; CI%95 = 15.1-2.2 dB and p = 0.023; CI%95 = 8.2-0.4 dB, respectively). Postoperative PTA and ABG averages for WsCCG and PCG groups were similar (p = 0.069 and p = 0.053, respectively). In addition, while there were 2 (5.1%) retractions in the PCG group and 1 (2.7%)in the ICG group, there was no retraction in the WsCCG group. The WsCCG provided comparable results with classical reliable graft techniques (PCG and ICG) and may recommend as a more suitable graft due to hearing results and resistance against retraction.

Correlation of the Neutrophil-to-Lymphocyte Ratio with the Middle Ear Risk Index in Patients with Chronic Otitis Media

This study aimed to investigate the neutrophil-to-lymphocyte ratio (NLR) and severity of the chronic otitis media according to middle ear risk index (MERI) scores. The NLR and middle ear risk index were calculated for 210 chronic otitis media (COM) patients retrospectively. NLR compared between COM patients and 159 participants in control group. Pearson correlation analysis was performed for NLR and MERI. In addition, The cut-off value, sensitivity, and specificity for NLR were determined in COM according to the severity of the disease with ROC analysis. The average of NLR in all patients was 1.94 ± 0.89. NLR was calculated as 2.05 ± 1.03 in the patients with COM and 1.79 ± 0.64 in the control group (p = 0.006, 95% CI 0.07-0.44, t test). According to the ROC analysis, the cut-off point was determined as 1.95 for moderate and severe disease in MERI. For the cut of a NLR = 1.95, sensitivity was calculated as 48.5% and the specificity 57.1% for moderate and severe COM. MERI score was found significantly higher in patients with postoperative graft perforation (p < 0.001, 95% CI 0.7-1.8). NLR has not related significantly with the MERI score according to linear regression analysis (p = 0.927). NLR was found to be significantly higher in chronic otitis media patients compared to the control group. But NLR was not related to the severity of the disease classified with MERI. The cut-off value, sensitivity and sensitivity rates of NLR obtained was not available for clinically use.

The Role of Serum Adhesion Molecules s-ICAM-1 and s-VCAM-1 in Chronic Otitis Media Pathogenesis: A Prospective Controlled Study

The aim of this study was to determine the levels of soluble intracellular adhesion molecule-1 (s-ICAM-1) and soluble vascular cell adhesion molecule- 1 (s-VCAM-1) in patients with chronic otitis media (COM) according to the disease profile and to compare with ears without otitis media. Eighty-nine patients had ear surgery were included in the study prospectively. 78 patients who underwent tympanomastoidectomy included in the study group and 11 patients who underwent exploratory tympanotomy included in the control group prospectively. The level of s-ICAM-1 and s-VCAM-1 measured with ELISA technique. s-ICAM-1 and s-VCAM-1 levels compared between COM specific diseases group and with the control group. Levels of s-ICAM-1 and s-VCAM-1 measured as 584.5 ± 165.3 ng/ml and 541.1 ± 237.3 ng/ml in patients with COM, 384.4 ± 99.6 ng/ml and 551.7 ± 336.4 ng/ml in the control group respectively. The mean of s-ICAM-1 detected significantly higher in the COM group (p < 0.001). But the mean of s-VCAM-1 in the COM and control group was similar (p = 0.895). Also, s-ICAM-1 was significantly higher in patients with cholesteatoma, ossicular chain defects and tympanic membrane retraction (p = 0.037, 0.045 and 0.032, respectively). Although s-VCAM-1 level was not affected by cholesteatoma, ossicular chain defect and tympanic membrane retraction (p = 0.178, 0.243, p = 0.164, respectively). While the mean of s-ICAM-1 was detected significantly higher in COM and related pathologies therefore, increased serum levels may reflect the severity of the disease. But, s-VCAM-1 was not affected by COM and COM-specific diseases.

