Endoscopic approach to geniculate ganglion: a multicentric experience

PURPOSE

A variety of lesions could arise from the GG area, or extend into this region from adjacent sites. The management of perigeniculate lesions includes observation, surgery, and radiation, according to the nature, the size of the lesion, and the accompanying symptoms. Preliminary experiences on the exclusive transcanal endoscopic approach to the GG area have shown safety and feasibility avoiding of any postauricular incision, or brain manipulation. The experience from two referral centers on patients treated for a GG lesion with a totally endoscopic approach is herein reported.

METHODS

Data about patients who underwent exclusive endoscopic approach to the GG area at the Otolaryngology Departments of the University Hospitals of Modena and Bologna between May 2017 and February 2022 were retrospectively collected.

RESULTS

The total number of patients included in our study was 11. 10 patients (91%) had progressive unilateral facial paralysis and 1 patient (11%) presented with chronic otorrhea. The mean largest diameter of the treated lesions was of 8 mm. The resection was extended to the fundus of the IAC in 2 patients (expanded approach). The remaining 9 patients (82%) underwent partial ossicular replacement prosthesis (PORP). No major complications occurred. Facial nerve outcomes were good in all patients and the mean ABG worsened from 12 dB pre-operatively to 22 dB post-operatively.

CONCLUSIONS

The exclusively endoscopic approach to GG lesions represents a viable alternative to traditional microscopic approaches and may be included in the armamentarium of ear surgeons.

Permanent occlusion of the Eustachian tube: a retrospective study on reopening procedures

PURPOSE

This study retrospectively evaluated the efficacy and versatility of reopening procedures for the permanent occlusion of the cartilaginous Eustachian tube (POET) by analyzing four consecutive cases.

METHODS

The study included all patients diagnosed with POET who suffered from Eustachian tube occlusion and glue ear. A combined approach of endoscopic transnasal/transoral laser surgery was utilized to reopen the POET. This was subsequently followed by balloon dilation (BET) and stenting for a duration of six weeks. In one distinct case, the Eustachian tube orifice was approached via a transtympanic method, where a balloon catheter was placed. The primary outcome measures targeted the success rate of reopening, which was quantified using audiological outcomes and Eustachian tube patency verified by a positive Valsalva maneuver.

RESULTS

Four patients, with an age range of 14-62 years (mean age of 29.3 years), were subject to Eustachian tube reopening. The duration of follow-up varied between 10 and 24 months, averaging at 16.2 months. Notably, 75% of the surgically treated ears displayed no evidence of glue ear upon their last follow-up and showed restoration of Eustachian tube patency. The procedures were executed without any surgical complications. The causes for POET in these patients were heterogeneous: two were attributed to scarring post adenoidectomy, one to occlusion following orthognathic surgery and the remaining one due to prior radiotherapy treatment for squamous cell carcinoma located at the soft palate.

DISCUSSION

Total occlusion of the cartilaginous Eustachian tube may be linked to persistent middle ear diseases. It is imperative to conduct nasopharyngeal endoscopy in these cases. The findings from this study suggest that the Eustachian tube reopening procedure is predominantly effective and safe for patients with POET stemming from a variety of pathologies. Future research should focus on exploring advanced stenting devices and necessitate longer follow-up periods for comprehensive understanding.

Balloon Eustachian Tuboplasty-A Feasible Double-Blinded Sham Surgery Randomized Clinical Trial Protocol to Study Efficacy

INTRODUCTION

Balloon Eustachian tuboplasty (BET) is used to treat obstructive Eustachian tube dysfunction (OETD) and recurrent otitis media with effusion (OME). However, there are no indisputable evidence of its efficacy. Here, we present a multicenter, double-blinded, randomized, placebo-controlled trial (MDRCT) design to evaluate the efficacy of BET, and the results of a pilot trial with 3- and 12-months' follow-up.

MATERIAL AND METHODS

This was a prospective MDRCT. For a pilot study, OETD (n = 10) and OME (n = 5) patients were recruited and followed. Detailed inclusion and exclusion criteria were used. Participants were randomized at beginning of the operation to active or sham surgery. All procedures were performed under local anesthesia. Controls were performed in double-blinded manner (both patient and physician), at 3 and 12 months after the procedure.

RESULTS

Altogether, 20 ears were treated and followed for 12 months, including 14 active BETs and 6 sham surgeries. Both the active and sham surgery were performed under local anesthesia without problems or deviations from the protocol. There were no differences in the preoperative symptoms (ETDQ-7) or objective measures (tympanometry, Valsalva and Toynbee maneuvers, tubomanometry, Eustachian tube score) between active and sham surgery arms. During follow-up, we noticed largely similar reduction in subjective symptoms and improvement in Eustachian tube score both in active and sham surgery arms.

CONCLUSIONS

The pilot study demonstrates that our MDRCT protocol is feasible, and that blinded RCTs are dearly needed to objectively measure the efficacy of BET.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1874-1881, 2024.

Outcomes of an Ear Camp Conducted in Bhutan by Thai Rural ENT Foundation-A Descriptive Study

BACKGROUND

The Thai Rural ENT foundation has been conducting ear camps in Bhutan for many years to address the shortage of ENT specialists in the kingdom where patients are examined and treated for various ear illnesses. However, there has been no study conducted to assess the outcomes of such camps. This is the first study of its kind to be carried out in Bhutan.

OBJECTIVE

To study the spectrum of ear cases seen during the mobile ear camp, the intervention done and treatment outcomes.

MATERIALS AND METHODS

The study enrolled patients with ear disorders who presented to the mobile ear camp at Monggar Regional Referral Hospital, Bhutan, from January 6, 2020, to January 8, 2020. The following data were recorded: demographic details, preoperative clinical symptoms and otoscopic findings, preoperative audiogram, treatment or surgery done, postoperative middle ear and mastoid infection, wound infection, graft condition, any complications, and postoperative audiogram of operated cases. Patients who underwent surgery were followed up at 1 day, 6 weeks, and 2 months postoperatively.

RESULTS

Two hundred ten patients presented with otologic conditions and 43 underwent surgeries. Otitis media was the commonest disease detected, and tympanoplasty was the commonest surgery performed. The tympanic membrane closure rate was 92.1%, and the rate of hearing improvement was 63.2%.

CONCLUSION

The ear camp had beneficial effect and showed good results.

