Department of Otolaryngology--Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock 72205, USA. DornhofferJohnL@uams.edu
OBJECTIVES/HYPOTHESIS The purpose of this study was to analyze the anatomical and audiologic results in more than 1,000 cartilage tympanoplasties that utilized a logical application of several techniques for the management of the difficult ear (cholesteatoma, recurrent perforation, atelectasis). Our hypothesis was that pathology and status of the ossicular chain should dictate the technique used to achieve optimal outcome. STUDY DESIGN Retrospective clinical study of patients undergoing cartilage tympanoplasty between July 1994 and July 2001. A computerized otologic database and patient charts were used to obtain the necessary data. METHODS A modification of the perichondrium/cartilage island flap was utilized for tympanic membrane reconstruction in cases of the atelectatic ear, for high-risk perforation in the presence of an intact ossicular chain, and in association with ossiculoplasty when the malleus was absent. A modification of the palisade technique was utilized for TM reconstruction in cases of cholesteatoma and in association with ossiculoplasty when the malleus was present. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average air-bone gap (PTA-ABG). The Student t test was used for statistical comparison. Postoperative complications were recorded. RESULTS During the study period, cartilage was used for TM reconstruction in more than 1,000 patients, of which 712 had sufficient data available for inclusion. Of these, 636 were available for outcomes analysis. In 220 cholesteatoma cases, the average pre- and postoperative PTA-ABGs were 26.5 +/- 12.6 dB and 14.6 +/- 8.8 dB, respectively (P <.05). Recurrence was seen in 8 cases (3.6%), conductive HL requiring revision in 4 (1.8%), perforation in 3 (1.4%), and post- and intraoperative tube insertion in 11 (5.0%) and 18 ears (8.2%), respectively. In 215 cases of high-risk perforation, the average pre- and postoperative PTA-ABGs were 21.7 +/- 13.5 dB and 11.9 +/- 9.3 dB, respectively (P <.05). Complications included recurrent perforation in 9 ears (4.2%), conductive HL requiring revision in 4 (1.9%), postoperative and intraoperative tube insertion in 4 (1.9%) and 6 ears (2.8%), respectively. In 98 cases of atelectasis, the average pre- and postoperative PTA-ABGs were 20.2 +/- 10.9 dB and 14.2 +/- 10.2 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 2 cases (2.0%), and post- and intraoperative tube insertion in 7 (7.1%) and 12 ears (12%), respectively. In 103 cases to improve hearing (audiologic), the average pre- and postoperative PTA-ABGs were 33.6 +/- 9.6 dB and 14.6 +/- 10.1 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 11 (11%), and post- and intraoperative tube insertion in 6 (5.8%) and 2 (1.9%), respectively. CONCLUSIONS Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized. Significant hearing improvement was realized in each pathological group. In the atelectatic ear, cartilage allowed us to reconstruct the TM with good anatomic results compared to traditional reconstructions, which have shown high rates of retraction and failure. In cholesteatoma, cartilage tympanoplasty using the palisade technique resulted in precise reconstruction of the TM and helped reduce recurrence. In cases of high-risk perforation, reconstruction with cartilage yielded anatomical and functional results that compared favorably to primary tympanoplasty using traditional techniques. We believe the indications for cartilage tympanoplasty (atelectatic ear, cholesteatoma, high-risk perforation) were validated by these results.
Evaluation of the organic and functional results of tympanoplasties through a retro-auricular approach at a medical residency unit.
José Carlos Bolini de Lima, Silvio Antonio Monteiro Marone, Oswaldo Martucci, Fabiana Gonçalez, João Jovino da Silva Neto, Alice Carolina Mataruco Ramos
Medical School, Pontifical Catholic University in Campinas, SP, Brazil.
UNLABELLED Tympanoplasty aims at rebuilding the tympanic membrane with or without middle ear functional recovery. AIM To evaluate the surgical results of tympanoplasties with a retro-auricular surgical approach at a medical residency unit. MATERIALS AND METHODS Thirty-nine patients with diagnosis of simple chronic otitis media were evaluated; these patients underwent tymplanoplasty by a retro-auricular approach (underlay technique) at a medical residency unit. Patients were included in a prospective medical and audiologic investigation protocol that consisted of a clinical, otomicroscopic and audiometric evaluation. All procedures were supervised by training specialists otorrinolaringology. RESULTS The rate of surgical success - full integration of the graft - was 95% of cases. Improvement of hearing, as demonstrated in audiometry, occurred in 72% of cases. Improvement in tinnitus was demonstrated subjectively on a visual analog scale in 69% of cases. CONCLUSION Tympanoplasty through a retro-auricular approach is easy to perform. Full graft integration occurred in 95% of cases and was independent of factors deemed by many authors as relevant. The results - improvement of the quality of hearing and tinnitus - were significant.
Tympanoplasty in chronic otitis media patients with an intact, but severely retracted malleus: a treatment challenge.
