Reconstruction of an obliterated Eustachian tube: transnasal lighted guidewire catheter stenting

An obliterated Eustachian tube (ET) is a rare occurrence that can lead to chronic otitis media (OM) and aural fullness even with treatment. Our study presents a review of the literature on methods of stenting the ET. We additionally present a case of a man with mucoepidermoid carcinoma of the ET who underwent a radical nasal pharyngectomy with reconstruction and adjuvant radiation, and who had symptoms of intolerable otorrhea after tympanostomy tube placement to treat aural fullness and mucoid OM. We used a novel method of stenting the ET using a transnasal lighted guidewire catheter and steroid eluting stents placed along the entire medial ET. Previously described methods in the literature were unable to be used due to the complex middle ear anatomy filled with granulation tissue and the lack of a visible nasopharyngeal ET ostium available for straightforward placement of the stent. The procedure was successful, and postoperatively, the patient experienced decreased otorrhea.

Imaging of Pathologies of the Temporal Bone and Middle Ear: Inflammatory Diseases, Their Mimics and Potential Complications-Pictorial Review

Imaging of the temporal bone and middle ear is challenging for radiologists due to the abundance of distinct anatomical structures and the plethora of possible pathologies. The basis for a precise diagnosis is knowledge of the underlying anatomy as well as the clinical presentation and the individual patient's otological status. In this article, we aimed to summarize the most common inflammatory lesions of the temporal bone and middle ear, describe their specific imaging characteristics, and highlight their differential diagnoses. First, we introduce anatomical and imaging fundamentals. Additionally, a point-to-point comparison of the radiological and histological features of the wide spectrum of inflammatory diseases of the temporal bone and middle ear in context with a review of the current literature and current trends is given.

A homozygous missense variant in the PLCB4 gene causes severe phenotype of auriculocondylar syndrome type 2

Auriculocondylar syndrome (ARCND) is a rare craniofacial birth defect characterized by malformations in the mandible and external ear (Question Mark Ear). Genetically, three distinct subtypes of ARCND (ARCND1, ARCND2, and ARCND3) have been identified. ARCND2 is linked to pathogenic variants in the PLCB4 gene (phospholipase C β4). PLCB4 is a key effector of the EDN1-EDNRA pathway involved in craniofacial development via the induction, migration, and maintenance of neural crest cells. ARCND2 is typically inherited in an autosomal dominant pattern, with recessive inheritance pattern being rare. In this study, we report the first homozygous missense variant (NM_000933.4: c.2050G>A: p.(Gly684Arg)) in the PLCB4 gene causing ARCND in a 3-year-old patient with a severe clinical phenotype of the syndrome. The patient presented with typical craniofacial ARCND features, in addition to intestinal transit defect, macropenis, and hearing loss. These findings further delineate the phenotypic spectrum of ARCND associated with autosomal recessive PLCB4 loss of function variants. Notably, our results provide further evidence that these variants can result in a more severe and diverse manifestations of the syndrome. Clinicians should consider the rare features of this condition for better management of patients.

External auditory canal sebaceous carcinoma

The incidence of sebaceous carcinoma (SC) in the outer one-third of the external auditory canal is considered extremely rare, and only eight case reports have been published. We present a case of a male patient in his late 70s known case of hypertension on indapamide. His medical history included a postspinal tumour that had been treated with surgery and radiation more than 40 years ago and current complaints of right ear pain and purulent discharge. A right ear soft granular tissue mass was found. Complete debulking of the right ear mass was done in conjunction with middle ear exploration, moderately differentiated SC diagnosis was made based on the histopathological analysis. The patient was free of recurrence but then died of an unrelated pulmonary infection. SC should be suspected in elderly patients who present with long-term complaints of a mass with or without otalgia, and these patients should be examined for the presence of such tumours especially if they report a history of radiation. Additionally, more research is warranted to investigate the association of diuretics with SC.

Continuous positive airway pressure device-associated nonhealing ulcer on the nasal dorsum: chondrodermatitis nodularis nasi

With increasing use of positive airway pressure devices for disordered breathing during sleep, appreciation for potential associated side effects is essential. Chondrodermatitis nodularis nasi is a rare variant of chondrodermatitis nodularis chronic helicis that presents as a nonhealing erosion or ulcer on the nose and can occur in association with chronic use of positive airway pressure devices. We present a case of symptomatic chondrodermatitis nodularis nasi associated with continuous positive airway pressure use, fully responsive to treatment, and propose that this condition is highly underrecognized. Dermatology referral can assist in diagnosis, management, and exclusion of cutaneous malignancy.

CITATION

Reinhart JP, Isaq NA, Peters MS, Vidal NY. Continuous positive airway pressure device-associated nonhealing ulcer on the nasal dorsum: chondrodermatitis nodularis nasi. J Clin Sleep Med. 2023;19(6):1157-1159.

Taste Alteration in External Auditory Canal Cholesteatoma: Indicator of Impending N VII Affection

INTRODUCTION

External auditory canal cholesteatoma (EACC) is a rare disease, with an estimated incidence of approximately 1:1,000 adult and 1.6:1,000 pediatric otologic patients. Systematic studies of chronic ear disease and taste alteration prior to surgery are rare; in fact, there are no such studies for EACCs. Therefore, we describe chorda tympani nerve (CTN) dysfunction and the related clinical consequences in EACC patients.