The Otoscopic, Radiological and Audiological Study of Contralateral Ear in Unilateral Chronic Otitis Media

Chronic otitis media is a disease developing due to Eustachian tube dysfunction secondary to any insult in nasopharynx which is likely to be bilateral with different stages of disease in both ear. The objective of this study was to examine contralateral ear through otoscopic, radiological and audiological study. Study was conducted between December 2018 and July 2020 in Otorhinolaryngology and Head and Neck Suregery Department. The Contralateral ear was defined as the ear with no tympanic membrane perforation and with no symptoms in patients of unilateral chronic otitis media. Otoscopy, Pure tone audiometry and HRCT temporal bone were done. Results were recorded and analysed. Descriptive stastical analysis was done using SPSS software version 22 of Windows 7. Grade1 pars tensa retraction which is most common abnormal finding in contralateral ear on otoscopy in both unilateral mucosal and squamosal COM patients. On otoscopy of contralateral ear 71.43% squamosal COM patients were having abnormal tympanic membrane. Hearing loss was seen in 25.71% patients of mucosal COM and 22.9% patients of squamosal COM patients. 17.1% patients of mucosal COM and 20% patients of squamosal COM show mastoid sclerosis of contralateral ear on HRCT temporal bone. Majority of patients with unilateral COM have initial findings of pathogenesis of COM in contalateral ear. These findings in contralateral ear are more common in patients with squamosal COM than patients with mucosal COM.

A Study of Middle Ear Diseases in Children with Congenital Bilateral Severe to Profound Sensorineural Hearing Loss

(1) To find the presence of middle ear diseases present in the patients with congenital bilateral severe to profound SNHL (2) If it poses as a threat to rehabilitative efforts for the existing severe to profound SNHL. Study setting: Department of ENT, C U Shah medical college and hospital. Study design: Prospective study Study population: Patients attending ENT department with complaints of congenital bilateral severe to profound sensorineural hearing loss. A total of 50 cases were studied during the study period. Methods of data collection: The Proforma was designed based on objective of the study. Detailed history was taken followed by thorough ENT and systemic examinations. Otoscopy and otoendoscopy were carried out and all patients were subjected to hearing tests consisting of Pure Tone Audiometry (PTA), Impedance Audiometry (IA), Brainstem Evoked Response Audiometry (BERA) and Oto Acoustic Emissions (OAE). HRCT and MRI scanning of temporal bones of all the patients was included as a part of the routine workup. Out of the 50 children with bilateral congenital hearing loss studied in this study, 13(26%) children were observed to have concurrent middle ear pathologies. 2 patients had bilateral retracted drum with tympanosclerosis; 3 had bilateral retraction pocketswith mastoiditis; 1 had bilateral SOM; 1 had right SOM and left retracted drum; 2 had bilateral PSQ cholesteatoma; 1 had left SOM and right sided tympanic membrane perforation, 3 had right sided tympanic membrane perforation with left sided normal ears. Children with congenital bilateral severe to profound hearing loss should be examined for middle ear pathologies, which can most often be overlooked otherwise, hence rendering the patient unfit for definitive management of the severe to profound SNHL in the form of Hearing Aid trial or Cochlear Implantation, further delaying the development of speech. Hence, all children with congenital bilateral severe to profound hearing loss should undergo regular screening for assessment of middle ear pathologies with prompt treatment when any middle ear pathology is encountered, therefore rendering the patient fit for fitting of cochlear implantation at the earliest possible to decrease permanent impairment of speech.

Success Rate of Type I Tympanoplasty Using Temporalis Fascia by Underlay Technique in Safe Mucosal COM in KMCH, Katihar

Otitis media is inflammation of middle ear, commonly seen in children of school going age. Chronic otitis media is permanent abnormality of tympanic membrane most commonly as a result previous acute otitis media. Early diagnosis and management of chronic otitis media is important because it may affects hearing of child which in turn may affect cognitive development of children. This is a retrospective observational study done on 60 patients of age between 18 and 60 yrs during the period from May 2019 to November 2019 in ENT department of Katihar Medical College, Katihar, Bihar and assessed success rate of Type I Tympanoplasty using Temporalis Fascia by Underlay technique in safe mucosal COM. Success rate was 90% when preoperative dry ear was for more than one month. Graft taken up properly in 50 patients out of 60 cases i.e. 83.33%.