Department of Otorhinolaryngology, University Medical Centre, St Radboud, Nijmegen, The Netherlands. firstname.lastname@example.org
To analyze the outcome of patients with chronic otitis media (COM) with an intact, but markedly medialized ossicular chain, treated by removing the malleus head and interposing an autologous incus and then an underlay myringoplasty. Retrospective clinical study. Tertiary referral center. The search criteria within the prospective surgical database was COM with a central perforation (without cholesteatoma) with a markedly medialized malleus handle (the umbo adherent to the promontory) with an intact ossicular chain (study, n = 15) or an incus necrosis at the lenticular process (incus, n = 23). Only primary surgeries performed at our otorhinolaryngology department were included. All patients underwent the same surgical procedure consisting of an autologous incus interposition and underlay myringoplasty with temporalis fascia. The patients' audiological and follow-up data were retrieved from the database. The postoperative audiogram (0.5-3 kHz) with the longest follow-up was used. The preoperative air-conduction thresholds were less impaired in the study group than in the incus group. After their surgery, all, except 3 patients, improved their hearing, and 97% had an intact tympanic membrane at a mean follow-up of 2 years. The air-bone gap was closed within 20 dB in 80%(study) and in 87%(incus), in one third of all patients even within 10 dB. Although the largest improvement was seen in the lower frequencies, closure of the air-bone gap at 4 kHz was difficult to achieve. Patients presenting with COM, a (central) perforation, a medially rotated malleus and intact ossicular chain are a treatment challenge. Lateralizing the malleus handle may require disconnection of the ossicular chain and an autologous incus interposition to bring back the reconstructed tympanic membrane in its original position and improve the hearing.
Department of Otolaryngology, Staedt, Kliniken Neuss, Neuss, Germany. email@example.com
Department of Otolaryngology, La Mancha Centro General Hospital, Alcázar de San Juan, Ciudad Real, Spain. firstname.lastname@example.org
Department of Otorhinolaryngology Head and Neck Surgery, Second Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510120, China.
BACKGROUND: Classic mastoidectomy and modified mastoidectomy are traditional surgical procedures for middle ear cholesteatoma with goals of eradicating diseases, creating dry ears and preventing severe complications. However, the drawback of these procedures is the lack of hearing improvement. Therefore, our study aimed to investigate the effects and safety of a modification of closed tympanoplasty for middle ear cholesteatoma. METHODS: Eighty-three patients were recruited in this study based on the following two criteria: each patient had middle ear cholesteatoma in one ear; the affected ears had a functional eustachian tube and had neither intracranial nor extracranial complications. All the patients received a modification of closed tympanoplasty which included ossicular reconstruction with total ossicular replacement prosthesis (TORP) or partial ossicular replacement prosthesis (PORP) and membrane repair with conchal cartilage-perichondral complex. RESULTS: All the 83 cases had dry ears with membranes healed within 4 - 6 postoperative weeks. After 6 postoperative months, there were 3 cases with re-perforation at the tympanic membrane center and after 1.5 postoperative years, there were 5 cases with cholesteatoma recurrence (6.02%). Function tests after one postoperative year exhibited an improvement of pure tone audiometry (PTA) in 27 cases that was more than 30 dB, in 33 cases between 20 - 29 dB, 14 cases with improvement between 10 - 19 dB, and in 9 cases there was no improvement. CONCLUSIONS: The modified closed tympanoplasty procedure for middle ear cholesteatoma in the present study has all the advantages of both close-cavity and open-cavity procedures. It has low recurrence rate and good hearing improvement.
Perichondrium/cartilage composite graft for repairing large tympanic membrane perforations and hearing improvement.
Department of Otolaryngology-Head and Neck Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China (Email: email@example.com).
BACKGROUND: The main risk factors for postoperative failure in tympanoplasties are large perforations that are difficult to repair, annular perforations, and a tympanic membrane (TM) with extensive granular myringitis that require middle ear exploration and mastoidectomy. The aim of this study was to investigate a novel technique of perichondrium/cartilage composite graft for repairing the large TM perforation in the patient of otitis media. METHODS: Retrospective chart reviews were conducted for 102 patients with large tympanic membrane perforations, who had undergone tympanoplasty from August 2005 to August 2008. Tympanoplasty or tympanomastoidectomy using a perichondrium/cartilage composite graft was analyzed. The tragal or conchal perichondrium/cartilage was used to replace the tympanic membrane in patients. RESULTS: Patients aged from 13 to 67 years were followed up in average for 24 months (10 - 36 months). Seventy-four ears (72.61%) were used the tragal perichondrium/cartilage as graft material and 27 ears (27.39%) were used the conchal perichondrium/cartilage. Graft take was successful in all patients. Postoperative complications such as wound infection, hematoma, or sensorineural hearing loss were not identified. Nine patients (8.82%) had the partial ossicular replacement prosthesis, 14 patients (13.72%) using the autologous curved incus and 79 patients (77.45%) without prosthesis. Successful closure occurred in 92% of the ears. A total of 85.8% patients achieved a postoperative hearing improvement. CONCLUSIONS: The graft underlay tympanoplasty using perichondrium/cartilage composite is effective for the majority of patients with large perforation. The hearing was improved even if the mastoidectomy was required in the patients with otitis media with extensive granulation.