METHODS/STUDY DESIGN

Between 1992 and 2021, we retrospectively analyzed the symptoms, signs, and radiological and intraoperative descriptions of CTN involvement in 73 patients. Liquid taste tests and, since 2009, Taste StripsTM as well as an olfactory screening test (Smell DiskettesTM) have been performed for all symptomatic patients and, when feasible, all other EACC patients.

LEVEL OF EVIDENCE: 4

RESULTS

Ten of 73 patients complained subjectively of dysfunction, and 8 showed abnormal taste test results. Four patients complained of olfactory dysfunction (3 cases with pathological taste tests). Gustatory dysfunction was most frequent in radiogenic EACC cases (n = 4), followed by postoperative EACC (n = 3). Two postoperative patients were asymptomatic despite abnormal test results. Rarely, patients with idiopathic (n = 2) and posttraumatic (n = 1) EACC showed acute taste dysfunction that was confirmed in each with abnormal test results.

DISCUSSION/CONCLUSION

CTN dysfunction often developed asymptomatically in chronic ears, except for idiopathic and posttraumatic EACCs under previous healthy middle ear conditions. Taste disturbance is not a cardinal symptom of EACC, but objective testing suggests that up to one out of 10 EACC patients with advanced disease may experience regional gustatory dysfunction prior to surgery. Especially in context of a new and acute presentation, regional taste dysfunction may alert the clinician of potential progressive EACC invasion and danger to the facial nerve.

Patulous Eustachian Tube Patients With Oculopharyngeal Muscular Dystrophy

OBJECTIVES

To describe cases of patulous Eustachian tube (PET) or patent ET conditions in oculopharyngeal muscular dystrophy (OPMD).

PATIENTS

Four cases of PET or patent ET conditions with OPMD.

MAIN OUTCOME MEASURES

Clinical case records, objective ET function tests (tubo-tympano-aerodynamic graphy and sonotubometry), and swallowing function (videoendoscopic examination and Food Intake Level Scale) were analyzed.

RESULTS

Two cases of definite PET, one case of possible PET, and one case lacking aural symptoms with findings of patent ET. All patients have ptosis, and three cases have dysphagia. Body mass index indicated that three cases were underweight. Magnetic resonance imaging in case 4 showed atrophy and fat replacement of palatine and masticatory muscles.

CONCLUSIONS

It is important to consider PET or patent ET conditions when OPMD patients describe aural symptoms.

Endoscopic Transcanal and Transmastoid Laser-Assisted Resection of Middle Ear Capillary Hemangioma

OBJECTIVE

To present a rare case of a middle ear capillary hemangioma in an adult.

PATIENT

A 31-year-old woman with a 6-month history of left ear fullness, pressure, tinnitus, and progressive hearing loss.

INTERVENTION

Endoscopic laser-assisted resection.

MAIN OUTCOME MEASURES

Clinical, radiographic, and histopathological findings of a capillary hemangioma.

RESULTS

Otoscopy revealed an erythematous and slightly pulsating multilobulated middle ear retrotympanic mass. Her audiogram demonstrated a left-sided mixed hearing loss with air-conduction thresholds in the severe-to-profound range. Computed tomography (CT) imaging was significant for total opacification of the left middle ear and mastoid air cells. She underwent a combined endoscopic transcanal and transmastoid excision of the mass with ossicular chain reconstruction. A KTP laser was used to ablate and shrink down the periphery of the lesion. Pathology of the specimen was consistent with a capillary hemangioma. The patient's pulsatile tinnitus and spontaneous vertigo resolved postoperatively.

CONCLUSIONS

Capillary hemangiomas are an uncommon cause of vascular middle ear lesions in adults and typically present with symptoms of aural fullness, pulsatile tinnitus, conductive hearing loss, otalgia, and vertigo. Surgery resection provides definitive treatment and the use of laser ablation techniques can allow for hemostasis and excellent visualization.

Sarcoidosis of the ear, nose and throat: A review of the literature

OBJECTIVES

Sarcoidosis is a multisystemic inflammatory disease with extrathoracic manifestations, most commonly affecting the young and middle-aged, female and Black populations. Diagnosis usually requires evidence of non-caseating granulomata and, when treated, prognosis is usually favourable. We aim to establish the incidence, clinical features and optimal treatment of ENT manifestations of this disease.

DESIGN

We performed a PubMed literature review to determine the evidence base supporting this.

RESULTS

ENT manifestations are present in 5%-15% of patients with sarcoidosis, often as a presenting feature, and require vigilance for swift recognition and coordinated additional treatment specific to the organ. Laryngeal sarcoidosis presents with difficulty in breathing, dysphonia and cough, and may be treated by speech and language therapy (SLT) or intralesional injection, dilatation or tissue reduction. Nasal disease presents with crusting, rhinitis, nasal obstruction and anosmia, usually without sinus involvement. It is treated by topical nasal or intralesional treatments but may also require endoscopic sinus surgery, laser treatment or even nasal reconstruction. Otological disease is uncommon but includes audiovestibular symptoms, both sensorineural and conductive hearing loss, and skin lesions.

CONCLUSIONS

The consequences of ENT manifestations of sarcoidosis can be uncomfortable, disabling and even life-threatening. Effective management strategies require good diagnostic skills and use of specific therapies combined with established treatments such as corticosteroids. Comparisons of treatment outcomes are needed to establish best practice in this area.