Eustachian tube balloon dilation

Eustachian tube dysfunction is a frequent pathology of middle-ear ventilation, leading to many more or less disabling otologic symptoms. Severity varies from simple otitis media with effusion to aggressive chronic otitis or cholesteatoma. First-line treatment is medical, but surgery can also be proposed. It consists in balloon dilation of the Eustachian tube, in order to increase ventilation and improve symptoms. It is performed in second-line in patients with Eustachian tube dysfunction confirmed by tubomanometry, after failure of local drug treatment. It can be performed under general or local anesthesia but it is mandatory to use a medical device with market authorization for this indication. The main aim of this surgical note is to describe the technique of balloon dilation in the treatment of Eustachian tube dysfunction and the three balloon models with CE label and market authorization currently available in France and in Europe. Balloon dilation of the Eustachian tube appears to be a promising option to restore natural middle-ear ventilation in patients with chronic obstructive Eustachian tube dysfunction.

Treatment of auricular pseudocysts using enhanced negative drainage: a prospective study of 21 cases

OBJECTIVE

Auricular pseudocysts are rare, painless, benign intracartilaginous cysts of the auricle that are not lined by epithelium and have no known aetiology.

METHOD

This was a prospective study conducted in an ENT department from January 2020 to June 2022. In 21 patients, complete aspiration of the pseudocyst with enhanced negative drainage was performed. They were followed for a minimum of six months.

RESULTS

All patients completely responded to the negative drainage treatment. No cases of recurrence or obvious deformities were observed.

CONCLUSION

Aspiration with intensified negative drainage was associated with a positive response in patients with auricular pseudocysts. Complete resolution of the swelling can be achieved without any serious complications. Thus, it appears to be a simple and effective method for managing the condition.

Balloon dilation improves both the hearing level and the quality of life in patients suffering from obstructive Eustachian tube dysfunction

PURPOSE

Chronic obstructive Eustachian tube dysfunction (OETD) can lead to tympanic membrane (TM) retraction and middle ear effusion (MEE) which can cause conductive hearing impairment, which among other ear symptoms can lower the quality of life (QoL). In this prospective study we assess hearing results and subjective changes in QoL following balloon Eustachian tuboplasty (BET) in treatment of OETD.

METHODS

Totally 25 ears with TM retraction and 18 ears with MEE due to chronic OETD underwent BET as the sole intervention. Outcomes including otoscopy, ability to perform the Valsalva maneuver, tympanometry, audiometry, Eustachian tube inflammation scale and the Glasgow Benefit Inventory questionnaire (GBI) were obtained on all patients preoperatively and 6 months postoperatively.

RESULTS

Hearing thresholds improved statistically significantly (p < 0.05) with means of 3 dB in the TM retraction group and 9 dB in the MEE group. Total GBI results indicated a positive influence on patients' QoL. Valsalva success rate was 80% in patients with TM retraction and 67% in patients with MEE. Tympanometry results improved in 50% of TM retraction patients and in 33% of MEE patients.

CONCLUSIONS

Here we demonstrated that the BET has a positive impact on patients' conductive hearing loss and QoL in patients with TM retraction or MEE. Results were better in TM retraction group than in MEE group.

Safety, tolerability, and effect of a single aural dose of Dornase alfa at the time of ventilation tube surgery for otitis media: A Phase 1b double randomized control trial

BACKGROUND

One third of children require repeat ventilation tube insertion (VTI) for otitis media. Disease recurrence is associated with persistent middle ear bacterial biofilms. With demonstration that Dornase alfa (a DNase) disrupts middle ear effusion biofilms ex vivo, we identified potential for this as an anti-biofilm therapy to prevent repeat VTI. First, safety and tolerability needed to be measured.

METHODS

This was a phase 1B double-blinded randomized control trial conducted in Western Australia. Children between 6 months and 5 years undergoing VTI for bilateral middle ear effusion were recruited between 2012 and 2014 and followed for two years. Children's ears were randomized to receive either Dornase alfa (1 mg/mL) or 0.9 % sodium chloride (placebo) at time of surgery. Children were followed up at 2 weeks post-VTI and at 3-monthly intervals for 2 years. Outcomes assessed were: 1) safety and tolerability, 2) otorrhoea frequency, 3) blocked or extruded ventilation tube (VT) frequency, 4) time to blockage or extrusion, 5) time to infection recurrence and/or need for repeat VTI.

RESULTS

Sixty children (mean age 2.3 years) were enrolled with 87 % reaching study endpoint. Treatment did not change otorrhoea frequency. Hearing improved in all children following VTI, with no indication of ototoxicity. Dornase alfa had some effect on increasing time until VT extrusion (p = 0.099); and blockage and/or extrusion (p = 0.122). Frequency of recurrence and time until recurrence were similar. Fourteen children required repeat VTI within the follow-up period.

CONCLUSION

A single application of Dornase alfa into the middle ear at time of VTI was safe, non-ototoxic, and well-tolerated.

TRIAL REGISTRATION

ACTRN12623000504617.

Racial Disparity in Tympanostomy Tube Placement in Inpatient Pediatric Admissions

This study aims to evaluate if race and ethnicity affect rates of tympanostomy tube (TT) placement during inpatient pediatric admissions in children with otologic conditions. A review of the 2016 Kids' Inpatient Database was conducted based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for common otologic conditions. Among 85 827 weighted pediatric inpatient discharges with ICD-10-CM codes for common otologic conditions, 213 underwent TT placement. Odds ratios (ORs) for children of Hispanic ethnicity and Asian or Pacific Islander race undergoing TT placement when compared to other ethnicities and races were 0.60 (P = .011) and 0.21 (P = .040), respectively. Multiple logistic regression showed Hispanic ethnicity was associated with lower rates of TT placement when compared to non-Hispanic white children (OR = 0.62; 95% confidence interval = 0.40-0.96). Future studies should assess why these differences exist and if these differences are associated with racial/ethnic bias or attributed to patient/family preference.

Tympanic membrane findings and Eustachian tube function after transtympanic plugging for the chronic patulous Eustachian tube

OBJECTIVE

To evaluate Eustachian tube (ET) function after Kobayashi plug surgery based on the tympanic membrane (TM) findings and active opening (AO) of the ET assessed with sonotubometry.

SUBJECTS AND METHODS

A retrospective survey of medical records identified 74 ears of 66 patients with patulous ET (PET) received transtympanic insertion of the Kobayashi plug. Excluding the six ears (6 patients) with abnormal preoperative TM, sixty-eight ears of 60 patients were found to have normal TM preoperatively. Among these 68 ears, there were 51 ears in which sonotubometry was performed both before and after surgery to evaluate whether the AO of the ET was positive or not.