Department of Otorhinolaryngology, Cerrahpasa Medicine Faculty, Istanbul University, Istanbul, Turkey.
Tympanoplasty is a surgical procedure used for eradicating chronic middle ear infection and for reconstructing hearing in infected ears. Independent from the graft placing technique, the atrophy and the insufficiency of the graft material would be seen.For cases at high risk for failure, such as recurrent perforations, total perforations, and severely atelectatic tympanic membranes, many surgeons have used cartilage as a grafting material because of its increased stability and resistance to negative middle ear pressure. Various cartilage grafting techniques have been described, including the palisade, cartilage island, and cartilage shield.In our study, we investigated audiological and otological outcomes of tympanoplasty type 1 with composite cartilage island grafts. Between 2004 and 2008, 100 cases of composite cartilage island tympanoplasty were identified. A total of 74 patients were attended to in this study. Graft take was evaluated in all patients, and postoperative complications were noted. Hearing results were analyzed by comparing the preoperative and postoperative pure-tone average air-bone gap. Graft take was accomplished in 72 patients (97.29%). There was no graft lateralization or displacement in the middle ear. The mean postoperative pure-tone average air-bone gap improvement was 20.2 dB at 500 Hz, 23.58 dB at 1000 Hz, 22.23 dB at 2000 Hz, and 24.79 at 4000 Hz.Our study indicates that composite cartilage island tympanoplasty has a high degree of reliability and excellent hearing improvement especially in patients at high risk for graft failure.
Ear Science Institute Australia, Ear Sciences Centre, School of Surgery, The University of Western Australia, Sir Charles Gairdner Hospital, Perth, WA, Australia. firstname.lastname@example.org
Chronic perforations of the eardrum or tympanic membrane represent a significant source of morbidity worldwide. Myringoplasty is the operative repair of a perforated tympanic membrane and is a procedure commonly performed by otolaryngologists. Its purpose is to close the tympanic membrane, improve hearing and limit patient susceptibility to middle ear infections. The success rates of the different surgical techniques used to perform a myringoplasty, and the optimal graft materials to achieve complete closure and restore hearing, vary significantly in the literature. A number of autologous tissues, homografts and synthetic materials are described as graft options. With the advent and development of tissue engineering in the last decade, a number of biomaterials have been studied and attempts have been made to mimic biological functions with these materials. Fibroin, a core structural protein in silk from silkworms, has been widely studied with biomedical applications in mind. Several cell types, including keratinocytes, have grown on silk biomaterials, and scaffolds manufactured from silk have successfully been used in wound healing and for tissue engineering purposes. This review focuses on the current available grafts for myringoplasty and their limitations, and examines the biomechanical properties of silk, assessing the potential benefits of a silk fibroin scaffold as a novel device for use as a graft in myringoplasty surgery.
Dirk Beutner, Karl-Bernd Huttenbrink, Robert Stumpf, Thomas Beleites, Thomas Zahnert, Jan-Christoffer Luers, Victor Helmstaedter
Department of Otorhinolaryngology/Head and Neck Surgery, University of Cologne, Cologne, Germany. email@example.com
OBJECTIVES The purpose of this work was to report our modified cartilage plate tympanoplasty technique ("tulip leaves") and to analyze its clinical outcome in primary and recurrent cases of chronic otitis media with and without cholesteatoma. STUDY DESIGN Clinical retrospective study. METHODS Patients being operated on with this technique at the University Department of Otorhinolaryngology, Dresden, Germany, between 1993 and 2001 were invited for survey, otomicroscopy, and pure-tone audiometry in 2003. Patients' charts were used to draw necessary conclusions. RESULTS A total of 39 patients who were treated with this technique after canal wall down tympanomastoidectomy and cavity obliteration were included in this long-term analysis after a median follow-up of 6 years. Seventeen patients (44%) experienced chronic otitis media with cholesteatoma, whereas 22 (56%) of them had a diagnosis of chronic otitis media without cholesteatoma. At the time of examination, all patients displayed a closed tympanic membrane. However, retractions were observed in 19 patients (48%). One patient required (3%) revision surgery for recurrent cholesteatoma due to prosthesis extrusion during the study period. CONCLUSION On the basis of this study, we recommend the tuliplike arrangement of thin but large auricular cartilage slices for the reconstruction of tympanic membrane defects in high-risk ears. This combination proved its high stability and long-lasting vitality in our long-term study. These characteristics are crucial for permanent disease removal and for reducing the risk of recurrent pathologic abnormality.