Screening Anti-Inflammatory Effects of Flavanones Solutions

There are a large number of remedies in traditional medicine focused on relieving pain and inflammation. Flavanones have been a potential source in the search for leading compounds and biologically active components, and they have been the focus of much research and development in recent years. Eysenhardtia platycarpa is used in traditional medicine for the treatment of kidney diseases, bladder infections, and diabetes mellitus. Many compounds have been isolated from this plant, such as flavones, flavanones, phenolic compounds, triterpenoid acids, chalcones, sugars, and fatty acids, among others. In this paper, natural flavanone 1 (extracted from Eysenhardtia platycarpa) as lead compound and flavanones 1a–1d as its structural analogues were screened for anti-inflammatory activity using Molinspiration^® and PASS Online in a computational study. The hydro alcoholic solutions (FS) of flavanones 1, 1a–1d (FS1, FS1a–FS1d) were also assayed to investigate their in vivo anti-inflammatory cutaneous effect using two experimental models, a rat ear edema induced by arachidonic acid (AA) and a mouse ear edema induced by 12-O-tetradecanoylphorbol acetate (TPA). Histological studies and analysis of pro-inflammatory cytokines TNF-α, IL-1β, and IL-6 were also assessed in AA-inflamed rat ear tissue. The results showed that the flavanone hydro alcoholic solutions (FS) caused edema inhibition in both evaluated models. This study suggests that the evaluated flavanones will be effective when used in the future in skin pathologies with inflammation, with the results showing 1b and 1d to be the best.

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.

Efficient and accurate identification of ear diseases using an ensemble deep learning model

Early detection and appropriate medical treatment are of great use for ear disease. However, a new diagnostic strategy is necessary for the absence of experts and relatively low diagnostic accuracy, in which deep learning plays an important role. This paper puts forward a mechanic learning model which uses abundant otoscope image data gained in clinical cases to achieve an automatic diagnosis of ear diseases in real time. A total of 20,542 endoscopic images were employed to train nine common deep convolution neural networks. According to the characteristics of the eardrum and external auditory canal, eight kinds of ear diseases were classified, involving the majority of ear diseases, such as normal, Cholestestoma of the middle ear, Chronic suppurative otitis media, External auditory cana bleeding, Impacted cerumen, Otomycosis external, Secretory otitis media, Tympanic membrane calcification. After we evaluate these optimization schemes, two best performance models are selected to combine the ensemble classifiers with real-time automatic classification. Based on accuracy and training time, we choose a transferring learning model based on DensNet-BC169 and DensNet-BC1615, getting a result that each model has obvious improvement by using these two ensemble classifiers, and has an average accuracy of 95.59%. Considering the dependence of classifier performance on data size in transfer learning, we evaluate the high accuracy of the current model that can be attributed to large databases. Current studies are unparalleled regarding disease diversity and diagnostic precision. The real-time classifier trains the data under different acquisition conditions, which is suitable for real cases. According to this study, in the clinical case, the deep learning model is of great use in the early detection and remedy of ear diseases.

Chronic obstructive Eustachian tube dysfunction: CT assessment with Valsalva maneuver and ETS-7 score

Chronic obstructive Eustachian tube dysfunction (ETD) is a common disorder of the middle ear. In recent years, two main diagnostic tools have become available: Eustachian tube score (ETS-7) and computed tomography (CT) combined with Valsalva maneuver. The aim of this study is to evaluate the outcomes of ETS-7 and CT in a group of patients affected by middle ear atelectasis with a strong suspicion of ETD. Three males and nine females, affected by middle ear atelectasis with retraction of the TM were enrolled. Each patient underwent to Eustachian tube dysfunction evaluation adopting the ETS-7 score and a temporal bone CT with Valsalva maneuver. The ears analyzed at steady state were divided into 2 groups: ETS<7 group and ETS≥ 7 group. The same division was applied for the ears analyzed after the Valsalva maneuver: ETS<7 group and ETS≥ 7 group. ETs were categorized as “well defined” (WD) and “not defined” (ND). The results of the analysis of the ETS-7 score in all 24 ears showed that 42% presented ETS ≥7, while 58% had ETS <7, indicating a diagnosis of ETD. In the ETS<7 group after Valsalva, ET was visualized in 33% of patients. In the ETS≥7 group it was WD in 29% after the Valsalva manoeuver. In both groups the comparison between the visualization of the ET before and after the Valsalva manoeuver did not present a statistical difference. No correlation emerged between ET evaluation with CT scan during Valsalva maneuver and ETS-7 score. It confirms that there is not a gold standard for the study of ET dysfunction.

