[Otoscopic pitfall : the congenital cholesteatoma]

The congenital cholesteatoma is a rare benign tumor whose diagnosis is mainly made during childhood. Otoscopic examination shows a white retrotympanic collection with or without hearing loss. In case of a late diagnosis, the disease will spread to the surrounding structures, leading to ossicules destruction, facial palsy, sensorineural hearing loss and vestibular dysfunction. Surgery is the therapeutic gold-standard, with different techniques chosen based on the cholesteatoma's extension. Patient should benefit from a long term medical and radiological (MRI) follow-up.

[The comparison of clinical features of 2 cases of intracranial otogenic complications]

Two cases of special intracranial otogenic complications were analyzed in the aspects of clinical characteristics, diagnosis and therapy. We concluded that for patients with huge cholesteatoma which damaged the bone of skull base, or chronic otitis media patients with sharp deterioration in symptoms, accompanied by headache and fever, we should promptly do the enhanced magnetic resonance to avoid the missed diagnosis of intracranial complications.

[A middle to long-term clinical study on pars flaccida and pars tensa cholesteatoma using survival analysis]

The current clinical study was performed on 311 cases of pars flaccida and 89 cases of pars tensa cholesteatoma which were treated with canal wall reconstructed tympanoplasty between 1991 and 2012. The average follow-up time of these patients was 5.3 years. Since follow-up periods were different in each case and some censored patients were involved, we used survival analysis on this study to discuss the cumulative rates of disease-free successful cases and the rates of recurrent cholesteatoma throughout the postoperative course. The disease-free successful cases were defined as those cases in which patients were both out of re-operation with recurrent and residual cholesteatoma and out of revision operation with another problem, furthermore, maintained good hearing outcome. Based on the criteria set by the Japan Otological Society (2010), the cases that satisfied the following were evaluated as good hearing results; (a) a successful case in which preoperative bone conduction was used, and (b) a case in which the postoperative air-bone gap was within 20dB after tympanoplasty for chronic otitis media. The analysis results were shown for each of (a) and (b). 1. In pars flaccida cholesteatoma, the 5-year survival rate of successful case was (a) 76.1% and (b) 83.9%, the 10-year survival rate was (a) 58.9% and (b) 73.0%. In pars tensa cholesteatoma, the 5-year survival rate of successful cases was (a) 57.7% and (b) 63.5%, the 10-year rate was (a) 42.1% and (b) 56.9%. A significant difference was seen between pars flaccida and pars tensa cholesteatoma (p < 0.001). 2. In pars flaccida cholesteatoma, the 5-year recurrence rate was 7.6% and the 10-year rate was 15.3%, and the recurrence rate increased gradually throughout the follow-up period. On the other hand, in pars tensa cholesteatoma, the increase in the recurrence rate reached a peak 15.8% at 5.5 years after the surgery. A long-term follow-up is necessary when evaluating the clinical results after tympanoplasty.

[The surgical treatment of cholesteatoma of the pyramid of the temporal bone]

This paper presents in brief the data on epidemiology, classification, diagnostics, and current tendencies in the surgical treatment of cholesteatoma of the pyramid of the temporal bone. A clinical case of diagnostics and the surgical treatment ofpetrous apex cholesteatomainthe temporal bone is described.

Clinical characteristics of spontaneous cholesteatoma of the external auditory canal in children comparing with cholesteatoma in adults

The purpose of this study was to investigate the characteristics of external auditory canal cholesteatoma (EACC) in children through evaluation of the clinical and radiologic features as well as treatment outcomes. The clinical records were retrospectively reviewed for children under 15 years of age diagnosed with spontaneous EACC between March 2004 and December 2011. The clinical data of adults diagnosed with spontaneous EACC during the same period were evaluated to compare with EACC in children. Eight patients (3 males and 5 females) with pediatric EACC and 18 patients (7 males and 11 females, 20 ears) with adult EACC were included within the boundary of the study. The mean ages were 12.4 years (age range 9-15) for pediatric EACC and 49.8 years (age range 29-79) for adult EACC patients. Follow-up periods ranged from 8 to 86 months (mean 32.5 ± 8.62) in pediatric EACC and from 6 to 72 months (mean 22.2 ± 5.36) in adult EACC. Pediatric EACC, showed involvement most commonly in the posterior wall, while the inferior wall was most commonly involved in adult EACC. Pediatric EACC tended to show a more focal involvement and was not as extensive as adult EACC. Extension into the adjacent structures was similar in both groups, but bony destruction was more common in the adult group. Two children and eight adult patients were treated with surgery, but four adult cases needed more extensive surgical treatment because their disease was widely spread to included areas such as the mastoid segment of facial nerve and the temporomandibular joint. Six pediatric cases treated with conservative management showed no progression of disease on physical examination at the last visit, but two cases of adults progressed and required canaloplasty. Pediatric EACC shows less aggressive behavior compared to adult EACC. Adequate management may work better in pediatric than in adult EACC, even though the treatment modality is conservative management.

[Criteria for the objective assessment of the dynamic state of the retraction pockets in the children presenting with excudative otitis media]

This publication continues the preceding paper entitled "Early diagnostics of the retraction pockets in the tympanic membrane of the children". The objective of the present work was to develop the criteria for the objective estimation of the dynamic state of the retraction pockets (RP) in the children at different stages of excudative otitis media. The secondary objective was to develop an approach to the early diagnostics of cholesteatoma of the middle ear. A group of 138 children at the age varying from 1 to 17 years was placed under dynamic observation for the purpose of drawing up the individual "photo-roentgenological passport of the retraction pockets". Special attention was given to RP-semiotics of different forms of the syndrome and its severity in accordance with the classification universally accepted by foreign researchers. The results of the dynamic observations were used to develop the indications for the early preserving surgical treatment. It was given to 16 children six of which presented with cholesteatoma. The original illustrative materials for all variants of the retraction pockets are presented.

Modeling the Cholesteatoma Microenvironment: Coculture of HaCaT Keratinocytes With WS1 Fibroblasts Induces MMP-2 Activation, Invasive Phenotype, and Proteolysis of the Extracellular Matrix

BACKGROUND

Increased keratinocyte proliferation, increased keratinocyte migration, elaboration of proteases resulting in proteolysis of the extracellular matrix (ECM), and destruction of surrounding tissues all typify the course of cholesteatoma growth. The contribution of stromal fibroblasts to these behaviors remains relatively unexplored.