ENT Clinic, University Hospital, Olomouc, Czech Republic. firstname.lastname@example.org
Myringoplasty is considered the simplest reconstructive procedure of the middle ear. There are many variations and types of myringoplasties. In the past, these variations were categorized according to the types of tissue and the way the tissue was fixated in the middle ear. Currently, the types of myringoplasties are differentiated only by the fixation of the transplant, because a majority of ear surgeons use only fascia, perichondrium, or cartilage. The percentage of successful healings after myringoplasties does not depend on the tissue used. More important is the condition of the middle ear at the time of the operation and the experience and skill of the surgeon. Regardless which type of tissue is used, 90% to 95% of good anatomical healing can be achieved. The author of this article performed more than 7,000 cartilage myringoplasties and presents his experience and alternatives of cartilage use in the eardrum reconstructions. He introduces three types of cartilage grafts: 1) island cartilage graft, 2) ring cartilage graft, and 3) double island cartilage graft.
Other papers by authors:
Michael Landgrebe, Andréia Azevedo, David Baguley, Carol Bauer, Anthony Cacace, Claudia Coelho, John Dornhoffer, Ricardo Figueiredo, Herta Flor, Goeran Hajak, Paul van de Heyning, Wolfgang Hiller, Eman Khedr, Tobias Kleinjung, Michael Koller, Jose Miguel Lainez, Alain Londero, William H Martin, Mark Mennemeier, Jay Piccirillo, Dirk De Ridder, Rainer Rupprecht, Grant Searchfield, Sven Vanneste, Florian Zeman, Berthold Langguth
Department of Psychiatry and Psychotherapy, University of Regensburg, Germany; Interdisciplinary Tinnitus Clinic, University of Regensburg, Germany.
Chronic tinnitus is a common condition with a high burden of disease. While many different treatments are used in clinical practice, the evidence for the efficacy of these treatments is low and the variance of treatment response between individuals is high. This is most likely due to the great heterogeneity of tinnitus with respect to clinical features as well as underlying pathophysiological mechanisms. There is a clear need to find effective treatment options in tinnitus, however, clinical trials differ substantially with respect to methodological quality and design. Consequently, the conclusions that can be derived from these studies are limited and jeopardize comparison between studies. Here, we discuss our view of the most important aspects of trial design in clinical studies in tinnitus and make suggestions for an international methodological standard in tinnitus trials. We hope that the proposed methodological standard will stimulate scientific discussion and will help to improve the quality of trials in tinnitus.
Mark Mennemeier, Kenneth C Chelette, Shawn Allen, Twyla B Bartel, William Triggs, Timothy Kimbrell, Joseph Crew, Tiffany Munn, Ginger J Brown, John Dornhoffer
Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA. email@example.com
OBJECTIVES/HYPOTHESIS The objective was to determine whether low-frequency repetitive transcranial magnetic stimulation (rTMS) improves tinnitus by decreasing neural activity in auditory processing regions of the temporal cortex and the utility of positron emission tomography (PET) for targeting treatment. STUDY DESIGN Randomized, sham-controlled crossover. METHODS Patients received a five-day course of active and sham 1-Hz rTMS (1800 pulses at 110% of motor threshold) to the temporal cortex, with a week separating active and sham treatment. Visual analogue ratings of tinnitus loudness (VARL) were assessed at baseline and the end of each treatment week; regional brain blood flow (rBBF) and glucose metabolism (via PET) were measured before and after treatment in regions of interest (ROI) beneath the stimulating coil and control sites. RESULTS The VARL for both ears significantly decreased after active but not sham treatment. Responders comprised 43% of patients, experiencing at least a 33% drop in tinnitus loudness. The site most consistently associated with a positive response was the secondary auditory cortex (Brodmann Area 22) in either hemisphere. PET asymmetries were variable across patients and not always accessible to rTMS. Whereas PET activity decreased significantly beneath the stimulating coil following active treatment, similar changes occurred at control sites and after sham stimulation. Change in tinnitus perception did not correlate significantly with change in PET activity at the treatment site ROI. CONCLUSIONS Active TMS led to a significant reduction in tinnitus loudness, but PET scans failed to support the hypothesis that low-frequency rTMS improves tinnitus by reducing cortical activation at the stimulation site, questioning the utility of PET for targeting rTMS.
Verification of Speech Spectrum Audibility for Pediatric Baha Softband Users with Craniofacial Anomalies.