Mast Cells Limit Ear Swelling Independently of the Chymase Mouse Mast Cell Protease 4 in an MC903-Induced Atopic Dermatitis-Like Mouse Model

Atopic dermatitis (AD) is a complex, often lifelong allergic disease with severe pruritus affecting around 10% of both humans and dogs. To investigate the role of mast cells (MCs) and MC-specific proteases on the immunopathogenesis of AD, a vitamin D₃-analog (MC903) was used to induce clinical AD-like symptoms in c-kit-dependent MC-deficient Wsh^−/− and the MC protease-deficient mMCP-4^−/−, mMCP-6^−/−, and CPA3^−/− mouse strains. MC903-treatment on the ear lobe increased clinical scores and ear-thickening, along with increased MC and granulocyte infiltration and activity, as well as increased levels of interleukin 33 (IL-33) locally and thymic stromal lymphopoietin (TSLP) both locally and systemically. The MC-deficient Wsh^−/− mice showed significantly increased clinical score and ear thickening albeit having lower ear tissue levels of IL-33 and TSLP as well as lower serum levels of TSLP as compared to the WT mice. In contrast, although having significantly increased IL-33 ear tissue levels the chymase-deficient mMCP-4^−/− mice showed similar clinical score, ear thickening, and TSLP levels in ear tissue and serum as the WT mice, whereas mMCP-6 and CPA3 -deficient mice showed a slightly reduced ear thickening and granulocyte infiltration. Our results suggest that MCs promote and control the level of MC903-induced AD-like inflammation.

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.

Effect of Terpenoids and Flavonoids Isolated from Baccharis conferta Kunth on TPA-Induced Ear Edema in Mice

In this study, we isolated from the aerial parts of Baccharis conferta Kunth (i) a new neoclerodane, denominated "bacchofertone"; (ii) four known terpenes: schensianol A, bacchofertin, kingidiol and oleanolic acid; and (iii) two flavonoids: cirsimaritin and hispidulin. All structures were identified by an exhaustive analysis of nuclear magnetic resonance (NMR) and mass spectroscopy (MS). Extracts from aerial parts were screened for anti-inflammatory activity in the mice ear edema model of 12-O-tetradecanoylforbol-13-acetate mice. Dichloromethane extract (BcD) exhibited 78.5 ± 0.72% inhibition of edema, followed by the BcD2 and BcD3 fractions of 71.4% and 82.9% respectively, at a dose of 1 mg/ear. Kingidiol and cirsimaritin were the most potent compounds identified, with a median effective dose of 0.12 and 0.16 mg/ear, respectively. A histological analysis showed that the topical application of TPA promoted intense cell infiltration, and this inflammatory parameter was reduced with the topical application of isolated compounds.

Chondrodermatitis nodularis helicis in an adolescent boy: not just for old men

Chondrodermatitis nodularis helicis (CNH) is a solitary, chronic, painful, often ulcerated lesion on the upper portion of the ear, mostly in older men. We present an unusual case of CNH in a 17-year-old adolescent boy who was a lifeguard. Correlation between clinical and histopathologic characteristics of CNH is outlined in the context of the existing literature to increase awareness of this condition in younger patients as well as to guide appropriate management and surveillance.

Influence of middle ear disorder in round-window stimulation using a finite element human ear model

PURPOSE

The aim of this work was to study the effect of middle ear disorder on round window (RW) stimulation, so as to provide references for the optimal design of RW stimulation type middle ear implants (MEIs).

METHODS

A human ear finite-element model was built by reverse engineering technique based on micro-computed tomography scanning images of human temporal bone, and was validated by three sets of comparisons with experimental data. Then, based on this model, typical disorders in otosclerosis and otitis media were simulated. Finally, their influences on the RW stimulation were analyzed by comparison of the displacements of the basilar membrane.

RESULTS

For the otosclerosis, the stapedial abnormal bone growth severely deteriorated the equivalent sound pressure of the RW stimulation at higher frequencies, while the hardening of ligaments and tendons prominently decreased the RW stimulation at lower frequencies. Besides, among the hardening of the studied tissues, the influence of the stapedial annular ligament's hardening was much more significant. For the otitis media, the round window membrane (RWM)'s thickening mainly decreased the RW stimulation's performance at lower frequencies. When the elastic modulus' reduction of the RWM was considered at the same time especially for the acute otitis media, it would raise the lower-frequency performance of the RW stimulation.

CONCLUSIONS

The influence of the middle ear disorder on the RW stimulation is considerable and variable, it should be considered during the design of the RW stimulation type MEIs.

Aligned Carbon Nanotubes Reduce Hypertrophic Scar via Regulating Cell Behavior

Hypertrophic scars, characterized by excessive cell proliferation, disordered cell growth, and aberrant deposition of collagens, could cause significant clinical problems. Herein, aligned carbon nanotubes (ACNTs) were synthesized via chemical vapor deposition, and bulk ACNTs were pulled out from the arrays. The capacity of the ACNTs to reduce hypertrophic scar formation was evaluated both in vitro and in vivo. The results demonstrated that the ACNTs suppressed the overproliferation of fibroblast cells, directed their growth, and inhibited collagen expression in vitro without cell cytotoxicity. Moreover, in vivo evaluation in a rabbit ear model indicated relieved scar hypertrophy after the ACNTs treatment. The gene expression microarray was further used to understand the mechanism, which showed that ACNTs could inhibit the TGFβ pathway to alter the components in the extracellular matrix, cell proliferation, cell cytoskeleton, and cell motility. These findings may provide a potent strategy of using carbon nanotubes in the bioengineering field.