RESULTS

Out of the 68 ears with normal preoperative TM, 52 ears (76.5%) were judged successful (sum of complete relief and significant improvement). The postoperative TM was normal in 41 ears (60.3%), while 27 ears (39.7%) had abnormal TM findings postoperatively. The success rate was 75.6% (31/41) in ears with normal postoperative TM, while it was 77.8% (21/27) in ears with abnormal TM. Success in maintaining normal postoperative TM was found in 45.6% (31/68) of the total ears treated. Out of the 51 ears in which sonotubometry was performed both before and after surgery, AO was preoperatively positive in 88.2% of the ears (45/51), while it was positive in 64.7% (33/51) postoperatively. In thirty-four ears with normal TM postoperatively, AO was positive in 24 ears (70.6%), while it was positive in 9 out of 17 ears (52.9%) with abnormal postoperative TM. The success rate was 70.6% (36/51) for the 51 ears in which AO was assessed both pre- and postoperatively, and it was 66.7% (22/33) in ears with positive AO postoperatively, while it was 77.8% (14/18) in ears without AO postoperatively. The incidence of ears either having normal postoperative TM or positive AO postoperatively was 84.3% (43/51). Abnormal postoperative TM findings without effectiveness were found in 8.8% (6/68).

CONCLUSION

The obstructive dysfunction of the ET is a calculated risk but did not occur in most ears after plugging with the Kobayashi plug. Therefore, routine insertion of the VT at the same time as the initial surgery is not recommended for PET cases that are adequately followed up.

[Contemporary diagnosis and management of congenital microtia and aural atresia : Part 1: Principles and diagnosis]

Congenital malformations of the pinna and aural atresia can result in major aesthetic and functional deficits. Knowledge about embryologic developments and established classification systems is an essential requirement when dealing with affected patients. Early detection of deficiencies and introduction of appropriate diagnostic measures is vital to initiate adequate therapies and prevent long-term disabilities. Treatment for malformations of the pinna-if requested-is mostly surgical, infrequently an epithesis is applied. As in other surgical fields, tissue engineering will likely play a crucial role in the future. Treatment of aural stenosis and atresia aims at improvement of hearing levels and prevention of secondary complications like cholesteatoma and chronic otorrhea. Auditory rehabilitation comprises a spectrum from conventional hearing aids to invasive hearing implants, the latter being favored in recent years.

Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate

OBJECTIVE

Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing.

METHODS

We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results.

RESULTS

Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups.

CONCLUSIONS

Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.

Attic reconstruction techniques in cholesteatoma surgery: a comparative analysis of cartilage versus bone pate

BACKGROUND

Cholesteatoma surgery involves canal wall down (CWD) and canal wall up (CWU) mastoidectomy. CWU is associated with higher cholesteatoma recurrence, often linked to attic retraction pockets. Attic reconstruction with cartilage or bone pate lacks comparative evidence.

AIMS/OBJECTIVES

To compare the effectiveness of cartilage and bone pate in attic reconstruction during CWU mastoidectomy for cholesteatoma.

MATERIAL AND METHODS

We conducted a retrospective study at King Abdullah University Hospital (KAUH) in Jordan, analyzing surgeries performed from 2011 to 2021. Patients who underwent CWU mastoidectomy with attic reconstruction using tragal cartilage with perichondrium or bone pate were included.

RESULTS

Of 48 patients analyzed, 26 had cartilage graft attic reconstruction, and 22 received bone pate. Recurrent cholesteatoma occurred in 19.23% of the cartilage group but none in the bone pate group (p = .001). Ear discharge was observed in 19.23% of the cartilage group and 18.18% of the bone pate group, while tympanic membrane perforations and external auditory canal cholesteatoma were more prevalent in the cartilage group.

CONCLUSIONS AND SIGNIFICANCE

Our study indicates that bone pate results in significantly lower cholesteatoma recurrence than cartilage grafting in CWU mastoidectomy attic reconstruction. Bone pate offers stability and favorable long-term outcomes for outer attic wall repair.

Otorhinologic Disorders in 22q11.2 Deletion Syndrome

OBJECTIVE

Investigate incidence and natural history of otologic and sinonasal disease associated with 22q11.2 deletion syndrome.

STUDY DESIGN

Case series.

SETTING

Tertiary care children's hospital.

METHODS

Charts from consecutive children born 2000 to 2018 with a diagnosis of 22q11.2 deletion, DiGeorge, or velocardiofacial syndrome based on the International Classification of Diseases (ICD)-9 and ICD-10 codes were reviewed. Otologic and rhinologic diagnoses and surgeries and immune and microbiologic laboratory findings were collected from the medical record.

RESULTS

After the exclusion of patients with no 22q11.2 deletion (n = 101), otologic care at an outside hospital (n = 59), and loss to follow-up prior to 3 years of age (n = 22), 128 were included. Males comprised 80 (62.5%) patients, 115 (89.8%) were white, and the median age at genetic confirmation of 22q11.2 deletion was 119 days (range 0 days to 14.6 years). Recurrent acute otitis media (RAOM), chronic otitis media with effusion, chronic rhinosinusitis, and recurrent acute sinusitis were diagnosed in 54 (42.2%), 37 (28.9%), 10 (7.8%), and 8 (6.3%), respectively. Tympanostomy tubes were placed in 49 (38.3%). Adenoidectomy and sinus surgery were performed in 38 (29.7%) and 4 (3.1%), respectively. Neither immunoglobulin nor cluster of differentiation deficiency increased the odds of RAOM diagnosis, tympanostomy tube placement, or chronic/recurrent sinusitis. Methicillin-resistant Staphylococcus aureus was the most common organism in sinus cultures (4/13, 30.8%). Streptococcus pneumonia dominated otorrhea cultures (11/21, 52.4%).

CONCLUSION

Approximately half of children with 22q11.2 deletion may experience otologic disease that often requires surgical management. Future studies will utilize a larger cohort to examine the role of immunodeficiency in otologic and rhinologic disease in this population.

External Ear Disease: Keratinaceous Lesions of the External Auditory Canal

Keratosis obturans (KO) and external auditory canal cholesteatoma (EACC) are two distinct keratinaceous lesions of the external ear. This article reviews the signs, symptoms, pathophysiology, workup, and treatment of each. Patients with either pathology can often be managed in the clinic with debridement; however, EACC is more likely to involve osteonecrosis and require more extensive operative management if disease is not confined to the canal on account of the bony erosion characteristic of cholesteatoma. If required for extensive disease, surgical approaches to both pathologies are similar.