OBJECTIVES

Our objective for the current studies was to create a simple model with which to study these cholesteatoma behaviors, specifically, cell migration, invasion, and proteolysis of the extracellular matrix as well as the role of fibroblasts in the activated keratinocyte phenotype of cholesteatoma.

DESIGN

The authors conducted an in vitro culture model.

METHODS

The resulting model consists of activated keratinocytes (HaCaT cells) cocultured with normal dermal fibroblasts (WS1 cells) within a three-dimensional reconstituted ECM. We used a confocal imaging assay and software analysis to quantify total functional proteolysis of the ECM in monotypic and organotypic cocultures. This was accomplished by growing cells on an artificial ECM comprised of Matrigel and DQ-collagen IV. DQ-collagen is a "quenched" fluorescent peptide whose fluorescence is unmasked by proteolytic cleavage.

RESULTS

Organotypic cocultures of keratinocytes and fibroblasts exhibited increased cell migration, increased cell invasion, increased matrix metalloproteinase-2 secretion and activation, and increased proteolysis of type IV collagen in three-dimensional ECM. Exposure to NSC27366, inhibitor of the small GTPase, Rac, resulted in reduction in both cell invasion and ECM proteolysis.

CONCLUSIONS

Stromal fibroblasts may stimulate the invasive phenotype of keratinocytes, including ECM proteolysis. Increased cell invasion and proteolysis are dependent on the Rac pathway in this model. This simple culture model may help further our understanding of these destructive behaviors in cholesteatoma keratinocytes.

A possible role for nitric oxide in osteoclastogenesis associated with cholesteatoma

HYPOTHESIS

This study was designed to investigate the potential role of nitric oxide in cholesteatoma-induced bone resorption, in vitro and in vivo.

BACKGROUND

Cholesteatoma is a disease of inflammatory bone resorption in the middle ear leading to hearing loss and vestibular dysfunction. Inappropriate activation of osteoclasts causes the morbidity associated with this disease. Previous studies suggest nitric oxide may be an important mediator of osteoclast function.

METHODS

A murine model of cholesteatoma induced bone resorption was used to demonstrate nitric oxide synthase (NOS) gene expression and the effect of a NOS inhibitor. An in vitro osteoclast culture method was used to demonstrate the effect of nitric oxide on isolated osteoclasts. Osteoclast development was assayed by counting the number of mature osteoclasts; activity was assayed by measuring the amount of resorbed bone.

RESULTS

Quantitative reverse transcriptase-polymerase chain reaction results demonstrated the temporal expression of all three NOS isoforms in vivo. NOS I demonstrated very low levels of expressions throughout the duration of the study with no change in expression in response to keratin implant. Similarly, NOS III also demonstrated low levels of expression and no change in response to keratin. NOS II was highly upregulated in response to keratin throughout the duration of the study. In vitro, pharmacological nitric oxide donors--sodium nitroprusside and S-nitroso-N-acetyl-D,L-penicillamine--dose-dependently stimulated osteoclast resorption. Alone, interferon gamma (IFNgamma)--but not IL-1beta or TNFalpha--generated nitrite in vitro. A cytokine cocktail of IL-1beta, TNFalpha, and IFNgamma synergistically enhanced nitrite production. Nitrite production was blocked by the addition of aminoguanidine (AG), suggesting that AG-inhibited cytokine mediated nitrite production. However, in an in vivo model of cholesteatoma-induced bone resorption, the osteoclast response of AG-treated mice was not statistically different from untreated controls.

CONCLUSIONS

All three NOS isoforms were expressed in an in vivo model of cholesteatoma-induced bone resorption with significant upregulation of NOS II throughout the study. Exogenously administered nitric oxide dose-dependently enhanced osteoclast activation in vitro. The pro-inflammatory cytokines, IL-1beta, TNFalpha, and IFNgamma, synergistically induce nitrite production, which was abrogated by treatment with the nitric oxide synthase inhibitor, AG. Although AG suppresses nitrite production in vitro, treatment had no effect on osteoclast response in vivo, suggesting that the effects of inflammatory cytokines on osteoclast response were mediated through other pathways.

Tympanometry Versus Direct Middle Ear Pressure Measurement in an Artificial Model: Is Tympanometry an Accurate Method to Measure Middle Ear Pressure?

HYPOTHESIS

Indirect tympanometric pressure measurements of the middle ear (ME) do not correspond to direct pressure measurements.

BACKGROUND

Tympanometry is an accepted method for estimating ME pressures. These pressure values are different, however, when measurements are made directly.

MATERIALS AND METHODS

Negative pressures were induced by volume changes in an artificial ME model with various "mastoid" volumes. Both tympanometric and direct pressure measurements were obtained simultaneously.

RESULTS

A substantial difference was demonstrated between tympanometric and direct pressure measurements. There was a linear correlation between tympanometry and direct pressures between -46.8 and -93.6 mmH2O, with a tympanometric overestimation of 40% to 20%, respectively. The smaller the "mastoid" volume, the greater the overestimation. The correlation was not linear for direct pressures between zero and -46.8 mmH2O. Tympanometric overestimation was greatest (i.e., 4-14-times the actual pressure) in the pressure range between zero and -12 mmH2O.

CONCLUSIONS

Tympanometry does not yield precise ME pressure values. In a model with a larger "mastoid" and an actual pressure range of -46.8 to -93.6 mmH2O tympanometric readings are somewhat less unreliable (error of 40%-20%). However, tympanometry is in error of more than 400% in a model with a small mastoid in which the actual ME pressure is only slightly negative (i.e., range between -3.9 and -46.8 mmH2O). Therefore, this study implies that tympanometry has little use for measuring ME pressure especially in chronic ears or their sequelae that are usually characterized by having small negative pressures and small mastoids.

Multichannel cochlear implantation in radical mastoidectomy cavities

OBJECTIVE

We report on our experience in cochlear implantation in patients with radical mastoidectomy cavities. Study Design, Setting, and Methods: Retrospectively, records of patients from the Department of Otolaryngology, University of Parma between December 1991 and March 2000 were reviewed, and 6 postlingually deafened adults who received a cochlear implant in a radical cavity were identified. Speech performances were evaluated in terms of bisyllabic word and sentence recognition and common phrase comprehension.

RESULTS

To date, with a follow-up of 1 to 9 years, no patient has experienced extrusion of electrodes or other local or intracranial complications. Mean bisyllabic word and sentence recognition scores were 74% and 80%, respectively. Mean comprehension score for common phrases was 86%.