A comparison between video otoscopy and standard tympanometry findings in adults living with human immunodeficiency virus (HIV) in South Africa

BACKGROUND

Literature suggests that there is a correlation between video otoscopy and standard tympanometry findings. However, there is limited evidence on whether these two measures are comparable in the identification of middle ear pathologies in adults living with human immunodeficiency virus (HIV). Objective: This study aimed to determine the correlation between video otoscopy and standard tympanometry with 226 Hz probe tone in the identification of middle ear pathologies in adults living with HIV in Limpopo, South Africa. Method: A prospective, non-experimental, comparative design was employed on HIV-positive adults aged 18 years and older. All participants underwent basic audiological assessment including case history interviews, video otoscopy, tympanometry with a 226 Hz probe tone and pure tone audiometry. Two ear, nose and throat (ENT) specialists independently analysed video otoscopic images and provided their reports to the researcher, and these were compared to the tympanometry results. The IBM SPSS v.24 was used for data analysis, including the use of Cohen's kappa to determine the agreement between the two procedures. Pearson's correlation coefficient was used to determine the strength of the correlation between tympanometry and video otoscopy. Results: A total of 87 adults (N = 161 ears) took part in the study. Middle ear pathology was observed in 8% (n = 13) of the sample when tympanometry was used, and this increased to 10.6% (n = 17) when video otoscopy was utilised. Kappa statistics found a good agreement (k = 0.7) between the diagnoses made by two ENTs. However, there was poor agreement (k = 0.2) between the diagnoses by video otoscopy and tympanometry. Pearson's correlation coefficient indicated weak correlation between video otoscopy and tympanometry (r = 0.195). Conclusion: Findings from this study suggest that video otoscopy may be more accurate in the identification of middle ear pathologies in adults living with HIV when compared to tympanometry. These findings have training implications in the use of video otoscopy to ensure accuracy and reliability. Clinical implications of current findings include the use of both video otoscopy and tympanometry in a complementary manner for more sensitive identification of middle ear pathologies in this population. Lastly, tele-audiologic implications of the use of video otoscopy to increase access in resource-constrained contexts are raised.

Lobomycosis: a therapeutic challenge

Lobomycosis or lacaziosis is a chronic granulomatous fungal infection caused by Lacazia loboi. Most cases are restricted to tropical regions. Transmission is believed to occur through traumatic inoculation in the skin, mainly in exposed areas. It is characterized by keloid-like nodules. There are only a few hundred cases reported. The differential diagnoses include many skin conditions, and treatment is difficult. The reported case, initially diagnosed as keloid, proved to be refractory to surgical treatment alone. It was subsequently approached with extensive surgery, cryotherapy every three months and a combination of itraconazole and clofazimine for two years. No signs of clinical and histopathological activity were detected during follow-up.

Relapsing polychondritis in a liver transplant recipient: A case report

RATIONALE

Relapsing polychondritis (RP) is a multisystemic, progressive disease of unknown etiology characterized by recurrent inflammation and progressive cartilage destruction. It can involve all types of cartilage including ears and nose, tracheobronchial tree, joints, and any other tissue rich in proteoglycans such as heart, eyes, and blood vessels. Recurrent chondritis can be life-threatening if the respiratory tract, heart valves, or blood vessels are affected. To date there is no data in the literature on the post solid organ transplantation RP.

PATIENT CONCERNS

We present a 59-year-old male liver transplant recipient with primary sclerosing cholangitis who developed RP of the earlobes and nose despite post-transplant immunosuppression.

DIAGNOSES

Based on the clinical criteria, scintigraphy and biopsy from the left auricle his condition was diagnosed as RP.

INTERVENTIONS

Pulses of methylprednisolone followed by high-dose oral steroids along with azathioprine were administered.

OUTCOMES

Such therapy diminished local cartilage inflammation, improved patient's general condition and the laboratory results. Significant loss of ear cartilage and characteristic "saddlenose" were observed after remission of acute symptoms. The control scintigraphy proved very good treatment response.

LESSONS

To the best of our knowledge this is the first report on the RP in liver transplant recipient. Based on our patient presentation, we suggest that RP should be suspected in any transplant recipient with cartilage inflammation, and that the Michet's clinical criteria and scintigraphy seem to be the best diagnostic tools for solid organ transplant recipients suspected of RP.

Auricular Hemosiderosis in a Diabetic Patient

A 74-year-old Caucasian man with poorly controlled diabetes and hypertension was seen in the dermatology clinic for treatment of a nodular basal cell carcinoma on his right temple. He had poorly controlled diabetes for decades and had been insulin dependent for 20 to 25 years. He had not been on any anticoagulation therapy in the past or present and had no history of a hematologic disorder. He was retired and did woodworking as a hobby. During a routine presurgical head and neck skin examination, he was noted to have macular bluegray dyspigmentation of the central portion of the anterior portion of his ear lobes, bilaterally (Figure 1). He had first noticed this color change approximately 2 years ago and thought the pigmentation was darkening. It was not symptomatic. A punch biopsy was obtained.