Acquired Stenosis of the External Ear Canal

Acquired stenosis of the external ear canal (ASEEC) is a relatively uncommon condition. Stenosis or narrowing of the external ear canal (EEC) occurs lateral to the tympanic membrane resulting in a skin lined blind canal. Recurrent otorrhea, and conductive hearing loss are typical clinical features. Although ASEEC can be due to different etiologies, a common pathogenesis, namely an inflammatory cascade, has been implicated. Clinical evaluation, audiogram, and Computed tomography (CT scan) form the mainstay of diagnosis. Surgery is the primary modality for treatment. Restenosis is the most common postsurgical complication.

Outcomes of Spontaneous Cerebrospinal Fluid Leak Repair With Concurrent Eustachian Tube Dysfunction

OBJECTIVE

To compare the presentation and outcomes of patients with and without obstructive eustachian tube dysfunction (oETD) undergoing repair of lateral skull base spontaneous cerebrospinal fluid (sCSF) leaks.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adults with lateral skull base sCSF leaks who underwent repairs from January 1, 2011, to December 31, 2020, were collected.

MAIN OUTCOME MEASURE

Comparative statistics and effect sizes were used to compare clinical features, operative findings, and outcomes between groups.

RESULTS

Of 92 ears from 89 patients included, 51.1% (n = 47) had oETD. There were no differences in demographics between patients with and without oETD. Mean age was 60.7 ± 13.1 versus 58.5 ± 12.8 years ( d = -0.17 [-0.58 to 0.24]), mean body mass index was 33.8 ± 8.5 versus 36.0 ± 8.0 kg/m 2 ( d = 0.27 [-0.14 to 0.68]), and female sex preponderance was 59.6% (n = 28) versus 68.8% (n = 31; Φ = -0.09), respectively. There were no differences in the radiologic number, size, and locations of defects. Patients with oETD had less pneumatized mastoids than those without oETD ( p = 0.001; Φ = 0.43). Mean change from preoperative to postoperative air pure-tone average for those with and without oETD was -1.1 ± 12.6 versus 0.1 ± 17.2 dB ( d = 0.09 [-0.04 to 0.58]), respectively. Six ears (6.5%; three with and three without oETD) underwent revisions for rhinorrhea/otorrhea between 5 and 28 months postoperatively, during which four leaks were found, the two patients without leaks had oETD.

CONCLUSIONS

The presentation of sCSF leaks and outcomes of repairs in patients with oETD do not differ from those without oETD. Although postoperative otorrhea might represent an inflammatory or infectious process in patients with oETD, reexploration is warranted if patients do not improve with conservative treatment.

Outcomes of Mastoidectomy With Antibiotic Catheter Irrigation for Patients With Draining Ventilation Tubes

OBJECTIVES

To evaluate the effectiveness of mastoidectomy with antibiotic catheter irrigation in patients with chronic tympanostomy tube otorrhea.

METHODS

A chart review of adult and pediatric patients with persistent tympanostomy tube otorrhea who had failed outpatient medical management and underwent mastoidectomy with placement of a temporary indwelling catheter for antibiotic instillation was performed. Patients were retrospectively followed for recurrent drainage after 2 months and outcomes were categorized as resolution (0-1 episodes of otorrhea or otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes).

RESULTS

There were 22 patients and 23 operated ears. Median age was 46 years (interquartile range, IQR = 29-65). The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had episodic. The observed percentage of resolved/improved ears (87%) was significant (P = .0005, 95% CI = 67.9%-95.5%). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages improved (difference of medians = -3.3 dB, P = .02) with no significant difference in word recognition scores (P = .68). Methicillin-resistant Staphylococcus aureus was the most common isolated microbe while no growth was most frequently noted on intraoperative cultures.

CONCLUSIONS

Mastoidectomy with antibiotic catheter irrigation may be an effective surgical strategy, and single stage alternative to intravenous antibiotics, for select patients with persistent tube otorrhea who have failed topical and oral antibiotics.

Balloon Eustachian tuboplasty for obstructive Eustachian tube dysfunction: retrospective multicentre cohort study of 248 patients

OBJECTIVE

To present the results after balloon eustachian tuboplasty (BET) in patients with obstructive Eustachian tube dysfunction (OETD) grouped up into: baro-challenge, chronic serous otitis media and adhaesive otitis media.

METHODS

A retrospective study was carried out on patients who underwent BET surgery. As outcome measures, otoscopy, tympanometry, Eustachian tube dysfunction questionnaire-7 (ETDQ-7) and ability to perform the Valsalva manoeuvre were recorded at baseline and at 3, 12 and 24 months after BET. A p value of 0.05 was used to indicate a statistically significant difference for all statistical tests.

RESULTS

Three hundred and nineteen ears (248 patients) were included with a 3-month follow-up, 272 ears had a 12-month follow-up, and 171 ears had 24-month follow-up. Globally, a statistical significance improvement in all groups in all outcome measures was found. According to BET indication, in the baro-challenge group, there was no improvement in otoscopy, but ETDQ-7, Valsalva manoeuvre and tympanogram improved significantly. In the chronic serous otitis media group, otoscopy, ETDQ-7 and Valsalva manoeuvre were significantly improved in all the three timelines, including the avoidance of a new transtympanic tube after the BET in over 80% of cases. In the adhaesive otitis media group, Valsalva manoeuvre improved significantly, ETDQ-7 decreased and tympanogram improved but not significantly. Few mild complications were reported.

CONCLUSIONS

BET is an effective method for the treatment of OETD in all etiologic groups. The greatest benefit was observed in patients with baro-challenge. A long-term follow-up is recommended since the benefit seems to increase over time.

Modified-modified radical mastoidectomy

PURPOSE

It is unusual to have communication from the external auditory canal (EAC) directly to the mastoid, totally sparing the tympanum. These patients need a different surgical approach, a modified canal wall-down procedure, to completely clear the disease but fully preserve the tympanum. We present one such exceptional case.

CASE PRESENTATION

A 28-year-old lady presented with ear discharge for 1 year. Imaging confirmed the canal-mastoid fistula, but the entire tympanum was normal. We performed a modified-modified radical mastoidectomy.

CONCLUSIONS

Canal-mastoid fistula is an infrequent entity and may be idiopathic. Despite being evident on clinical examination, imaging aids in assessing size and location of the defect. Although EAC reconstruction may be attempted, the majority require a canal wall-down procedure.