1 University of Arkansas for Medical Sciences.
Abstract Objective: The purpose of this study was to (a) determine benefit of Baha coupled to the Softband for infants and children with bilateral conductive hearing loss; and (b) verify audibility of the speech spectrum for octave frequencies 500 through 4000 Hz. Design: The research design for this retrospective chart study is pre-post repeated measures. Setting: The study was conducted in the Department of Audiology and Speech Pathology, Arkansas Children's Hospital. Participants: Twenty-five children aged 6 months to 18 years with craniofacial disorders and bilateral conductive hearing loss participated in the study. Participants were consistent full-time unilateral Baha users with the Baha Compact bone conduction amplifier coupled to the head via the Softband. Interventions: The intervention was the Baha device coupled to the head via the Softband as a prerequisite to surgical implantation. Main Outcome Measure(s): The primary study outcome measures utilized aided and unaided soundfield audiometric thresholds to calculate functional gain. Audibility of the speech spectrum was verified by comparison to target aided thresholds. Results: Results revealed an improvement in soundfield thresholds with Baha amplification for the four octave frequencies. Means, standard deviations, and confidence intervals for aided and unaided thresholds are reported. Percentage of thresholds meeting target levels were significant at all frequencies, exceeding the 80% criterion. Conclusions: Benefit of the Baha in providing audibility of the speech spectrum for infants and children with bilateral congenital conductive hearing loss has been demonstrated, providing important and timely data supporting third party reimbursement. Key Words: Baha, craniofacial, hearing loss, verification, audibility.
Int Tinnitus J. 2008 ;14 (2):97-100 19205158
Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
Acoustic neuromas are the most common tumor in the cerebellopontine angle (CPA) but are rare in the general population. Paragangliomas are rarer still and, in a minority of cases (20%), are known to be caused by errors in the SDHD gene. Mutations in this gene are highly penetrant when inherited paternally but not maternally. We present the first reported case of a patient with a CPA tumor and a maternally inherited SDHD gene mutation.
Laryngoscope. 2009 Jan 22;: 19165872
Response to a letter to the editor in reference to Impact on Quality of Life After Mastoid Obliteration (Laryngoscope 2008;118:1427-1432).
Professor of Otolaryngology, Samuel McGill Chair in Otolaryngology Research, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
In Reference to Maintenance Repetitive Transcranial Magnetic Stimulation can Inhibit the Return of Tinnitus.
Department of Neurobiology and Developmental Sciences University of Arkansas for Medical Sciences Little Rock, Arkansas (Mennemeier) Department of Otolaryngology-Head and Neck Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas (Dornhoffer).
Department of Otolaryngology/Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.
OBJECTIVE:: To review our long-term experience with the Meniett device in patients who failed medical management to analyze its efficacy in controlling vertigo and its impact on the functional level of the patient. STUDY DESIGN:: Retrospective case review with long-term follow-up of patients receiving the Meniett device at our institution between May 2002 and April 2005. SETTING:: Tertiary referral center. PATIENTS:: Patients who failed medical therapy for Ménière's disease and opted to receive the Meniett over chemical labyrinthectomy, surgical labyrinthectomy, endolymphatic shunt surgery, or vestibular nerve section. INTERVENTION:: The Meniett is a small, portable, low-pressure pulse generator meant to be self-administered, requiring 5-minute sessions 3 times a day. MAIN OUTCOME MEASURE:: Patient's current perception of usefulness of Meniett device for controlling vertigo and current level of Meniett treatment. RESULTS:: Of 14 patients meeting the study criteria, 12 were able to be contacted, giving an average follow-up of 4 years. Three patients (25%) showed no benefit; 9 patients (75%) did respond to the Meniett and thought it had reduced the frequency and severity of their vertigo attacks. Seven patients (58%) continued to use the device on a daily basis; the other 2 patients (17%) went into remission 2 and 3 years after initiating treatment. CONCLUSION:: The Meniett device is a minimally invasive, nondestructive treatment that may be used to provide longer-term reduction of vestibular symptoms in patients with Ménière's disease.
Mark Mennemeier, Kenneth C Chelette, Jeffery Myhill, Patricia Taylor-Cooke, Twyla Bartel, William Triggs, Timothy Kimbrell, John Dornhoffer
Department of Neurobiology and Developmental Science, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA. firstname.lastname@example.org
OBJECTIVES/HYPOTHESIS A single patient was tested to examine the safety and feasibility of using maintenance sessions of low-frequency repetitive transcranial magnetic stimulation (1 Hz rTMS) to reduce tinnitus loudness and prevent its return over time. STUDY DESIGN Interrupted time series with multiple replications. METHODS Tinnitus loudness was assessed using a visual analogue rating (VAR) with 0 = no tinnitus, and 100 = loudest tinnitus experienced; 1,800 TMS pulses delivered at 1 Hz and 110% of motor threshold were administered over the posterior, superior lateral temporal gyrus of the subject's right hemisphere until subjective tinnitus fell to a VAR of 25. TMS was reapplied as tinnitus returned to a VAR of 25 or higher. Cerebral metabolism was measured using positron emission tomography before and after treatment. RESULTS In this patient, tinnitus could be reduced to a VAR of 6 or lower each time it reoccurred using one to three maintenance sessions of rTMS. Tinnitus loudness remained at or below a VAR of 25 and was reported to be unobtrusive in daily life when last assessed 4 months after the third and final round of maintenance treatment. Asymmetric increased cerebral metabolism in the right hemisphere reduced following treatment and as tinnitus improved. Maintenance treatment was well tolerated with no side effects. CONCLUSIONS Although a case study cannot establish treatment efficacy, this study demonstrates for the first time that it is feasible to use maintenance rTMS to manage chronic tinnitus. Maintenance rTMS might impede cortical expansion of the tinnitus frequency into adjacent cortical areas, but group studies are necessary to confirm this speculation.