CONCLUSION

By obliterating and isolating the radical mastoidectomy cavity from the outer environment, patients who previously had undergone radical surgery of the middle ear can be safely implanted with satisfactory hearing results.

Keratin particle-induced osteolysis: a mouse model of inflammatory bone remodeling related to cholesteatoma

We implanted keratin and poly(methyl methacrylate) (PMMA) particles to the surface of mouse calvariae to produce a quantitative, localized, inflammatory bone remodeling similar to that seen in cholesteatoma. Both types of particles resulted in increased osteoclast density compared with controls. Osteoclasts infiltrated from marrow and vascular spaces and were active at the periphery of these spaces leading to significant bone remodeling, as demonstrated by the incorporation of bone-labelling fluorophores. Osteoclasts were rarely found on the surface of the calvariae, and mineral apposition rate at the ventral surface was not altered in keratin-implanted animals compared with nonoperated controls. While not useful for the study of the root cause of cholesteatoma, this model will allow the study ofpathologic bone remodeling related to cholesteatoma in a genetically defined animal.

Tympanic membrane displacement patterns in experimental cholesteatoma

Tympanic membrane (TM) stiffness changes in the pars tensa in response to experimentally induced ear canal cholesteatoma by obstruction of the ear canal were studied. To this aim TM displacement versus pressure was measured with a high resolution, differential moiré interferometer. The measurements were performed on fresh, isolated gerbil temporal bones after removal of the cholesteatoma bulk. Besides an overall stiffness reduction we found that local stiffness variations were present in nine out of 18 studied ears. The stiffness changes as a function of time after ear canal obstruction had a pattern similar to those previously shown to develop in response to various forms of otitis media, showing that the TM stiffness properties decrease in a similar way in response to different inflammatory middle ear diseases. The stiffness changes correlated with an increased overall TM thickness and increased thickness of the lamina propria in particular as measured in histology sections. The stiffness changes may play an important role in the pathophysiology of cholesteatoma.

Management of acquired cholesteatoma of the middle ear and the mastoid by combined approach tympanoplasty: a long-term view

Mastoid cavities following surgery for cholesteatoma of the middle ear and the mastoid can be subject to recurrent infections, life-long attendance for cavity cleaning and restrictions in social activity. These problems may be avoided with a successful combined approach tympanoplasty. One hundred and forty-one patients (151 ears) treated by combined approach tympanoplasty, followed over a period ranging from 5 to 23 yr were analysed. The results are presented with an average follow-up of 14.5 yr. A fixed retraction pocket, recurrent cholesteatoma or conversion to a cavity was regarded as a failure. Failures and evidence of future failures in the form of fixed retraction pockets occurred in the first 5 yr. By not including cases with a follow-up period of less than 5 yr, we have attempted to achieve stable long-term results; 73.5% of the cases were successful. The success rate could be improved further and should provide an acceptable method of treatment.

Evaluation of mastoid air cell system by three-dimensional reconstruction using sagittal tomography of the temporal bone

The mastoid air cell system has been recognized as an important contributor to the pathophysiology of middle ear inflammatory diseases. Various methods of temporal bone imaging have been designed to investigate the correlation between middle ear disease and mastoid pneumatization. In this study, the mastoid air cell system was reconstructed three-dimensionally from sagittal tomographic images of the temporal bone on X-ray films, using a personal computer to evaluate the mastoid pneumatization in a total of 29 patients with chronic otitis media, adhesive otitis media, adhesive-type cholesteatoma, attic cholesteatoma and cholesterol granuloma, and in five normal subjects as controls. Reconstructed three-dimensional images of the mastoid air cell system and its volume were analyzed. The reconstructed images were helpful in recognizing the three-dimensional solid appearance of the mastoid air cell system. The volume of the reconstructed mastoid air cell system was significantly reduced compared with that in the controls in each of the patient groups. Mastoid pneumatization in the patients with adhesive-type cholesteatoma was significantly suppressed compared with that in the adhesive otitis media patients. Interestingly, the adhesive otitis media group showed cell development at the tip of mastoid process, whereas the group of adhesive-type cholesteatoma did not, suggesting a difference in the pathophysiology in the two diseases. We found that three-dimensional reconstruction of the temporal bone using sagittal tomographic images was useful in evaluating the state of mastoid air cell system development in individual cases and in investigating the pathophysiology in middle ear disease.

Retraction cholesteatoma of the sinus tympani

Posteromedial retraction of the tympanic membrane, between the oval window superiorly and the round window niche inferiorly, results in the formation of an epithelium-lined pocket within the sinus tympanic recess. Failure to recognize posterior invagination of the tympanic membrane intraoperatively leads to inadvertent tearing of the tympanomeatal flap at the level of the annulus with epithelial seeding of the middle ear and probably cholesteatoma recurrence. This article focuses on the clinical manifestations and radiographic findings suggestive of sinus tympanic epithelial retraction of the pars tensa and provides direct correlation between human cross-sectional temporal bone anatomy and otomicroscopy. The surgical management of these challenging lesions includes initial endaural access, external meatal bone removal posteromedial to the tympanic annulus and anterior to the vertical portion of the facial nerve, and middle ear ventilation after marsupialization of the epithelial retraction. Although early tympanic membrane retraction can be treated with a ventilation tube, deep epithelial pockets may require additional surgical treatment. A method for the management of sinus tympanic cholesteatomas is demonstrated.

Effects of extracellular calcium on cholesteatoma migration and adhesion in vitro

Cholesteatoma matrix and tympanic epithelia share the unique property of en mass migratory locomotion in vitro. Although this migratory behavior is not well understood, it is thought to be a major contributor to the pathogenesis and pathophysiology of cholesteatoma disease. We have surmised that en mass migration depends on tight calcium-dependent intercellular and substrate cellular adhesions. The purpose of this investigation was to determine the effects of a diminished extracellular calcium level on cholesteatoma migration and adhesion. Cholesteatoma matrixes obtained intraoperatively from patients undergoing mastoidectomies for chronic ear disease were cut into small fragments and grown in culture. When cultured specimens were exposed to low-calcium medium (0.14 mmol/L calcium), a greater than 10-fold reduction in the rate of migration was observed when compared with control values (1.8 mmol/L calcium). This reduction of migration returned to normal within 48 hours after extracellular calcium was replenished. Substrate cellular adhesion was also significantly reduced when cholesteatoma cells were grown in low-calcium medium. These observations were further supported by histomorphologic findings. Our findings suggest that calcium-dependent intercellular and substrate cellular adhesions are essential for cholesteatoma migration and adhesion. These studies further our understanding of the pathophysiology of cholesteatoma disease and may provide clues on how to better treat patients with this disease.