Autologous Fat Injection for the Treatment of Patulous Eustachian Tube

BACKGROUND

Patulous eustachian tube is a disorder that leads to disturbing symptoms such as autophony, respiratory noise, and aural fullness. There has not been an established treatment found for this disorder. This study aims to assess the efficacy of autologous fat injection for a novel treatment of patients with patulous eustachian tube.

METHODS

Twenty-eight patients with refractory patulous eustachian tube were recruited for the study. Endoscopic autologous fat injection was performed submucosally into the anterior and posterior portion of the pharyngeal orifice of the eustachian tube. The outcomes were quantitatively assessed by comparing the difference between pre- and postoperative scores with the visual analog scale on 4 criteria: aural fullness, respiratory noise, tinnitus, and autophony.

RESULTS

Autologous fat injection was performed successfully in all patients without major complications. According to the combined visual analog scale scores, after the treatments, 20 patients showed significant improvement and 6 showed moderate improvement. The overall success rate of the treatment was 92.9%.

CONCLUSION

Autologous fat injection is an effective and safe procedure for the treatment of patulous eustachian tube.

Water protection in paediatric patients with ventilation tubes: Myth or reality? A systematic review

BACKGROUND

Myringotomy with ventilation tube (VT) insertion is one the most performed procedures in children and adolescents worldwide. VTs usually remain in the eardrum between 6 and 12 months and during this period otorrhoea is the most frequent complication. For years, parents have been advised to protect the ears of children with VTs from contact with water, as water exposure in the middle ear is likely to cause acute otitis media. However, there is a growing evidence that water should not traverse VTs unless under significant pressure, so routine water precautions should not be prescribed. Despite these recommendations, many otolaryngologists and paediatricians continue to prescribe earplugs during bathing or swimming or advise against aquatic activities. There are already two reviews in the current literature on this topic: the first used strict selection criteria and included only 2 high-quality studies, while the second presented evidence up to 2005. The aim of this review is to identify, summarize and critically appraise the current evidence concerning water precautions for children with VTs.

METHODS

Two independent reviewers separately searched for related scientific papers. A qualitative synthesis analysis was performed considering the selected studies regarding the effects of water exposure on paediatric subjects with VTs.

RESULTS

Four randomized clinical trials (RCT) and five prospective cohort studies were included, for a total of 1299 patients aged from 3 months to 14 years. No statistically significant difference in otorrhoea incidence between water exposure with and without ear protection in children with VTs, and between water exposure and no water exposure in children with VTs, was found. Therefore avoiding water is at best inconvenient and at worst may delay learning to swim. The decision to protect the ear when exposed to water should be individualized and protection should be recommended during the first month after surgery and in cases of recurrent otorrhoea.

CONCLUSION

Based on the literature available, allowing water surface activities with no ear protection seems to present a minimum risk, so it is not necessary to prohibit patients from swimming. However, some recommendations should be followed.

Comparative study on adhesive otitis media and pars tensa cholesteatoma in children

OBJECTIVE

Recurrent otitis media and persistent otitis media with effusion in early childhood may cause an atelectatic eardrum and adhesive otitis media, which sometimes progress to pars tensa cholesteatoma. When and how children with adhesive otitis media should be operated on remain controversial. Therefore, this study aimed to analyze the clinical characteristics of children with adhesive otitis media and pars tensa cholesteatoma, and to determine the risk factors of progression to cholesteatoma.

METHODS

Seventeen ears of 15 children with adhesive otitis media (adhesive group) and 14 ears of 13 children with pars tensa cholesteatoma (tensa cholesteatoma group) who underwent tympanoplasty were included in this study. We analyzed the following clinical characteristics of children in both groups: medical and life history, associated diseases, sites of the adhesion, and development and aeration of mastoid air cells as shown by temporal bone computed tomography.

RESULTS

Most of the children in both groups had a history of recurrent otitis media and/or persistent otitis media with effusion. They showed a male predominance and a frequent association of allergic rhinitis. The number of ears showing undeveloped mastoid air cells in the tensa cholesteatoma group was significantly larger than that in the adhesive otitis media group (P=0.0068). A lack of aeration of the middle ear, including the eustachian tube, was more frequently found in ears with pars tensa cholesteatoma than in ears with adhesive otitis media (P=0.0012). Using multivariate logistic regression, the presence of otorrhea (odds ratio [OR], 14.847; 95% confidence interval [CI], 0.834-264.184), total adhesion (OR, 28.550; 95% CI, 0.962-847.508), and undeveloped mastoid air cells (OR, 19.357; 95% CI, 1.022-366.589) were related to pars tensa cholesteatoma.

CONCLUSION

Children with adhesive otitis media should be carefully followed up in the outpatient setting. Ears with poor mastoid development may develop pars tensa cholesteatoma. Additionally, ears with middle ear effusion, total adhesion, and the presence of otorrhea tend to be at risk of pars tensa cholesteatoma. Tympanoplasty or tympanostomy tube insertion should be considered for children with adhesive otitis media who have these risk factors to prevent progression to pars tensa cholesteatoma.

Transtympanic Tripod-shaped Angiocatheter Insertion for Patients With Intractable Patulous Eustachian Tube

OBJECTIVE

Despite the efforts to treat patients with patulous Eustachian tube (PET), intractable symptoms of PET may require surgical intervention. In this study, we introduce our surgical technique of "transtympanic tripod-shaped angiocatheter" (TTA) insertion and evaluate the safety and efficacy of the procedure in patients with intractable PET.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Thirty-two cases (26 patients) diagnosed with intractable PET between the years 2011 and 2019 were included in this study.

INTERVENTION

All cases were surgically treated with TTA insertion.

MAIN OUTCOME MEASURES

The clinical characteristics, surgical results, complication rates, and the level of satisfaction by questionnaires were analyzed for evaluation.

RESULTS

The mean age of enrolled patients was 40.9 ± 19.5 years, with slight male gender predominance (59.4% vs. 40.6%). Both ears were operated in six patients, simultaneously in three. All patients successfully received the insertion of TTA, with no immediate complication. Eleven cases were re-inserted after the first insertion due to the recurrence of symptoms or spontaneous extrusion of TTA. No major complications were observed during the follow-up period of 1 to 115 months (mean 37.7 mo). The average Visual Analogue Scale score of PET symptoms was significantly decreased (p < 0.05), along with 92% of patients with relief from autophony symptoms.