Microbiological Assessment of Chronic Otitis Media: Aerobic Culture Isolates and Their Antimicrobial Susceptibility Patterns

As there are changing trends in the microbiology of chronic otitis media, this study was carried out to look for the current aerobic microbes and their antimicrobial susceptibilities in patients of chronic otitis media from north Indian region. A total of 322 patients who met the inclusion criteria were studied and aerobic ear swab culture was done under aseptic conditions. Gram staining was performed and antibiotic susceptibility testing was done using Kirby-Bauer disc diffusion method on Mueller-Hinton Agar. A total of 341 culture positive results were obtained from 322 patients. The culture results revealed 10 different aerobic microbes. Gram-positive floras were seen in 152 (44.57%), and Gram-negative in 189(55.43%) isolates. Staphylococcus aureus was the most common isolate present in 131 samples (38.41%), followed by pseudomonas aeruginosa in 101 (29.62%) and proteus in 36 (10.56%). In overall susceptibility of antibiotics against Gram-positive culture isolates, Vancomycin was most effective (97.37%). For Gram-negative microbes, Piperacillin-Tazobactum combination was most effective with overall susceptibility of 79.37% susceptibility. Microbiological assessment of Chronic Otitis Media should be carried out in an area on regular intervals because of the changing patterns of bacteriology and their antimicrobial susceptibilities.

Status of Contralateral Ear in Patients with Unilateral Chronic Otitis Media

This study was conducted to evaluate the existence of otoscopic abnormality, hearing status and radiological changes in contralateral ear of patients with chronic otitis media. 300 patients having unilateral Chronic Otitis Media attending OPD in the Department of Otorhinolaryngology, Institute of Medical Sciences, Banaras Hindu University, Varanasi during the period of March 2019 to March 2020 were selected. Otoscopy, Pure Tone Audiometry and Bilateral X-ray mastoids (lateral oblique view) and/or HRCT Temporal bone were done. Contralateral ear was affected in more than 30% cases. Out of 188 patients having Mucosal COM, 58 cases (30.9%) had abnormal TM. Out of 112 patients having Squamosal COM, 48 cases (42.9%) had abnormal CLE. Out of 300 cases, 231 (77.0%) of them had normal hearing in contralateral ear. It was followed by 65 cases (21.6%) with conductive hearing loss. Mixed hearing loss and SNHL were seen in 2 patients each. In contralateral ear of Mucosal COM, pneumatic pattern of pneumatisation was seen in 69.1% followed by Diploic pattern (30.9%). In squamosal COM, X-ray mastoid showed pneumatic pattern (64.3%) followed by Diploic pattern (33.9%) in the contralateral ear. Sclerotic pattern was seen in only 1.8% of cases in contralateral ear. Chronic otitis media as a disease is not limited to one ear. The precise and critical evaluation of both ears does not play a role in prognostic evaluation of the patient only, but it can also serve as a guide for early detection of probable evolution of the disease process in a patient in contralateral ear with unilateral chronic otitis media.

A Comparative Study on Outcomes of Type 1 Underlay Tympanoplasty with and Without Anterior Tucking of Temporals Fascia Graft

Tympanoplasty is a surgical procedure which includes eradication of disease from the middle ear and reconstruction of the hearing mechanism with or without tympanic membrane repair. The purpose of this article was to compare the clinical and audiological outcomes of Type 1 underlay tympanoplasty with or without anterior tucking of the temporals fascia graft. This is a prospective interventional study which included 100 patients between 15 and 60 years of age, diagnosed with chronic otitis media, mucosal disease inactive stage. 100 patients were divided into two groups 50 each, who underwent type 1 underlay tympanoplasty, group A underwent anterior tucking of the temporals fascia graft and group B without anterior tucking of the temporals fascia graft. Analysis of data was made of the demographic details, graft uptake status and audiological outcomes following surgery. Among the 100 patients included in the study, majority were seen between 21 and 40 years of age group. In our study successful graft uptake was seen in 93.4% in group A temporalis fascia with anterior tucking which was better than group B which showed 84% results. However hearing outcome was almost similar in both the groups. In conclusion, graft uptake in tympanoplasty with anterior tucking was found to be better than without anterior tucking. There is significant hearing improvement following underlay technique of tympanoplasty both with and without anterior tucking. There is no significant difference in the hearing improvement with anterior tucking when compared to without anterior tucking of the temporalis fascia graft.