Localized cutaneous argyria: Report of two patients and literature review

BackgroundLocalized cutaneous argyria is a rare skin condition caused by direct contact with silver or silver particles. It presents as asymptomatic gray or blue-gray macules that appear similar to blue nevi. Histologic features include brown-colored or black-colored silver granules in the basement membrane and dermis, most commonly surrounding eccrine glands, elastic fibers, and collagen fibrils. The condition is most frequently observed in individuals who are regularly exposed to small silver particles, such as silversmiths and welders. However, localized cutaneous argyria has also been associated with acupuncture needles, silver earrings, and topical medications containing silver nitrate. Although the condition is benign, patients who are concerned about the cosmetic features of localized cutaneous argyria may benefit from laser therapy.PurposeWe describe the clinical and pathologic findings of two women who developed localized cutaneous argyria. We also review the characteristics of other patients with localized cutaneous argyria and summarize the differential diagnosis and treatment options for this condition.Materials and methodsThe features of two women with localized cutaneous argyria are presented. Using PubMed, the following terms were searched and relevant citations assessed: acquired localized argyria, acupuncture, argyria, argyrosis, colloidal silver, cutaneous argyria, and localized cutaneous argyria. In addition, the literature on localized cutaneous argyria is reviewed.ResultsTwo women presented with small, asymptomatic blue-gray macules appearing at sites directly adjacent to ear piercings. A punch biopsy was performed on one woman. Microscopic examination revealed a yellowish-brown colored granular material found adjacent to elastic fibers. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of localized cutaneous argyria was established. The second woman did not undergo a biopsy. However, the clinical presentation was highly suggestive of localized cutaneous argyria. Both women were reassured of the benign nature of the condition and agreed to return for clinical follow-up if they observed any changes in the appearance of the lesions.

Perforating gout of the ear

Gout is the most common cause of inflammatory arthritis in men over 40 [1]. The prevalence of gout in the US is approximately 3.9%. Tophus is a characteristic sign of gout and results when monosodium urate deposits at the joint, skin, or cartilage. Tophi develop in 12-35% of patients who are diagnosed with gout [2]. We report a case of a 70-year-old man who was diagnosed with squamous cell carcinoma of the helix via shave biopsy. During Mohs micrographic surgery, a vigorous foreign-body reaction was noted. Review of the initial biopsy slides identified crystals with pseudoepitheliomatous hyperplasia (PEH) rendering a diagnosis of gout. This case emphasizes the importance of recognizing causes of PEH and the predilection for tophi to form on the ear.

Optical coherence tomography based microangiography provides an ability to longitudinally image arteriogenesis in vivo

BACKGROUND

Arteriogenesis describes the active growth of the pre-existing collateral arterioles, which is a crucial tissue-saving process in occlusive vascular diseases.

NEW METHOD

We propose to use optical coherence tomography (OCT)-based microangiography (OMAG) to monitor arteriogenesis following artery transection in mouse ear and focal stroke in mouse brain.

RESULTS

Our longitudinal mouse ear study shows that the growth phase of arteriogenesis, indicated by changes in collateral vessel diameter and velocity, occurs between 12 and 24h after vessel transection. Additionally, the magnitude of local inflammation is consistent with the time course of arteriogenesis, judging by the tissue thickness measurement and lymphatic vessel signals in OCT. In the mouse brain study, collateral vessel morphology, blood flow velocity and directionality are identified, and an activation of the collateral flow at the arteriolo-arteriolar anastomoses (AAA) is observed during stroke.

COMPARISON WITH EXISTING METHODS

In comparison with histology and fluorescence imaging, OCT/OMAG is completely non-invasive and capable of producing consistent results of longitudinal changes in collateral vessel morphology and vasodynamics.

CONCLUSION

OCT/OMAG is a promising imaging tool for longitudinal study of collateral vessel remodeling in small animals. This technique can be applied in guiding the in vivo experiments of arteriogenesis stimulation to treat occlusive vascular diseases, including stroke.

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.

Clinical characteristics and follow-up of patients with external ear canal cholesteatoma treated conservatively

We conducted a retrospective study to evaluate the clinical properties and follow-up of patients with external ear canal cholesteatoma (EECC) who were treated conservatively. Our study group was made up of 15 patients-6 men and 9 women, aged 21 to 82 years (mean: 48). In addition to demographic data, we compiled information on presenting signs and symptoms, the location of the lesion, treatment, and follow-up. All EECCs occurred spontaneously, and all were limited to the temporal bone. Lesions were left-sided in 7 patients, right-sided in 7, and bilateral in 1. For purposes of defining the location of the lesions, the ear canal was divided into four quadrants: anterior, posterior, superior, and inferior. Temporal bone computed tomography (CT) and otomicroscopic evaluation revealed that 7 of the 16 lesions (44%) were located in the anterior and inferior quadrants, 6 (38%) in the inferior quadrant only, 2 (13%) in the anterior, inferior, and posterior quadrants, and 1 (6%) in the anterior quadrant only. Otorrhea was present in 7 of the 15 patients (47%), otalgia in 6 (40%), itching in 4 (27%), fullness in 2 (13%), and occlusion in 1 (7%); 3 patients (20%) were asymptomatic. All patients were treated with local debridement and aspiration under otomicroscopy, and they were followed up with repeat aspirations approximately every 10 weeks under microscopy. The duration of follow-up ranged from 6 to 75 months (mean: 41). At study's end, cholesteatoma had not progressed in any patient during follow-up, indicating that repeat aspirations and regular follow-up of limited EECC prevent recurrence of signs and symptoms and progression of the disease.