CONCLUSIONS

TTA insertion is a relatively simple procedure that can be performed in a short period under local anesthesia. Surgical intervention of TTA insertion for patients with intractable PET symptoms seems promising with a high success rate.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

An unexpected cyst of the ear lobule

Branchial cleft anomalies (BCA) are among the most common congenital anomalies found in the pediatric head and neck. The embryology of these congenital anomalies is well understood, which allows clinicians to anticipate their diagnosis when a pediatric patient presents with a head or neck mass. The predictable anatomy of the various types of BCA allows for improved surgical planning to prevent recurrence and ensure complete resection. This report details an unusual location of a first BCA located in the ear lobule of a 10-month old male. There has been no documented first BCA at the ear lobule in the literature.

Case Series and Systematic Review of Treatment Outcomes for Auricular Pseudocysts

OBJECTIVE

Auricular pseudocyst (AP: intracartilaginous cyst, endochondral AP, cystic chondromalacia, and benign idiopathic cystic chondromalacia) is a benign condition of unknown etiology. This report systematically reviews the published demographics, treatment protocols, and outcomes of AP between the various medical disciplines, and compares the findings to a theretofore-unreported 12-patient cohort. Primary outcome measure was AP complete resolution without recurrence.

DATA SOURCE

A systematic literature search of "MEDLINE" via "PubMed" and "Google Scholar" was performed in June, 2020. The 12 new patients were enrolled between January 2016 and December 2020.

STUDY SELECTION

Seventy-four papers met the study inclusion criteria and provided data on sex distribution, surgical approach and outcome, performance of approaches according to medical specialty, and recurrence rates of the reported AP populations.

DATA EXTRACTION

The appropriateness and study design quality were independently assessed by two reviewers.

DATA SYNTHESIS

The primary outcome was therapeutic success. A comparative analysis was also performed on the same extracted information that was retrieved from the medical files of the 12 new patients (10 men, 2 women, average age 24 yrs, range, 17-38).

CONCLUSIONS

AP is not uncommon. In line with the published literature, incision and curettage with excision of the anterior pseudocystic wall (deroofing) resulted in a recurrence rate of less than 17% with good cosmetic outcome among all 12 patients. Aspiration alone was associated with increased recurrence rates. Deroofing emerged as the preferred modality, with good cosmetic outcome and reduced recurrence rate. It was usually performed by otolaryngologists, while dermatologists used more conservative approach more frequently. Incision and drainage combined with compression reduces risk of recurrence.

Endoscopic Management of Pediatric Chronic Ear Disease

Pediatric chronic ear disease and its sequelae often necessitate surgical intervention, such as ear tube insertion, ossiculoplasty, tympanoplasty, and cholesteatoma removal. Although these procedures have traditionally been performed with the microscope, use of rigid endoscopes provides an alternative method for visualization. The endoscope offers improved visualization of the middle ear space and adjacent structures and can either be used alone to perform surgery through the ear canal or together with the microscope if mastoidectomy is required. Endoscopic ear surgery can reduce the need for a postauricular incision or mastoidectomy while resulting in equivalent hearing outcomes compared with those performed with the microscope. In addition, use of the endoscope is associated with lower rates of residual disease following primary cholesteatoma procedures.

Comparison of Prominent Ear Recurrence in Different Age Groups

AIM

Although many prominent ear deformity (PED) surgery techniques have been described to date, there have been few comprehensive studies evaluating the recurrence rates in different age groups. Previous studies have focused either on the young or the elderly. The present clinical study compares recurrence rates among patients of different age groups undergoing PED repair and discusses cartilage morphology.

PATIENTS AND METHODS

A total of 380 patients with a mean age of 24.2 years underwent PED repair surgery between 2001 and 2019. The patients were divided into five subgroups according to age. Group I (5-10 years) was composed of 44 patients, Group II (10-20 years) was composed of 47 patients, Group III (20-30 years) was composed of 166 patients, Group IV (30-40 years) was composed of 90 patients, and Group V (over 40 years) was composed of 33 patients. The cephaloauricular angle (CAA) and the distance between the helix (upper, middle, lower) and mastoid were measured and recorded prior to surgery. The patients were all treated with three concha-mastoid sutures to achieve concha reduction and to narrow the cephaloauricular angle. The anterior aspect of the cartilage was thinned with a rasp, and an antihelix was created using non-absorbable sutures in patients with an inadequate antihelix.

RESULTS

The CAA and the upper pole-mastoid distance were measured immediately after surgery and at 15 days, 3 and 6 months after surgery. Recurrence was observed in a total of 18 patients, with PED recurring in one patient in Group I (2.3%), three patients in Group II (6.38%), 10 patients in Group III (6.8%), three patients in Group IV (3.3%) and one patient in Group V (3.03%). Although the difference in the recurrence rate among the age groups would appear to be clinically significant, the difference was not significant, statistically. Clinically, the differences among the groups could be attributed to intragroup numerical differences.

CONCLUSIONS

In the present study, no significant relationship was identified between the patient age and recurrence rate. Although PED repair is recommended in the preschool period, prominent ear repairs can be carried out in any age group, although the degree of cartilage scoring should differ depending on the age group.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recurrent angiolymphoid hyperplasia with eosinophilia during several pregnancies

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare, benign vascular tumor. Although its etiology is not clearly known, infection, hormonal factors, and trauma are the suspected reasons. There are few cases considered to be related to pregnancy described in the literature. Granulomas are rarely seen in the histopathology and only four patients with granulomas have been described. Herein, we will present a 28-year-old woman who has been pregnant three times; in every pregnancy, she developed pink nodular lesions on the back of her ear. In the first two pregnancies, the lesions had appeared during the pregnancy and regressed completely in the postpartum period. In her third pregnancy, the condition emerged again and lasted 1.5 years after birth of her child. Histopathology exhibited ALHE with granulomas. Although the relationship between ALHE and pregnancy is already known, there are few cutaneous ALHE cases associated with pregnancy reported in the literature. This association is further supported by this case having recurrent ALHE during each pregnancy period. Also, the presence of naked granuloma in histopathology, unlike most of the cases, contributes to the current histopathological data.

Change in Eustachian Tube Function With Balloon Dilation in Adults With Ventilation Tubes

OBJECTIVE

Assess the changes in Eustachian tube (ET) function (ETF) with balloon dilation of Eustachian tube (BDET).

STUDY DESIGN

Prospective cohort for repeated testing measures.