An Uncommon Differential for Mass in the Middle Ear Cleft-Temporal Meningoencephalocele

Meningoencephalocoele (ME) of the temporal bone is otherwise known as brain fungus. It is a rare and potentially life-threatening condition. It occurs in cases of chronic otitis media either as a complication or iatrogenically induced following mastoid surgeries. It requires prompt surgical intervention. High-resolution Computer tomography of Temporal bone and Magnetic resonance imaging of the brain are needed to detect these cases. Surgery can be otological, neurosurgical, or combined. We discuss a case of Iatrogenic Temporal meningoencephalocele and its management along with a review of the literature.

Outcome of Temporalis Fascia Myringoplasty With and Without use of Platelet Rich Plasma: A Randomized Control Trial

To compare efficacy of temporalis fascia myringoplasty using platelet-rich plasma(PRP) {MP-PRP} and conventional emporalis fascia myringoplasty (MP-C) in treatment of moderate to large central tympanic-membrane(TM) perforation. Randomized-Control-Trial. We randomly assigned eighty-patients with COMmucosal-type with medium to large central TM-perforation and conductive hearing loss planned for primary myringoplasty to receive either MP-PRP orMP-C. Myringoplasty was performed through postauricular approach underlay graft using temporalis fascia. Primary-outcome was graft uptake (an intact TM) at 6 months postoperatively. Secondary-outcome was the postoperative hearing improvement measured by pure-tone-audiometry (PTA). Eighty-myringoplasties (MP-PRP group-40, MP-C group-40) done for 80 patients (male = 41; female = 39, age-group = 18-45-years) were included in analysis. At 6 months postoperatively graft uptake rate was 94.4% in MP-PRP and 92.1%% in MP-C group. There was no statistically significant difference in graft-uptake between the two groups (p = 0.358). Success in terms of hearing gain (≥ 10 dB) was achieved in 34 patients (89.5%) in MP-C and 37 patients (94.9%) in MP-PRP group. At 6 months follow-up; mean-PTA-average improved from 35.10 ± 5.401 dB to 27.74 ± 5.660 dB and mean ABG improved from 24.00 ± 5.204 dB to17.42 ± 5.559 dB in MP-C group. At 6 months followup; mean-PTA-average improved from 37.00 ± 6.144 dB to 26.65 dB and mean air bone gap (ABG) improved from 25.98 ± 5.736 dB to 16.21 ± 4.318 dB in MP-PRP group. No statistically significant differences in improvement in PTA-values were observed between both groups (p = 0.336).Postoperative complications were similar in both groups. Graft-uptake, hearing outcomes and complications of MP-PRP were similar to MP-C. MP-PRP offers no advantages over MP-C for treatment of TM perforation.

Microbiology of Chronic Otitis Media and Shifting Trends of Its Antibiotic Susceptibility: A Prospective Observational Study in a Tertiary Care Institute of Western Rajasthan

COM is a prevalent disease in lower socio-economic group mainly of a developing country. COM in active stage presents with a discharging ear. The mucopus from an active ear, when put through microbiological culture, yields a variety of aerobic and anaerobic bacteria as well As fungi. Antibiograms provide us with culture specific antibiotics. The study aims to identify prevalent microbes in our region and their sensitivity towards respective antibiotics. A total of 100 patients diagnosed with active COM in the E.N.T. outpatient department of M.D.M. Hospital, Jodhpur from July 2019 to December 2019 were enrolled. 100 swabs were obtained, one from each patient, using sterile cotton swabs and cultured for microbial flora. Antibiotic susceptibility testing of bacterial isolates was done using Kirby-Bauer disc diffusion method. The most common organism isolated were Pseudomonas spp. (58%) and Staphylococcus aureus (25%), while 8% were fungal isolates. The sensitivity pattern of Pseudomonas spp. was maximum for meropenem while that of Staphylococcus species was maximum for linezolid and vancomycin. Both were fairly sensitive to amikacin, cephalosporins and Quinolones. Culture specific antibiotics help us achieve dry ear faster and better. There is a drifting trend in antibiotic susceptibility of both aerobic and anaerobic species, towards higher group of antibiotics. Thereby suggesting emergence of multi-drug resistant strains.