MD, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, MS 543, Little Rock, AR 72205, USA. DornhofferJohnL@uams.edu
We investigated the effects of tinnitus on measures of arousal and attention at various levels of the neuraxis to derive a profile of the pathophysiology of tinnitus. Individuals with tinnitus of at least 6 months' duration (14 male, 15 female) and healthy controls (14 male, 21 female) were tested for arousal and habituation to repetitive stimulation at the brainstem-thalamus level by measuring the P50 potential, a scalp-recorded, auditory-evoked response, using pairs of click stimuli. We used the psychomotor vigilance task, a reaction-time test, to assess attentional processes mediated by thalamocortical functions. We then correlated deficits in arousal and attention, as measured by these tests, with perceived tinnitus severity. Results showed no difference between tinnitus patients and controls in level of arousal or habituation to repetitive sensory stimulation, as measured by the amplitude of the P50 potential and the ability to suppress a second, closely paired stimulus, respectively. However, reaction-time assessments showed that patients with tinnitus have attentional deficits relative to controls (p =.02). We found no significant correlation between sleep disturbance or tinnitus severity and reaction-time testing.
Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
HYPOTHESIS The purpose of this animal study was to confirm the presence of all three atrial natriuretic peptide (ANP) receptor subtypes in the rat inner ear and compare the expression of each receptor after inner ear injection of ANP, phosphate-buffered saline, or a solution containing ANP incubated with anti-ANP antibody (to block upregulation). BACKGROUND Receptors for ANP and related compounds have been localized in the inner ear of animals and humans. A previous study at this institution demonstrated the ability to up-regulate the expression of the three ANP receptors (ANP-A, ANP-B, ANP-C) in response to round window injection of ANP in the rat inner ear. METHODS After surgical exposure, the round window of female Lewis rats was injected with various concentrations of ANP, ANP plus anti-ANP antibody, or control. Animals were killed 24 hours after injection, inner ear tissues were harvested and homogenized, and RNA was isolated for reverse-transcription polymerase chain reaction. RESULTS Electrophoresis showed the presence of all three receptor subtypes with exposure to phosphate-buffered saline. Expression was significantly higher 24 hours after injection with the two concentrations of ANP. This increase was partially blocked with increasing relative concentrations of anti-ANP antibody. CONCLUSIONS These findings confirm the presence and responsiveness of ANP receptors in the rat inner ear. The ability to block up-regulation with the antibody provides a potential new research tool for manipulating the function of this hormone system in experimental models and, ultimately, in understanding the mechanisms of fluid homeostasis in the inner ear.
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Comparison of different grafting techniques in type I tympanoplasty in cases of significant middle ear granulation.
Department of Otorhinolaryngology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
OBJECTIVE To assess anatomical and hearing results after different reconstruction methods of tympanic membrane in cases of severe middle ear granulation. STUDY DESIGN Retrospective review. SETTING Secondary care medical center. PATIENTS Forty patients with severe middle ear granulation were included. INTERVENTIONS Canal wall-up mastoidectomy with Type I tympanoplasty. Temporalis fascia was used in 22 patients, cartilage island flap was used in 10 patients, and cartilage palisade was used in 8 patients. MAIN OUTCOME MEASURES Graft take, air-bone gap, and air-bone gap closure ratio of 50% or more. RESULTS In the fascia group, the graft take rate was 91%, whereas the graft take rate for the cartilage island group and the cartilage palisades group was 100%(p = 0.617). Mean ± SD preoperative air-bone gaps for the fascia, island flap, and cartilage palisades were 30 ± 9.4, 26 ± 11.7, and 25 ± 10.8 dB, respectively. Postoperative air-bone gaps were 17 ± 10.2, 14 ± 8.4, and 19 ± 7.5 dB, respectively, in the same order. The cartilage palisades group failed to show statistically significant difference between preoperative and postoperative air-bone gaps (p = 0.195). Air-bone gap closure ratio of 50% or more was found in 11 cases (50%) of the fascia group, in 5 cases (50%) of the island flap group, and in 1 case (13%) of the cartilage palisades group. CONCLUSION Cartilage palisades showed reliable graft take but slightly poor hearing results. Thus, fascia or cartilage island grafting might be better for tympanoplasty in cases of severe middle ear granulation tissue.