SETTING

Clinical research center.

PATIENTS

Eleven adults with at least one patent ventilation tube (VT) inserted for chronic ET dysfunction (ETD) and history of otitis media with effusion.

INTERVENTIONS

Subjects with evidence of moderate to severe ETD on the side with a VT underwent unilateral BDET.

MAIN OUTCOME MEASURES

Changes in ETF parameters after BDET measured by Forced Response Test (FRT), Inflation Deflation Test (IDT), and Pressure Chamber test.

RESULTS

With the FRT at 11 ml/min, opening pressure (OP) decreased from 458 ± 160 to 308 ± 173 daPa and closing pressure (CP) from 115 ± 83 to 72 ± 81 daPa at the 3-month post-BDET visit. The IDT and Pressure Chamber test showed that the percentage of middle ear (ME) pressure gradient equilibrated with swallows improved from 28 ± 34 to 53 ± 5% for positive and from 20 ± 28 to 38 ± 43% for negative ME pressure. Images from the pre- and post-BDET functional CT scans did not show apparent changes in the anatomy. Comparisons of ETF test parameters pre- and post-BDET suggested that the ET was easier to open and stayed open longer after the procedure. However, during the limited duration of follow-up most subjects continued to have ETD, some requiring VT re-insertion after the study period.

CONCLUSIONS

Adults with severe ETD may benefit from BDET, however ETD may not be completely resolved and patients may continue to need VTs.

Otorrhoea - a parotid connection

A 36-year-old patient presented with an 18-month history of intermittent right parotid swelling accompanied by otorrhoea. The symptoms started subsequent to a palm leaf injury to the right ear. At right parotidectomy, a fistula connecting the right external auditory canal and the right parotid was demonstrated. A small fibrotic mass probably due to a remnant of the palm leaf was found intraoperatively. The symptoms resolved completely after the mass was excised by superficial parotidectomy, and the fistula closed spontaneously.

Angiolymphoid hyperplasia with eosinophilia treated with Mohs micrographic surgery

A 60-year-old healthy man presented with several enlarging, tender, spontaneously bleeding, and episodically pruritic nodules on his ear. Five agminated pink-red papulonodules of the superior postauricular sulcus were noted on examination. Pathological examination revealed a lobular dermal vascular proliferation with plump endothelial cells protruding into the lumen in a hobnail pattern, along with a dense perivascular inflammatory infiltrate composed of plasma cells, lymphocytes, and numerous eosinophils. The diagnosis of angiolymphoid hyperplasia with eosinophilia was confirmed. After discussing treatment modalities, the patient opted for Mohs micrographic surgery (MMS). Three stages of MMS were able to remove all large vessel involvement and clear the peripheral margins, but the tumor had a complex branching pattern of growth in the deep bed of the wound with numerous tiny foci remaining. Owing to risk of disfigurement, no further excision was undertaken. The area was reconstructed with a temporalis fascia flap and a full-thickness skin graft. Despite remaining microscopic disease, the patient remained without recurrence or symptoms at one year of follow up.

Butterfly tragal cartilage for repair of focal canal wall defects

BACKGROUND

Meato-mastoid fistula is a connection between the external auditory canal and the mastoid cavity. It may be iatrogenic or pathological. The repair of these focal canal wall defects is necessary to prevent retraction pockets or sequential cholesteatoma and attain relief from otorrhoea.

AIM/OBJECTIVE

To study the effectiveness of an innovative technique for repair of meato-mastoid fistula (less than or equal to 10mm in size) in the bony external auditory canal.

MATERIAL AND METHODS

We performed a retrospective review of 5 surgeries performed in our hospital between January 2017 and December 2017 for the repair of posterior bony canal wall defects. Active ear disease was ruled out before the repair. We used full-thickness butterfly tragal cartilage graft for the repair of these fistulae. All our surgeries were endoscopic and sutureless.

RESULTS

The butterfly tragal cartilage graft was in situ at the repair site and viable on examination at 2 years follow-up, in all our cases.

CONCLUSION AND SIGNIFICANCE

Small posterior canal wall defects can be successfully repaired using this technique. The method is minimally invasive and cosmetic, with good patient compliance. The curling property of the cartilage graft is exploited effectively in this method of repair.

Clinical analysis of pediatric primary external auditory canal cholesteatoma

OBJECTIVE

Pediatric primary external auditory canal cholesteatoma (EACC) is a rare disease. The present study aimed to explore the clinical features and prognosis of this disease.

METHODS

Clinical data of 41 ears with pediatric primary EACC were collected, and the clinical characteristics and prognosis were analyzed in this retrospective study.

RESULTS

A total of 35 patients (median age of 13 years) were recruited in this study. Of these, 13 suffered on the left side and 16 on the other side, while 6 suffered on the bilateral ears. A total of 35 ears had hearing loss, 26 had otalgia, 15 had otorrhea, 12 had tinnitus, and 4 had pruritus. The median course of the disease was 1 month. The bone destruction of the external auditory canal (EAC) was located on the inferior wall of 20 ears, the posterior wall of 22 ears, the superior wall of 15 ears, and the anterior wall of 15 ears. According to Shin's stages, 24 ears were in stage I, 2 in stage II, 15 in stage III. A total of 40 ears underwent transcanal cholesteatoma removal (TCR) and 1 underwent both TCR and tympanoplasty. Finally, 33 ears were followed up postoperatively, and only 1 ear presented recurrence.

CONCLUSION

The posterior wall of the EAC is the most commonly affected wall, and the involvement of multiple walls is common. Due to the remodeling of the EAC bone in pediatric patients, the high stage lesions can be treated by minimally invasive surgical debridement combined with a close follow-up postoperatively.

Osseointegrated implants for auricular prostheses: An alternative to autologous repair

OBJECTIVES/HYPOTHESIS

This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction.

STUDY DESIGN

Retrospective review.

METHODS

This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015.

RESULTS

A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P < .001). The average cost to the hospital for an osseointegrated repair was $6,491.39 versus $10,047.93 for autologous repairs (CI: $6,496.38 to $-616.68, P = .02) CONCLUSIONS: Osseointegrated implants for retaining an auricular prosthesis has a similar cost to autologous repair of ear defects, but patients underwent an average of two more surgeries with autologous repair. Patients should be able to choose the reconstruction option that best suits their condition and preferences.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2153-2156, 2018.