Incudal folds and epitympanic aeration

Thirty-seven temporal bones were dissected, and the posterior tympanic and epitympanic folds recorded and photographed. Histologic details were documented from four serially sectioned temporal bones, two normal and two inflamed. Of these 41 specimens, 31 were normal, and 10 showed signs of inflammation. The type for the lateral fold was incudomalleal in 16 and incudal in 25 ears. Incus intercrural and incudostapedial folds appeared only exceptionally. Medial and superior incudal folds were not present in normal ears. The anterior tympanic isthmus was a constant, large aeration pathway. In chronically inflamed ears, its partial or total block was caused by polypoid or large sheet-like folds. Inactive sequelae appeared as mature, simple, one-layer or extensive multilayer networks of webs, connected with a deeply indrawn incudomalleal fold. The small posterior isthmus was open to the incudal fossa in 13 ears, and in 28, it was sealed off by a posterior incudal fold. The mastoid air cell tracks were (in ten of 37 dissected ears) open to the incudal fossa, or directly, to the posterior tympanum. Auxiliary pathways due to membrane defects were found in both the horizontal and descending portions of the incudomalleal fold. Excepting the chordal, incudomalleal, and posterior incudal folds, fold-like webs in the posterior tympanum and epitympanum are of inflammatory origin.

Residue of middle ear cholesteatoma after intact canal wall tympanoplasty: surgical findings at one year

The rate of residual disease after surgery for acquired middle ear cholesteatoma was investigated in 167 ears of 164 patients who had undergone planned second-look tympanoplasty by the intact canal wall technique. Overall, operative findings at the second stage revealed 65 cases of residual disease in 48 ears (29%). These consisted of 50 squamous pearls, 11 cases of the flat, open type, and 4 cases of the extensive type. The configuration of residual disease is closely related to the technical difficulty of eradication, since en bloc removal is much easier in the squamous pearl than in the open or extensive type, mainly because of the unclear margin with the surrounding tissues. The proportion of cases of the open type was greater in children than in adults, in pars tensa cholesteatoma than in pars flaccida cholesteatoma, and in severe primary middle ear disease than in moderate or mild disease, although these differences were not statistically significant. The extensive type occurred in 4 ears with severe primary disease, 3 of which were in children. These results support the value and importance of the staged procedure for middle ear cholesteatoma, particularly when operated on by the intact canal wall technique.

[Considerations regarding functional cholesteatoma surgery. II. Open techniques]

A review was made of 128 canal wall-down tympanoplasties for chronic otitis media with cholesteatoma. The cholesteatoma was found in the attic (82.4%), antrum (71.7%), mastoid (45.8%), and mesotympanum (35.8%). In 89.1% of cases there was ossicular chain injury. In 39%, the ossicular chain was partially reconstructed (modified canal wall-down tympanoplasty). After one year, 84.4% of the operated ears were safe, dry and self-cleaning. The others (15.6%) had postoperative otorrhea. Canal wall-down modified mastoidectomy achieved closure of the air-bone gap from 40 to 24 dB (p < 0.001).

[A quantitative study of the presence of interleukin-1 and interleukin-6 in cholesteatoma of the middle ear]

Cholesteatoma of the middle ear is an inflammatory disease characterized by the presence of a keratinized squamous layer that leads to bone destruction. The process may be mediated by various factors (interleukins) produced by an activated macrophages and keratinocytes. Interleukin-1 (IL-1) and interleukin-6 (IL-6) concentrations were measured in extracts of cholesteatoma and normal tissue using the enzyme immunoassay technique (ELISA) after protein concentrations were determined. IL-1 alpha and IL-6 had higher concentrations in cholesteatoma than in normal skin and played a prominent role in bone resorption.

Outcome of residual cholesteatoma and hearing in mastoid surgery

OBJECTIVE

To review 12 years of the senior author's experience with mastoid surgery for cholesteatoma.

DESIGN

Retrospective review.

SETTING

Northwestern University Medical School.

METHODS

Available records included 97 mastoid procedures for cholesteatoma: 54 with intact canal-wall and 43 canal-wall-down.

MAIN OUTCOME MEASURES

Residual cholesteatoma, pure-tone audiometry, and speech audiometry were compared for both groups.

RESULTS

Residual disease rate was 11 of 54 (20%) for intact canal-wall procedures and 2 of 43 (5%) for canal-wall-down procedures. Average follow-up was 2 years. Hearing was preserved postoperatively, and neither procedure demonstrated clear superiority in this regard.

CONCLUSION

While canal-wall-down mastoidectomy provides a lower residual disease rate with equal hearing outcome, the role of intact wall mastoidectomy remains a viable choice in certain clinical situations.

Expression of transforming growth factor-alpha and epidermal growth factor receptor in middle ear cholesteatoma

To study the possible autocrine growth stimulation of cholesteatoma epithelium, the expression of transforming growth factor alpha (TGF-alpha) and epidermal growth factor receptor (EGFR) in middle ear cholesteatoma was investigated by immunohistochemical staining techniques. Twenty cholesteatoma samples obtained at operation and six normal skin specimens collected from the external ear canal were used in the study. Immunostaining for TGF-alpha showed a diffuse cytoplasmic staining pattern. It was weakly expressed in the basal layer of the normal epidermal epithelium but was more strongly expressed in all cholesteatoma specimens. EGFR showed a dot-like/diffuse cytoplasmic and cell membrane staining pattern. EGFR-positive cells were seen in the basal layer of normal epidermis. In the cholesteatoma specimens, expression of EGFR was not only confined to the basal layer but persisted into the upper layers of the epithelium. Our findings indicate that an autocrine growth stimulation by TGF-alpha and EGFR may contribute to the unrestrained growth of cholesteatoma epithelium in the middle ear cavity.