Clinic of Otorhinolaryngology, Head and Neck Surgery, Clinical Hospital Center Rijeka, Krešimirova 42, HR-51 000 Rijeka, Croatia. email@example.com
OBJECTIVE To show long-term anatomic and functional results of full thickness cartilage palisade tympanoplasty in children and adults. METHODS In 51 patients (56 ears); 9 children (12 ears) and 42 adults (44 ears) full thickness cartilage palisade tympanoplasty and interposition with malleus head autograft was performed. On average 11 years after the tympanoplasty, an otomicroscopy and a tonal audiogram were done to assess anatomic and functional results. RESULTS Anatomic results of 56 ears: 40 (71.43%) tympanic membranes have no anatomic irregularities; 14 (25.00%) have cartilage resorption (11 of them minor and 3 major resorptions), 2 (3.57%) have secondary perforation. In the group of children all ears tympanic membrane were with no or minor resorption and no perforations. Functional results (51 audiograms performed: in children 12 and in adults 39): pre- and post-operative average pure tone average air-bone gaps were 27.29 ± 10.26 and 10.73 ± 7.90 dB, respectively. In the group of children pre- and post-operative average pure tone average air-bone gaps were 29.44 ± 10.30 and 6.81 ± 3.47 dB, respectively. In the group of adults pre- and post-operative pure tone average air-bone gaps were 26.63 ± 10.30 and 11.93 ± 8.50 dB, respectively. The differences between the two groups preoperatively (z=0.733; p=0.463) and postoperatively are irrelevant (z=1.723; p=0.085). The hearing gain is bigger in children (F=4.788; p=0.033). CONCLUSION The full thickness cartilage palisade tympanoplasty with malleus autograft interposition is also nowadays a successful method in solving of an advanced ear pathology also in children.
Service ORL et chirurgie cervico-faciale, hôpital Bretonneau, CHRU de Tours, Tours cedex, France. firstname.lastname@example.org
OBJECTIVES The authors report their experience with a variant cartilage tympanoplasty technique in a canal wall up (CWU) procedure for middle ear cholesteatoma, comparing reliability with other techniques. Functional results are analyzed according to ossicular chain status. MATERIALS AND METHODS A retrospective study was performed in adults operated on with CWU tympanoplasty for middle ear cholesteatoma. The surgical technique of "modeling" cartilage is described. RESULTS One hundred and nine patients were included (113 procedures). There were four recurrences (3.5%). Mean follow-up was 48 months (range, 24-96 months). In case of normal ossicular chain, postoperative pure-tone average air-bone gap was always less than 20dB, and less than 20dB following myringostapedopexy in 60% of cases with incus destruction. CONCLUSION Modeling cartilage is a reliable reconstruction technique to prevent recurrent cholesteatoma, and contributes to the quality of functional results in ossiculoplasty.
Department of Otorhinolaryngology, Izmir Ataturk Research and Training Hospital, Izmir, Turkey.
OBJECTIVE To compare the functional results of primary type I tympanoplasty performed with temporalis muscle fascia and a perichondrium/cartilage island flap. DESIGN Retrospective chart review. SETTING Research and training hospital. METHODS The records of patients who underwent type I tympanoplasty between 2006 and 2009 were reviewed. This study aimed to comprise a homogeneous group of patients to make the comparisons as accurate as possible. For this purpose, primary tympanoplasty cases with an intact ossicular chain, a dry ear for a period of at least 1 month, and normal middle ear mucosa were included in the study. Finally, 48 patients in the fascia group and 44 patients in the cartilage group were reviewed for graft take, pre- and postoperative air-bone gaps, and pure-tone averages. MAIN OUTCOME MEASURES The functional results of cartilage and fascia in a homogeneous group of patients were analyzed. RESULTS The graft take rate was 89.6% for the fascia group and 93.2% for the cartilage group. Significant recovery was found in the postoperative pure-tone averages and air-bone gaps compared to preoperative thresholds in both the fascia and the cartilage group. Although there was no statistically significant difference between the two graft materials for graft take rates and mean pure-tone averages, cartilage allowed us to achieve slightly better functional results than fascia grafting. Furthermore, the difference between the two graft materials for air-bone gaps was significant postoperatively in favour of the cartilage. CONCLUSIONS Although one might expect some conductive hearing loss with cartilage owing to its thickness and rigidity, the hearing results of both methods are acceptable, with a slight statistical favouring of cartilage over fascia for air-bone gap measures.
Continuity of the incudostapedial joint: a novel prognostic factor in postoperative hearing outcomes in congenital aural atresia.
Dong Wook Kim, Jun Ho Lee, Jae-Jin Song, Hyun Chang, Yoon-Seok Choi, Jeong Hun Jang, Ji-hoon Kim, Seung Ha Oh, Sun O Chang
Department of Otorhinolaryngology, Seoul National University Hospital, Korea.