Use of narrow band imaging and 4K technology in otology and neuro-otology: preliminary experience and feasibility study

The advent of the endoscope has facilitated otological surgery in recent years. Advances in optical technology have led to the development of high definition visualisation, such as 4K magnification. Narrow band imaging (NBI) has been shown to improve visualisation of tissue based on varying degrees of vascularity. This is a feasibility study, the first of its kind, aiming to investigate the appearances of middle ear anatomy and pathology (tympanic membrane, tympanosclerosis, cholesteatoma, granulation, endolymphatic sac hydrops, otosclerosis) under the NBI filter, using a high definition 4K endoscope. Qualitative analysis of image detail and operating time in minutes were recorded. The study demonstrates that these two technologies can be implemented with ease into practice, and show a clear differentiation between pathology and normal anatomy. NBI and 4K magnification prove to be useful adjuncts to the surgeon during endoscopic ear surgery.

Meatal obstruction following canal wall down mastoidectomy

Chronic otitis media (COM) is completely treated with a single procedure in most patients but may require multiple surgeries in some cases. The main goals of open cavity mastoidectomy are to completely eradicate the disease, create a large enough meatus for examination and mastoid air cells, and provide a self-cleaning epithelized dry cavity, and achieve maximum hearing. In this report, we present a very rare case of COM who underwent revision mastoidectomy in our clinic due to meatal obstruction in the right ear, total sensorineural hearing loss, and pain and tenderness in the postauricular region.

A Rare Case of Endochondral Pseudocyst of the Auricle

Endochondral pseudocyst of the auricle is a very rare, benign, non-inflammatory cystic lesion. It most commonly develops in the scaphoid or triangular fossa of the ear. In this case report, we present a 46-year-old man with a painless lesion on the scaphoid fossa of the right ear. We removed the hypertrophic perichondrium forming the anterior wall of the pseudocyst, curetted the ear cartilage, and dressed it with compression. No complications, such as infection, seroma, or hematoma, occurred during the postoperative period. A good cosmetic result was ultimately obtained. The patient experienced no recurrence within a 14-month follow-up period.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Atypical manifestations of feline inflammatory polyps in three cats

Inflammatory polyps of the feline middle ear and nasopharynx are non-neoplastic masses that are presumed to originate from the epithelial lining of the tympanic bulla or Eustachian tube. The exact origin and cause are unknown, however, it is thought that inflammatory polyps arise as a result of a prolonged inflammatory process. It is unclear whether this inflammation initiates or potentiates the development and growth of inflammatory polyps. Cats with inflammatory polyps typically present with either signs of otitis externa and otitis media or with signs consistent with upper airway obstruction. Traditional diagnostics involve imaging of the tympanic bulla either with skull radiographs or computed topography (CT). Treatment consists of traction and avulsion of the polyp with or without ventral bulla osteotomy (VBO) to remove the epithelial lining of the tympanic bulla. The three cases described here are unusual manifestations or presentations of feline inflammatory polyps that address the following issues: (1) concurrent otic and nasopharyngeal polyps, (2) potential association with chronic viral infection, (3) polyp development in the contralateral middle ear, (4) CT appearance of the skull following VBO, and (5) development of secondary pulmonary hypertension.

Bilateral keratin horns arising from the tympanic membranes: a case report

A keratin horn is a horn-like projection composed of dense keratotic material. It usually arises in sun-exposed areas of the body. It can be derived from a variety of underlying benign, premalignant, or malignant epidermal lesions. Risk factors associated with malignant change within a keratin horn include a wide base, male sex, and increasing age, in addition to an origin in a sun-exposed area. The mainstay of management is to obtain a biopsy from the base of the horn and subsequent excision if the histopathologic analysis suggests a malignancy. We report an extremely rare case of bilateral keratin horns arising from the tympanic membranes in a 64-year-old woman. To the best of our knowledge, this is the first report of its kind to be published in the English-language literature.

Ear Keloid Treated with Infiltrated Non-cross-linked Hyaluronic Acid and Cortisone Therapy

BACKGROUND

Several treatments are available to treat the keloid scar. Keloids have the tendency to recur after surgical removal and new treatments for keloid scars include radiotherapy, cryotherapy or compressive therapy. Topical treatments have been also used to treat this pathology, such as injections or medical device applications.

CASE REPORT

A 33-year-old man came to our attention and we treated him for a keloid scar located between the ear's helical tubercle and the ante-helix upper root of the left ear. This keloid arose 20 years earlier following a bilateral otoplasty. We proposed an association therapy using a non-cross-linked hyaluronic acid and cortisone.

CONCLUSION

The associated treatment was able to determine a complete resolution of the keloid without recurrence several months later.

Middle Ear Extramedullary Hematopoiesis: A Case Report

BACKGROUND

Extramedullary hematopoiesis (EMH) in the middle ear is exceedingly rare, with fewer than five cases reported. The authors report the first Thai case of middle ear EMH

CASE REPORT

A 32-year-old Thai thalassemic man presented with complaint of right-sided hearing loss from a middle ear mass. The CT/MRI was done and the diagnosis of EMH was confirmed by a pathological examination after a surgical removal.

CONCLUSION

A differential diagnosis of EMH should also be done in thalassemic patients presented with a middle ear mass.

Local Anesthesia for Middle Ear Surgery

The adequacy of anesthesia and comfort during surgery was assessed for 100 consecutive patients undergoing middle ear surgery using local anesthesia, both by the patients themselves and by the surgeon. The possibility of inducing an iatrogenic facial weakness was also evaluated. Both the surgeon and the majority of patients were pleased with the quality of anesthesia and little adverse effects occured as a consequence of local anesthesia itself.

Alloplastic bone cements in otologic surgery: Long-term follow-up and lessons learned

Objective

Otolaryngologists are often confronted with structural defects in the tegmen, scutum, or external auditory canal . Carbonated calcium phosphate (CCP) bone cements offer an alternative way of managing these defects.

Study Design and Setting

Retrospective review in an academic otology practice. The technical feasibility of these techniques described as well as the wound healing and structural integrity results.

Results

CCP bone cement was used to reconstruct defects of the tegmen or EAC in 22 patients. The material was used to repair the EAC in 19 of these patients, including complete EAC reconstruction in 4 patients, and tegmen defects only in 3 cases.

Conclusion

The surgical technique is not technically difficult and the alloplastic material is hard within minutes of application. Twenty patients have been followed for over 1 year with an average follow-up period of 3.8 years. Failure, defined as infection or explantation, occurred in 4 patients followed over 3 years. There was a difference in outcomes for pediatric cases. EBM rating: C-4