Hearing results following modified radical versus canal-up mastoidectomy

Modified radical mastoidectomy (MRM) provides relatively safe surgical access for the removal of chronic middle ear and mastoid disease and gives reproducible results. However, it had been suggested that hearing may not be as good as that after "intact canal wall mastoidectomy" (ICWM). This paper reviews 153 tertiary referrals suffering from extensive disease who underwent MRM and compares their hearing results with those obtained by other authors using ICWM and MRM and a variety of reconstructive techniques. In this study there were no dead ears and no significant changes in bone conduction despite prolonged drilling and extensive disease. Hearing results after MRM were found to be better after primary surgery than after revision and better in the presence of an intact stapes. No rigid prostheses were used at first-stage surgery. There were no significant differences found between hearing results obtained by MRM in this series and other published results of canal wall down mastoidectomy and ICWM, irrespective of the use of ossicular replacement prostheses.

[Angiogenesis in cholesteatoma of the middle ear]

Middle ear cholesteatoma is characterized by the presence of a keratinizing squamous epithelium with hyperproliferative features. Such growth can only be supported by abundant blood vessels. The presence and distribution of blood vessels in cholesteatoma was studied to determine the mechanisms responsible for its origin and maintenance. Cholesteatoma (n = 30) and retroauricular skin samples (n = 30) were studied with indirect immunoperoxidase and alkaline phosphatase anti-alkaline phosphatase methods. Antibodies were used to recognize endothelial cells (von Willebrand Factor VII), vascular basal membrane components (type VI collagen), intercellular adhesion molecules (ICAM-1, 1CAM-2), human histocompatibility antigen (HLA-II) as a marker for cellular activation, angiogenetic growth factors and their receptors (TGF-alpha and VEGF), lymphocytes (CD3), and macrophages (KiM8). The cholesteatoma stroma had numerous vessels with intact basal membrane. The vessel concentration was higher in regions with abundant macrophage infiltration. Perivascular cell infiltrates were positive for antibodies against angiogenetic factors and HLA-II. Endothelial cells had increased expression of intercellular adhesion molecules and angiogenetic growth factor receptors. These results confirm the presence of increased vascularization in cholesteatoma, which may play an important role in sustaining continuous abnormal growth.

Ultrastructure of eustachian tube mucosa in chronic otitis media with cholesteatoma

PURPOSE

Acquaintance with the severity of inflammatory condition and mucociliary destruction of the protympanic eustachian tube (ET) mucosa may provide some insight for management during surgery for cholesteatoma.

MATERIALS AND METHODS

Protympanic eustachian mucosa was obtained from 25 patients undergoing ear surgery for cholesteatoma and from 5 cadavers undergoing dissection for a gross anatomy course. The specimens were processed for both scanning electron microscopy (SEM) and transmission electron microscopy (TEM).

RESULTS

According to SEM, decreased ciliated cells were noted. Residual ciliated cells and numerous white blood cells (WBC) were noted in the protympanic mucosa of the eustachian orifice. Bacilli were commonly noted at the mucosal surface. Cilia might be collapsed and stagnated with mucus secretion. This finding was consistent with those of the TEM: that cilia of varied directions were embedded in mucus. Mucociliary function was impaired under such conditions. The mucosal alteration was severe in some children; there was no ciliated cell visible. According to the TEM, the mucosal cells contained numerous secretory granules and mitochondria. Polymorphous nuclear cells were noted in the submucosal area that was edematous. Compound cilia were rather common. Mucus blanket covered mucosal cells with widening intercellular spaces. In addition, neither cilia nor microvilli were visible in severe mucosal alteration.

CONCLUSIONS

These occurrences indicated the presence of inflammatory reaction and impairment of clearance function of eustachian mucosa in cholesteatomatous ears. Thorough irrigation during surgery and antimicrobial therapy after surgery are warranted.

Expression of matrix-metalloproteinases and their inhibitors in human cholesteatomas

The proteolytic erosion of the temporal bone is the key event in the pathognomonic course of cholesteatoma progression. The molecular mechanisms of bone resorption, endangering the ossicles, the inner ear, the facial nerve, large vessels or the brain, are not understood. Recently, a new family of proteolytic enzymes, the matrix-metalloproteinases (MMP's) has been described and identified, which seems to play a pivotal role in matrix- and bone homeostasis and inflammatory osteolytic diseases, e.g. osteoarthritis and periodontitis. These enzymes are sophisticatedly controlled by specific inhibitors and activation cascades. We investigated whether human cholesteatoma tissue expresses MMP's and MMP-inhibitors. By immunocytochemistry of cholesteatoma-cryosections, the expression of MMP-2 (72 kD collagenase), MMP-9 (92 kD collagenase), and MMP-3 (stromelysin-1) could be seen to be strictly confined to the basal and suprabasal cell layer of the cholesteatoma epithelium. The neutrophil collagenase (MMP-8) showed a more disseminated expression in the epithelium and the granulation tissue as well. The tissue inhibitor of metalloproteases, TIMP-1, could be detected only in very limited areas of the granulation tissue in a quite randomized manner. Therefore, a derailment in favor of proteolysis of the normally tightly controlled MMP-system might be postulated. The results indicate that members of the MMP-family could play an active role in the molecular mechanisms of cholesteatoma invasion into the temporal bone. This offers new insights into the pathophysiology of the disease and of potential therapeutic approaches.

Epidermal growth factor receptor (EGF-R) in human middle ear cholesteatoma: an analysis of protein production and gene expression

Previous studies have shown an altered epithelial cell proliferation in middle ear cholesteatoma, reporting an aberrant expression of epidermal growth factor receptor (EGF-R) glycoprotein by immunohistochemistry. In this study, we quantified the presence of EGF-R using enzyme-linked immunosorbent assays (ELISAs) on tissue extracts, as well as the EGF-R gene expression by in situ hybridization on frozen sections. Human skin obtained from the external ear canal was used as control. The amounts of EGF-R glycoprotein in cholesteatoma were very similar to those in human skin. Human skin showed EGF-R messenger RNA (mRNA) only in the basal layer. A higher percentage of cells hybridized for the anti-sense probes EGF-R was found in cholesteatoma epithelium. Furthermore, we could find suprabasal cells with EGF-R mRNA. Our results confirm that the abnormal growth of cholesteatoma epithelium is reflected in an aberrant expression of EGF receptor.