A Study on Surgical Implications and Variations of Suprameatal Spine and Other Landmarks on the Lateral Surface of Temporal Bone

Mastoidectomy forms the main surgical procedure for eradication of disease in chronic otitis media. Such a surgery which contemplates a complete exenteration of all the tympano-mastoid cavities is rightly considered as a difficult one mainly because a large number of vitally important structures are crowded together in the small field of operation and there is always a risk of damaging them. It is therefore, extremely important that the otologist who would undertake this surgery be thorough with the details of the surgical relations of this region. Out of the various structures seen on the lateral surface of temporal bone one very important structure is the suprameatal spine. It is shown to have great variations in shape and size and has been a mystery to researchers due to the implications it is known to have on mastoid region anatomy. In this study we have evaluated the various types of suprameatal spine, prevalence of each type and the effect of each to other landmarks encountered during surgery and also the effect of mastoid pneumatisation on the same.

Is it useful to use computerized tomography image-based artificial intelligence modelling in the differential diagnosis of chronic otitis media with and without cholesteatoma?

OBJECTIVE

Cholesteatoma is an aggressive form of chronic otitis media (COM). For this reason, it is important to distinguish between COM with and without cholesteatoma. In this study, the role of artificial intelligence modelling in differentiating COM with and without cholesteatoma on computed tomography images was evaluated.

METHODS

The files of 200 patients who underwent mastoidectomy and/or tympanoplasty for COM in our clinic between January 2016 and January 2021 were retrospectively reviewed. According to the presence of cholesteatoma, the patients were divided into two groups as chronic otitis with cholesteatoma (n = 100) and chronic otitis without cholesteatoma (n = 100). The control group (n = 100) consisted of patients who did not have any previous ear disease and did not have any active complaints about the ear. Temporal bone computed tomography (CT) images of all patients were analyzed. The distinction between cholesteatoma and COM was evaluated by using 80% of the CT images obtained for the training of artificial intelligence modelling and the remaining 20% for testing purposes.

RESULTS

The accuracy rate obtained in the hybrid model we used in our study was 95.4%. The proposed model correctly predicted 2952 out of 3093 CT images, while it predicted 141 incorrectly. It correctly predicted 936 (93.78%) of 998 images in the COM group with cholesteatoma, 835 (92.77%) of 900 images in the COM group without cholesteatoma, and 1181 (98.82%) of 1195 images in the normal group.

CONCLUSION

In our study, it has been shown that the differentiation of COM with and without cholesteatoma with artificial intelligence modelling can be made with highly accurate diagnosis rates by using CT images. With the deep learning modelling we proposed, the highest correct diagnosis rate in the literature was obtained. According to the results of our study, we think that with the use of artificial intelligence in practice, the diagnosis of cholesteatoma can be made earlier, it will help in the selection of the most appropriate treatment approach, and the complications can be reduced.

Cartilaginous bending spring tympanoplasty: a temporal bone study and first clinical results

Objective

Anchoring grafts for tympanic membrane (TM) reconstruction in anterior and subtotal TM defects is essential to prevent medialisation and can be facilitated by cartilaginous bending spring tympanoplasty (CBST). The purpose of this study was to analyse the impact of spring cartilages on middle ear transfer functions and patient hearing levels.

Methods

In six fresh-frozen human temporal bones a cartilage graft (measuring 6 × 2 mm with a thickness of 0.1–0.2 mm) was formed into a ‘U’-shaped bending spring, to be placed between the medial tympanic wall and the tympanic underlay grafts. The stapes velocity for excitation by exponential sweeps from 400 to 10,000 Hz was measured with a laser Doppler vibrometer. The resulting middle ear transfer functions were compared with the reconstructed middle ear. For clinical evaluation, 23 ears in 21 patients with chronic otitis media and an intact ossicular chain were operated using CBST. At each follow-up visit, the patients underwent pure-tone audiometry and the Freiburg monosyllabic speech test at a presentation level of 65 dB SPL for the word recognition score (WRS).