Immunoglobulin Crystals in Reactive Plasma Cells in a Dog

Intracellular crystalline deposits of immunoglobulin are occasionally seen in human B-cell lymphoproliferative disorders such as multiple myeloma, chronic lymphocytic leukemia, and various forms of lymphoma. Even more uncommon is the occurrence of immunoglobulin crystals in benign plasma cells or reactive lymphocytes. Here we describe the histologic, immunohistochemical, and ultrastructural features of intracellular immunoglobulin crystals in nonneoplastic plasma cells in a chronic inflammatory lesion in a dog. Microscopically, the intracellular, nonbirefringent eosinophilic crystals were square to rectangular, 2–20 μgm long, and caused nuclear displacement to the periphery. The crystal-containing cells, as well as some of the crystals themselves, were positive for lambda light chain. Ultrastructural findings were consistent with a lattice network of protein-molecule alignment. The cause and significance of the crystals is unknown.

Cholesteatoma--pathology and treatment

(1) The prerequisite for development of cholesteatoma is a cholesteatoma bed, that is a loose subepithelial connective tissue layer which acts as a nutrient bed and makes papillary growth of squamous epithelium possible. (2) The formation of cholesteatoma is facilitated by disturbed tubal function with reduced ventilation of the middle ear. (3) The progression of cholesteatoma, especially the bone destruction, is due to enzyme-activated cell groups. The epidermal layer in the postero-superior area of the tympanic membrane has a higher papillary content and during an inflammatory process there is a marked vascular reaction. This particular area has a special nutritional zone and the epidermis is especially well nourished [Lange, 1925]. The main artery to the tympanic membrane travels along the handle of the malleus and gives off branches. In our animal experiments epithelial cones grew into this well-nourished subepithelial zone and formed cholesteatoma. The importance of tubal function as regards cholesteatoma formation can be seen in everyday clinical practice. In stapedectomy patients, the lateral attic wall is usually removed to allow full visualisation of the stapes, but retraction pockets in this area are never seen at subsequent follow-up. However, if the lateral attic wall is removed during surgery for chronic otitis media, reconstruction with cartilage or ceramic is necessary to prevent retraction. This adds weight to the hypothesis that tubal dysfunction is an important aetiological factor in cholesteatoma. This is further supported by the 30 times greater incidence of retraction pockets in patients with cleft palate.

Inhibition of the activation and recruitment of microglia-like cells protects against neomycin-induced ototoxicity

One of the most unfortunate side effects of aminoglycoside (AG) antibiotics such as neomycin is that they target sensory hair cells (HCs) and can cause permanent hearing impairment. We have observed HC loss and microglia-like cell (MLC) activation in the inner ear (cochlea) following neomycin administration. We focused on CX3CL1, a membrane-bound glycoprotein expressed on neurons and endothelial cells, as a way to understand how the MLCs are activated and the role these cells play in HC loss. CX3CL1 is the exclusive ligand for CX3CR1, which is a chemokine receptor expressed on the surface of macrophages and MLCs. In vitro experiments showed that the expression levels of CX3CL1 and CX3CR1 increased in the cochlea upon neomycin treatment, and CX3CL1 was expressed on HCs, while CX3CR1 was expressed on MLCs. When cultured with 1 μg/mL exogenous CX3CL1, MLCs were activated by CX3CL1, and the cytokine level was increased in the cochleae leading to apoptosis in the HCs. In CX3CR1 knockout mice, a significantly greater number of cochlear HCs survived than in wild-type mice when the cochlear explants were cultured with neomycin in vitro. Furthermore, inhibiting the activation of MLCs with minocycline reduced the neomycin-induced HC loss and improved the hearing function in neomycin-treated mice in vivo. Our results demonstrate that CX3CL1-induced MLC activation plays an important role in the induction of HC death and provide evidence for CX3CL1 and CX3CR1 as promising new therapeutic targets for the prevention of hearing loss.

Assessment of the effects of superior canal dehiscence location and size on intracochlear sound pressures

Superior canal dehiscence (SCD) is a defect in the bony covering of the superior semicircular canal. Patients with SCD present with a wide range of symptoms, including hearing loss, yet it is unknown whether hearing is affected by parameters such as the location of the SCD. Our previous human cadaveric temporal bone study, utilizing intracochlear pressure measurements, generally showed that an increase in dehiscence size caused a low-frequency monotonic decrease in the cochlear drive across the partition, consistent with increased hearing loss. This previous study was limited to SCD sizes including and smaller than 2 mm long and 0.7 mm wide. However, the effects of larger SCDs (>2 mm long) were not studied, although larger SCDs are seen in many patients. Therefore, to answer the effect of parameters that have not been studied, this present study assessed the effect of SCD location and the effect of large-sized SCDs (>2 mm long) on intracochlear pressures. We used simultaneous measurements of sound pressures in the scala vestibuli and scala tympani at the base of the cochlea to determine the sound pressure difference across the cochlear partition - a measure of the cochlear drive in a temporal bone preparation - allowing for assessment of hearing loss. We measured the cochlear drive before and after SCDs were made at different locations (e.g. closer to the ampulla of the superior semicircular canal or closer to the common crus) and for different dehiscence sizes (including larger than 2 mm long and 0.7 mm wide). Our measurements suggest the following: (1) different SCD locations result in similar cochlear drive and (2) larger SCDs produce larger decreases in cochlear drive at low frequencies. However, the effect of SCD size seems to saturate as the size increases above 2-3 mm long and 0.7 mm wide. Although the monotonic effect was generally consistent across ears, the quantitative amount of change in cochlear drive due to dehiscence size varied across ears. Additionally, the size of the dehiscence above which the effect on hearing saturated varied across ears. These findings show that the location of the SCD does not generally influence the amount of hearing loss and that SCD size can help explain some of the variability of hearing loss in patients.