External and middle ear pathology in TGF-alpha-deficient animals

Transforming growth factor-alpha (TGF-alpha) is a growth-regulatory peptide found in a wide range of embryonic and adult tissues. TGF-alpha is produced by keratinocytes and has been reported to be overexpressed in several epidermal diseases, including middle ear cholesteatoma. This report describes ear pathology in the waved-1 mutant mouse, which is severely deficient in TGF-alpha. Morphologic changes of the external and middle ear were studied histologically in waved-1 mutants 2 weeks to 6.5 months of age. Abnormalities found in the mutants included epidermal hyperplasia of the external ear canal (EAC) and tympanic membrane (TM) and enlargement of specialized sebaceous glands adjacent to the cartilaginous EAC. Sebum and desquamated keratin progressively accumulated within the EAC, displacing the TM into the middle ear. These changes appear similar to those occurring in Mongolian gerbils, which are known to develop cholesteatoma. The alterations found in waved-1 mutants are discussed in relation to the possible involvement of TGF-alpha in cholesteatoma pathogenesis.

Congenital cholesteatomas of the middle ear: a different experience

A retrospective analysis is presented of 44 cases of congenital cholesteatoma of the middle ear. Twenty-one patients had cholesteatoma localized to the posterosuperior mesotympanum in complete contrast to the commonly reported anterosuperior location seen in only two cases. The remaining 21 patients had cholesteatoma involving either the entire mesotympanum or epitympanum or both. The posteriorly located congenital cholesteatomas might represent a completely different entity and originate from the trapped epithelial cell rests in the posterior mesotympanum during the development of temporal bone. All but one patient were treated by using a closed tympanoplasty. Eight patients underwent a single-stage surgery. A preplanned second-stage procedure was performed in 33 patients, and three are awaiting their second stage. Residual disease was seen in 19 (57%) patients undergoing second-stage surgery. No patient has had recurrent disease so far. Thirty-eight (85%) patients had a preoperative air-bone gap of > or = 30 dB. Of the 33 patients considered for hearing results, 16 (48%) had a postoperative gap within 10 db.

Small cavity mastoidectomy--5 year review

It has been recognized that the traditional method of open mastoid surgery often produces a larger mastoid cavity than necessary. Small cavity mastoidectomy is advocated to reduce the size of the mastoid cavity by exteriorizing the cholesteatoma from the epitympanum backwards. When this operation is performed in a sclerotic mastoid bone, the resulting cavity is very small. The 5 year review of 39 ears with small cavity mastoidectomy is presented. Not only were the mastoid cavities small, they remained stable and trouble-free. It also enabled the patients to enjoy swimming and minimizing wax accumulation within the cavities. The hearing results after 5 years were comparable to that of the closed technique. Formation of cholesterol granuloma behind the concho-meatal flap was an uncommon complication.

Sinus tympani: retrofacial approach for the removal of cholesteatomas

The epithelium basement membrane of cholesteatomas in cases of chronic otitis media often extends into the sinus tympani. In the majority of cases it can be safely and completely removed by dissection through the ear canal and tympanum. In 2% of cases, not all squamous epithelium basement membrane can be removed because the sinus tympani extends more than 3 or 4 mm posterior to the anterior edge of the facial nerve and because the membrane is adherent to the irregular bony surface. Surgical exposure of the sinus tympani through the mastoid posterior and medial to the facial nerve allows complete removal of all basement membrane with a direct view. The technique using a retrofacial approach to expose this obscure sinus is described and a series of 48 cases treated successfully by this method are reported.

Cochlear fistula in chronic otitis media with cholesteatoma

Labyrinthine fistula in chronic otitis media with cholesteatoma most commonly involves the horizontal semicircular canal. We report three cases of cochlear fistula in chronic otitis media with cholesteatoma. All of them had a long history of otorrhea. One patient had total hearing loss of the affected side. The other two patients had conductive hearing loss. Radical mastoidectomy had been done in all cases. Cholesteatoma in the tympanic cavity destroyed the basal turn of the cochlea. These fistulas were sealed with muscle or Gelfoam with streptomycin. We found no fistula in the semicircular canal in any of the three cases. We report three cases of cochlear fistula in chronic otitis media with cholesteatoma, and review the literature.

Critical evaluation of the "jigsaw" assembly for ossiculoplasty

A modification of an ossiculoplasty technique, in which a hole is drilled through an ossicular or cortical bone graft so that it can encircle the malleus handle, has been evaluated during a 4-year period. During this time, 26 operations have been carried out. The 1-year hearing results obtained have been compared with those for conventional operations in ears with the same ossicular defect by creating matched pairs whose preoperative air-bone gaps differed by no more than 5 dB. There is no difference between the hearing results for the two groups. Revision operations have been carried out in five cases. In two of these the cause of failure was iatrogenic cholesteatoma. This probably occurred because the technique demands the separation of the malleus handle from the tympanic membrane. This can be easily achieved except at the lower end, where the attachment is much firmer. The incidence of cholesteatoma in the study group is higher than that found in the author's patients who have undergone conventional ossiculoplasty operations. The "jigsaw" technique has no advantage over conventional ossiculoplasty techniques and, in view of the risk of cholesteatoma formation, cannot be recommended.

Hypersomnia associated with a focal pontine lesion

A 50-year-old woman developed intractable excessive sleepiness after undergoing the surgical removal of a brainstem cholesteatoma. The 24-hour ambulatory monitoring revealed a normal architecture of sleep contents, with 62.7% of the time spent in sleep. Auditory and somatosensory evoked responses showed abnormal patterns. The MRI scan of her brain showed an extensive nonprogressive lesion in the brainstem. We speculate that the problem underlying the patient's hypersomnia is a defect in the ascending reticular activating system (ARAS) rather than in the REM and NREM sleep mechanisms.

Preservation of cochlear function after extensive labyrinthine destruction

We report a case of hearing preservation after removal of the semicircular canals and discuss the possible explanations for the mechanisms of preservation of hearing after removal of the labyrinth. We hope to promote the perspectives and possibilities of functional surgery of the inner ear and for tumors of the cerebellopontine angle.

A surgical solution for the difficult chronic ear

We all encounter them: difficult chronic ears that seem to confound management efforts and that constitute an unrelenting imposition to the patient. Typically these ears have undergone multiple surgeries and are chronically infected. Such cases are commonly associated with residual or recurrent cholesteatoma. Those rare ears that temporarily respond to therapy promptly recur once treatment is withdrawn. Even the most aggressive nonsurgical protocols fail these patients, who exhibit lifelong social and professional incapacity. They seem to ultimately defy resolution. The purpose of this article is to present a surgical solution to the difficult chronic ear dilemma that emphasizes disease control. Treatment outcome is reviewed in 541 cases. Management pitfalls are analyzed with follow-up, in some cases 20 years.