Results

The measured stapes velocities at one-third octave midband frequencies averaged 3.56 × 10^–2 ± 9.46 × 10^–3 (mm/s/Pa) compared to 3.06 × 10^–2 ± 6.86 × 10^–3 (mm/s/Pa) with the bending and underlay cartilage in place (p = 0.319; r = 0.32). The bending spring tympanoplasty reduced the transfer function by 1.41 ± 0.98 dB on average. In the clinical part of the study, the graft success rate was 96% (22 out of 23 patients) after a mean follow-up of 5.8 ± 2.4 months (min. 3.5 months, max. 12.0 months). The air–bone gap improved significantly by 6.2 dB (± 6.6 dB; p < 0.001; r = 0.69), as well as the WRS from 61.8 ± 33.3% preoperatively to 80.0 ± 20.9% postoperatively (p = 0.031; r = 0.35).

Conclusion

Experimental data as well as initial clinical results suggest that CBST is an effective method for reconstructing anterior or subtotal defects of the tympanic membrane with satisfactory audiologic results and graft success rates comparable to previously described methods. It can, therefore, be added to the arsenal of tympanoplasty techniques for anterior and subtotal TM perforations.

Titanium Angular Clip Prosthesis in Patients with Incudostapedial Joint Erosion Caused by Chronic Otitis Media; A Randomized Clinical Trial

Chronic otitis media (COM) is a common disease that can cause damage to the middle ear ossicles and thus lead to conductive hearing loss. The purpose of this study was to compare two methods of incus partial ossicular reconstruction prosthesis (PORP) and reconstruction with titanium angular clip prosthesis in patients with incudostapedial joint erosion. In this interventional randomized clinical trial carried out in a tertiary referral hospital, patients with chronic otitis media and incudostapedial joint erosion who were candidates for surgery, were randomly allocated into two groups of incus PORP surgery and reconstruction with a titanium angular clip prosthesis. Audiometry was performed for the patients prior to and six months after surgery. Pre- and post-operative air-bone gap (ABG) and bone conduction (BC) thresholds were calculated and means were compared by analysis of variances (ANOVA). A P value of <0.05 was considered statistically significant. The study consisted of 24 and 14 subjects in the incus PORP and angular clip groups, respectively. There was no statistically significant difference between the mean pre- and post-operative ABG, BC thresholds and ABG reduction in the compared groups. Considering issues such as high cost and inaccessibility of titanium angular clips in all centers, incus PORP may be a more acceptable method.

Comparison of endoscopic and microscopic tympanoplasty in patients with chronic otitis media

BACKGROUND

To compare the results between type I tympanoplasty performed with transcanal endoscopic ear surgery (TEES) and microscopic ear surgery (MES) for treatment of chronic otitis media in a homogenous group of patients.

METHODS

A retrospective study was performed in our department between January 2011 and January 2016 to review primary type I tympanoplasty cases with a subtotal perforation, an intact ossicular chain, a dry ear for at least 1 month, normal middle ear mucosa, and a follow-up period of at least 6 months post surgery. The adoption of TEES or MES was divided temporally (before and since 2013). TEES was undertaken in 224 patients (224 ears) and MES in 121 patients (121 ears).

RESULTS

The successful graft take rate was 94.64% (212/224) in the TEES group and 90.91% (110/121) in the MES group (P = 0.239). The improvements in the air conduction levels between the 2 groups were not statistically different at 1, 3, or 6 (> 6) months (P > 0.05) after surgery. The improvements in the air-bone gaps were not significantly different between the 2 groups (P > 0.05). The average hearing gains in the TEES group 6 (and > 6) months post surgery were 11.85 ± 5.47 dB, which was better than 10.48 ± 5.18 dB in the MES group (P = 0.031). The use of medical resources was lower in the TEES group than in the MES group regarding the average operating time (49.22 ± 8.24 min vs 81.22 ± 14.73 min, respectively; P < 0.0001). Patients receiving MES had a significant higher incidence of the wound problems (ear pain, numbness around the ears, and wet ear; P < 0.05).

CONCLUSION

TEES for type I tympanoplasty seems to achieve a shorter operative time and ideal tympanic membrane healing rate and hearing results in patients with chronic otitis media.