Aural myiasis caused by Parasarcophaga (Liosarcophaga) dux (Thomson) in Thailand

Herein is reported the first case in Thailand of aural myiasis caused by the flesh fly, Parasarcophaga (Liosarcophaga) dux (Thomson). A 5-day-old infant was taken to hospital with a slightly bloody ear. Two fly larvae exiting the ear and another recovered by a physician were alive, and confirmed as P. dux species from adult examination results. This case brought attention to the need for protection against synanthropic flies, particularly for infants and/or hearing impaired patients.

Amyloidosis in bilateral external auditory canals

We report a 76-year-old man, a retired farmer, presenting with bilateral external auditory canal obstruction. Skin examination revealed multiple pruritic nodules and periorbital purpura. Ear canal opening surgery was performed. Skin and ear canal biopsy revealed extensive amyloid depositions. Immunoelectrophoresis for urinary Bence-Jones protein was positive, and bone marrow examination showed plasma cell dyscrasia. He received chemotherapy for amyloid light-chain amyloidosis secondary to light-chain multiple myeloma but died from myeloma progression. This case demonstrated how infiltrative conditions such as amyloidosis can lead to bilateral auditory canal obstruction and that the diagnosis of amyloidosis can be missed if a clinician focuses solely on a single organ.

Modified radical mastoidectomy and its complications--12 years' experience

To find the incidence of complications of modified radical mastoidectomy and to evaluate different parameters that play a role in their causation, we conducted a retrospective study spanning a period of 12 years. Included were 210 patients who underwent primary modified radical mastoidectomies performed by one senior surgeon; of these patients, 163 fulfilled the inclusion criteria. The charts were evaluated for patients' age and sex, laterality, intraoperative pathology, and complications. The complications were grouped into nine categories for analysis of their etiology. The results in this study were compared with those from other published reports. Complications were documented in 46 of 163 (28.2%) operated ears; 21 (45.7%) of them were noted in children <15 years of age, and 25 (54.3%) were found in adults. Sex and laterality were of no significance. The most common complication recorded was residual/recurrent cholesteatoma (20 [12.3%]), followed by meatal stenosis (11 [6.7%]). A moist cavity with discharging ear was noted in only 4 (2.5%) patients. No facial nerve palsies or dead ears were observed. Eleven (6.7%) patients had more than one complication. The parameters evaluated were size of the meatus, tympanic membrane appearance, status of the mastoid cavity, height of the facial ridge, and extent of the disease process. Complications can be caused by a number of factors, such as congenital anomalies, disease process, and the surgeon's skill. Each complication must be thoroughly evaluated for immediate management and to learn how to avoid it in the future.

[Ear keloid and clinical research progress]

Keloid refers to the damaged skin due to excessive fibroblast proliferation. Ear is one predilection site. The pathogenesis of ear keloid is not very clear, and the treatment is also varied. Surgery, postoperative radiotherapy and laser treatment, steroid hormones, pressure therapy are the basic treatment methods. Integrated application of a variety of treatments, classification research and new materials using revealed the prospect for the treatment of the disease. This thesis reviews literature about ear keloid in recent 10 years, and introduces this disease and clinical research progress.

Cochlear implant outcomes in patients with superior canal dehiscence

OBJECTIVE

To determine whether adult cochlear implant (CI) users with superior canal dehiscence syndrome (SCDS) or asymptomatic superior semicircular canal dehiscence (SCD) have different surgical, vestibular, and audiologic outcomes when compared to CI users with normal temporal bone anatomy.

METHODS

A retrospective single institution review of CI users with either superior semicircular canal dehiscence syndrome or asymptomatic superior semicircular canal dehiscence identified eight post-lingually deafened adults with unilateral or bilateral cochlear implantation between 2006 and 2010. Preoperative and postoperative speech perception scores as well as medical and epidemiological data were recorded and analyzed.

RESULTS

One patient with superior canal dehiscence syndrome and seven patients with asymptomatic superior semicircular canal dehiscence were identified, representing 7% or 8/113 of CI patients that fulfilled selection criteria. Average dehiscence length was 3.3 mm ± 0.79 SEM. Three patients received bilateral implants and five patients received a unilateral implant. Among asymptomatic superior semicircular canal dehiscence patients, subjective rates of post-operative dizziness were similar to those seen in patients with normal temporal bone anatomy (12.5 % vs. 15.9%, respectively). Speech perception abilities after surgery were poorer in SCD patients compared to the non-SCD cohort (Consonant Nucleus Consonant 33.7 ± 7.78 SEM vs. 56.7 ± 2.15 SEM P = 0.011), although both groups improved substantially relative to pre-operative performance. We also completed detailed analyses of auditory and vestibular outcomes in one patient with SCDS who underwent CI surgery in the symptomatic ear, which demonstrated preservation of vestibular function post-operatively, improved quality-of-life measures, and reduced dizziness symptomatology.

CONCLUSIONS

Our data suggest that patients with asymptomatic superior canal dehiscence at the time of CI surgery have similar albeit decreased speech perception scores compared to non-SCD adult CI users. Subjective rate of dizziness or vertigo following CI surgery was similar in both asymptomatic SCD and non-SCD cohorts, with detailed analyses of a single symptomatic SCD patient revealing improved vestibular function and reduced SCD symptoms following CI.