Incidence of sniff-related cholesteatomas

High negative middle ear pressure created by habitual sniffing in patients with insufficient closure of the Eustachian tube has been claimed by Magnuson and colleagues to be an important causative factor of acquired cholesteatomas. The present study was conducted to ascertain the rate and types of cholesteatomas in which habitual sniffing is involved. Among 105 consecutive patients with acquired cholesteatomas (112 ears: 93 flaccida type, 15 tensa type, 4 extensive type), 27 patients (31 ears) were diagnosed as having a habitual sniff in response to aural discomfort resulting from insufficient closure of the Eustachian tube. This corresponds to 25.7% of the patients, which is significantly higher than the prevalence of habitual sniffing in normal subjects, being 2 out of 130 (1.5%) (p < 0.005: chi2-test). Habitual sniffing was found to be statistically more common in flaccida-type than in the tensa-type cholesteatomas. Habitual sniffing in response to aural discomfort was thus found to be an important risk factor for cholesteatomas. However, investigations into other pathogeneses of cholesteatomas should be continued, since the sniff-related cases reported here were limited to one-fourth of the cases of acquired cholesteatomas studied.

Role of interleukin 6 in epithelial hyperproliferation and bone resorption in middle ear cholesteatomas

Locally produced pro-inflammatory cytokines are considered to play an important role in the initiation and/or maintenance of inflammatory diseases. In cholesteatomatous lesions there are increased levels of some cytokines and inflammatory mediators like interleukin 1, tumor necrosis factor and colony-stimulating factor, etc. Interleukin 6 (IL-6) can be produced by different cells present in cholesteatoma (e.g. keratinocytes, lymphocytes, fibroblasts and macrophages). Until now, no data have been available on the role of IL-6 in cholesteatoma. In this study we used immunohistochemistry to investigate the presence and distribution of IL-6 in tissue samples from cholesteatoma patients. Levels of the cytokine were quantified in tissue extracts using an enzyme-linked immunosorbent assay. Finally, the presence of biologically active IL-6 was analyzed in the murine cell line 7TD1. Human skin samples obtained from the external ear canal were used as controls. Using the anti-IL-6 antibody in an alkaline phosphatase anti alkaline phosphatase technique, a moderate diffuse staining of the whole epidermis was observed in sections of normal skin. In cryostat sections of cholesteatoma samples, a stronger staining of the whole epithelium was observed. Many of the cells infiltrating the cholesteatoma stroma also showed positive immunostainings. The concentration of IL-6 in relation to the total protein concentration in cholesteatoma (119.33 +/- 30) were higher than in human skin (9.16 +/- 13). While IL-6 activity was not detected in skin samples, two of the ten cholesteatoma samples studied showed a stimulatory effect when incubated with the cell line 7TD1. The overexpression of IL-6 in middle ear cholesteatoma suggests a participation of this cytokine in some of the clinical features seen: epithelial hyperproliferation and bone resorption. The absence of biological activity in the majority of the cholesteatoma samples points to the presence of natural inhibitors for IL-6.

Cytokeratin expression patterns by one- and two-dimensional electrophoresis in pars flaccida cholesteatoma and pars tensa cholesteatoma

Expression patterns of cytokeratins (CKs) in normal skin, in pars flaccida type cholesteatoma (PFTC), and in pars tensa type cholesteatoma (PTTC) were examined by means of one- and two-dimensional electrophoretic techniques. Both CKs 14 and 5 pair (CKs 14/5) and CKs 10/1 were found in all materials. Neither CKs 16/6 nor 19 was found in the skin. CKs 16/6 and 19 were both found in 3 out of 5 PFTCs, only CKs 16/6 in 1 out of 5 and neither CKs 16/6 nor 19 in 1 out of 5. CKs 16/6 and 19 were both found in 1 out of 3 PTTCs, only CKs 16/6 in 1 out of 3 and neither CKs 16/6 nor 19 in 1 out of 3. There was no significant difference in the CKs expression patterns between PFTC and PTTC. The expression of CKs 16/6 and 19 suggested that their matrix epithelia were hyperproliferative. However, not all of the cholesteatomas were always hyperproliferative. Patterns of the terminal differentiation of CKs 1, 5, 10 and 14 in the PFTC or the PTTC were basically the same as those in the skin. In the cholesteatoma, eack CK gradually diminished in molecular weight in the cornified layer and debris. Desmosomal proteins were abundant in skin but not in cholesteatomas.

Modified canal wall-up mastoidectomy with mastoid obliteration for severe chronic otitis media

Mastoid tympanoplasty with a canal wall-up technique provides better conditions for a healthy skin lining than canal wall-down techniques. The formation of retraction pockets in residual pneumatized cavities is however a major cause of cholesteatoma recurrence with canal wall-up techniques. We have therefore attempted to combine the advantages of both canal wall-down and canal wall-up techniques. The posterior wall is kept up, the mastoid is obliterated with adipose tissue, the attic is exteriorized in the ear canal and hearing is restored with a minimal-size hypotympanic cavity only. Preliminary results from 41 cases with a follow-up of 6 months to 6 years suggest that skin conditions in the enlarged ear canal are adequate and that cholesteatoma do not recur.

Effect of endotoxin on cultured rat middle ear epithelium, rat meatal epidermis, and human keratinocytes

Several factors seem to contribute to the series of events in the pathogenesis of otitis media and cholesteatoma. Endotoxin is likely to be one of these factors, since it has been found in human middle ear effusions and since injection of this substance into the middle ear, in animal experiments, gave rise to prominent reactions. Provoking of epithelial cells in vitro with endotoxin led to distinct cell responses that might be associated with cholesteatoma formation. In this study the effect of endotoxin on serially cultured rat middle ear epithelium, rat meatal epidermis, and human keratinocytes was investigated. Endotoxin strongly stimulated the proliferation of middle ear epithelium and human keratinocytes and inhibited that of meatal epidermis. Furthermore, endotoxin affected the morphology of the three types of tissue. Rat middle ear epithelium revealed epithelial cell tracks with interconnecting bridge-like structures protruding above the culture plane, whereas rat meatal epidermis showed increased terminal differentiation expressing large areas of blister-like structures detaching from the culture dish. Cross-linked envelope analysis of human keratinocytes showed an increased terminal differentiation that was morphologically confirmed but was not confirmed by cytokeratin analysis. The results of this study support the hypothesis that endotoxin may play an important role in the pathogenesis of otitis media and cholesteatoma.

Hearing impairment in chronic otitis media with cholesteatoma

This study involved a five-year review of 94 patients with chronic otitis media with cholesteatoma. In total, 110 surgical procedures were carried out. The study comprised 96 cases; surgery that was a revision of previous surgery were excluded. The extent of cholesteatoma and its associated bone destruction were observed and recorded. Of the 96 cases, 14.6% were classified as Grade I, 13.5% as Grade II, 31.3% as Grade III and 40.6% as Grade IV. This indicated that the majority of patients with chronic otitis media with cholesteatomas were in an advanced stage. Preoperative pure tone audiogram showed that 49% of these patients had pure conductive hearing impairment; 29.2% had a mixed type hearing impairment; 15.6% had a sensorineural hearing impairment and only 6.2% had normal hearing. In 78% of these cases, the conductive component of hearing loss was improved with surgery. If 40 db was used as a standard for the social hearing level, 72.9% of these cases were handicapped.

[Surgical evaluation and clinical features of cholesteatoma in children]

There are two types of cholesteatoma in children, congenital and acquired. The pathogenesis of each type is thought to be different. The pathogenesis of congenital cholesteatoma is thought to be the embryonic inclusion of squamous epithelium, whereas acquired cholesteatoma is thought to develop from various factors including recurrent otitis media and tubal insufficiency. We reviewed a series of 23 patients with congenital cholesteatoma and 27 patients with acquired cholesteatoma, aged 2-15 years, who were operated on at our institution between January 1981 and December 1990. Planned staged surgery was performed in all patients. In the first-stage operation, the canal-wall-up technique was used in all cases. About 12 months after the first operation, the second-stage operation was performed to investigate the course of the disease. The presence of recurrent and residual cholesteatoma was evaluated at this time. In the congenital cholesteatoma series, 11 cases of residual cholesteatoma (48%) were detected at the second-stage operation. Since recurrent cholesteatoma was not observed in the series of congenital cholesteatoma cases, the prognosis of these cases was considered to be good. On the other hand, in the acquired cholesteatoma series, 9 cases (33%) of recurrent cholesteatoma and 13 (48%) of residual cholesteatoma were detected at the second-stage operation. For the second-stage operation, the canal-wall-up technique was performed on 18 patients with no recurrence, whereas the canal-wall-down technique was used on all 9 patients with recurrence. Additional mastoid obliteration was performed on 7 of these 9 patients. The prognosis of the patients who underwent obliteration was good, and there was no recurrence of cholesteatoma after the second operation. From these observations, it was concluded that planned staged tympanoplasty was useful for eliminating recurrent and residual cholesteatoma. It is also apparent that, in order to prevent recurrent cholesteatoma, it is necessary to reduce the air space to compensate for poor eustachian tube ventilation.

Neuroma of the facial nerve masked by chronic otitis media

The absence of facial twitching, weakness, or palsy makes the diagnosis of facial neuroma difficult. The authors report a case of neuroma of the horizontal portion of the facial nerve masked by the presence of a chronic ear. A woman with a long history of discharge and hypoacousia in her left ear presented with acute dizziness. Examination revealed grade 3 horizontal right nystagmus, left anacousia, and the appearance of an epitympanic cholesteatoma. Computed tomography (CT) was performed after the vestibular condition improved. The clinical diagnosis of chronic otitis media with cholesteatoma together with the radiologic finding of the mastoid and tympanic cavity completely occupied by soft tissue were enough to send the radiologist astray. The radiologic diagnosis confirmed that the bony destruction of the vestibule and lateral semicircular canal could be caused by a cholesteatoma. A neuroma of the horizontal portion of the facial nerve was discovered during surgery performed for the chronic ear. The postoperative study of the CT scans showed that there was no erosion of the malleus or incus, despite wide erosion of the vestibule and lateral semicircular canal. This finding would be enough to suggest the presence of pathology other than cholesteatoma. The patient refused exeresis of the neuroma. The authors recognize the difficulty in urging a patient to an operation that surely will result in worsening of the facial function. Follow-up in this case has revealed no change in tumor dimension or facial function over 3 years.

[Treatment of petrous bone cholesteatoma]

Cholesteatoma involving the petrous compartment of the temporal bone is rare and is a difficult surgical challenge for the neuro-otological surgeon. A series of 60 cases of petrous bone cholesteatoma is presented. The diagnosis, surgical treatment, results, and complications are discussed. Our present surgical attitude is based on closed obliterative procedures that allow a wide field exposure with radical removal excision, control and protection of vital structures, and management of problems related to the facial nerve. The treatment of dura mater involved by matrix is still unsolved. Regular follow-up with CT and MRI is mandatory.

[A CT cytomorphodensitometric study of the proliferating epithelial activity in middle ear cholesteatoma]

A cytomorphodensitometric study was made by analysis of the computerised image of the germinative and intermediate epithelial layers in a sample of five specimens of cholesteatoma and the corresponding skin from the external auditory canal. A morphometric variable corresponding to the nuclear area was determined and densitometric variables equivalent to the relative quantity of nuclear DNA were determined. Within the germinative layers of the cholesteatoma epithelium, we observed larger nuclei and more relative DNA per nucleus. The average densitometric values were in the range of 2C-4C, which is indicative of a greater cellular population in S phase in the cholesteatoma than in the skin.

Findings in revision operations for failures after cholesteatoma surgery

Surgical findings and long-term results of 112 revision operations performed for failures after cholesteatoma surgery were studied. The indication for revision was recurrence of cholesteatoma in 43 percent, persistent otorrhea in 27 percent, dry reperforation in 10 percent, and unsatisfactory hearing result in 18 percent. Of the recurrences, 71 percent were regarded as residual cholesteatomas (i.e., arising from a cholesteatoma remnant left at the primary operation). Infected unexenterated mastoid air cells were found in 63 percent of ears reoperated on for persistent discharge. Thus, it is reasonable to conclude that at least 48 percent of our revisions could have been avoided if the surgeon had used more skillful and more radical surgical technique when performing the primary operation. On the other hand, the persistence of cholesteatoma and the difficulty of eradicating the disease is highlighted by the finding that cholesteatoma again recurred in three patients (3%) after the first revision.