CONCLUSION Mean incudostapedial joint (ISJ) angulation of atretic ears was statistically wider than ISJ angulation of non-atretic ears. Postoperative hearing results in the narrow tympanoplasty type II (T2) subgroup were better than those in the wide T2 subgroup. In cases of abnormally wide ISJ angulation, we recommend that partial ossicular reconstruction (POR) be used as a surgical means of achieving hearing improvement. OBJECTIVE To report the results of ISJ angulation in patients with congenital aural atresia and its effects on postoperative hearing improvement. METHODS Patients undergoing canaloplasty with T2 (149 ears) and canaloplasty with POR (32 ears) were enrolled. The T2 group was dichotomized according to an ISJ cut-off of an angle of 120° into the 'narrow' T2 and 'wide' T2 subgroups. The pre- and postoperative air-bone gap (ABG) and ABG change were analyzed. RESULTS Mean ISJ angulation of non-atretic ears was 93.06 ± 13.21° and that of atretic ears in the T2 group was 118.39 ± 19.60° (p < 0.001). Mean short- and long-term postoperative ABGs were better in the narrow T2 subgroup than in the wide T2 subgroup (p = 0.01 and 0.03, respectively). The short-term postoperative ABG and ABG change in the POR showed superior results to those of the wide T2 subgroup (p < 0.001 and 0.041, respectively).
Department of Otorhinolaryngology Clinic I, Izmir Ataturk Research and Training Hospital, Izmir, Turkey.
The objective of the study was to assess the functional results after type I tympanoplasty with temporal muscle fascia, perichondrium/cartilage island and cartilage palisades. The records of 120 patients who underwent type I tympanoplasty operation between January 2003 and June 2007 were retrospectively reviewed. This study aimed to comprise a homogeneous group of patients to make the comparisons as accurate as possible. For this purpose, primary tympanoplasty cases with subtotal perforations, intact ossicular chain, dry ear for a period of at least 1 month, and normal middle ear mucosa were included in the study. Patients younger than 15 years of age and patients with cholesteatoma were excluded. Temporal muscle fascia was used in 67 (55.8%), perichondrium/cartilage island flap was used in 34 (28.3%), and cartilage palisades were used in 19 (15.8%) of the patients. Pre- and postoperative otoscopic examinations, pure-tone averages, and air-bone gaps were compared pre and postoperatively. Concerning all of the cases, the graft take rate was 85%(102/120). In the perichondrium/cartilage island flap group, the graft take rate was 97.7%, whereas the graft take rates for the fascia group and cartilage palisades group were 80.6 and 79.0%, respectively. In the perichondrium/cartilage island flap group, the pure-tone average was 36.36 dB, whereas the pure-tone averages for the fascia group and cartilage palisades group were 36.07 and 39.79 dB, preoperatively. The postoperative pure-tone averages were 24.54 dB fort he perichondrium/cartilage island flap group, 24.51 dB for the fascia group and 23.23 dB for the cartilage palisades group. Cartilage grafting is not only more enduring against infection and negative middle ear pressure but also it has low re-perforation rates on long-term follow-up. Thus, cartilage may be preferred more often for primary tympanoplasties with high graft rate and hearing improvement.
Department of Otolaryngology, Staedt, Kliniken Neuss, Neuss, Germany. email@example.com
Department of ENT Surgery, Southmead Hospital, Bristol, UK. firstname.lastname@example.org
J Craniofac Surg. 2010 Feb 24;: 20186074
From the Department of Otorhinolaryngology, Istanbul Education and Research Hospital, Istanbul, Turkey.
The ideal goals of chronic middle ear surgery should be the permanent removal of disease and the preservation of good hearing function. The postoperative outcome of hearing and the status of middle ear after canal wall-down tympanoplasty with primary ossiculoplasty were studied in 192 ears with chronic middle ear disease. Cholesteatoma was present in 121 (63.0%) of 192 cases; in the remaining 71 cases (27.0%), there was middle ear mucosa disease without cholesteatoma. The stapes superstructure was present in 142 (73.9%) of 192 cases. The results of preoperative and postoperative pure-tone averages were 55.12 (SD, 4.92) and 35.81 (SD, 4.84) dB, respectively. The preoperative and postoperative air-bone gaps in 192 cases were 32.70 (SD, 5.18) and 21.16 (SD, 5.09) dB, respectively. The mean hearing gain of the 192 ears was 19.17 (SD, 6.09) dB. The presence of stapes superstructure positively affects hearing status. Also, better hearing results were obtained in cholesteatoma cases presented. Recurrences of disease were seen rarely compared with literature. It was revealed that the postoperative outcome of primary canal wall-down tympanoplasty with ossicular chain reconstruction is suitable for safe ear and hearing ear.
Am J Otolaryngol. ;31 (4):235-40 20015752
University of Miami Miller School of Medicine, Miami, FL, USA.
OBJECTIVE The purpose of this study is to identify prognostic factors affecting outcome in ossicular chain reconstruction (OCR). STUDY DESIGN AND SETTING This study is a retrospective case series of electronic database at an academic institution. MATERIALS AND METHODS We reviewed 209 cases of chronic supportive otitis media performed from January 2000 through December 2007 and collected demographic, clinical, audiologic, and outcome information. Univariate analyses of group differences in terms of postoperative air-bone gap (ABG) changes were evaluated by analysis of variance. Multiple regression analyses were used to examine the relationship between postoperative ABG and the independent variables. RESULTS There were 105 cases of OCR the met the inclusion criteria (44 primary and 61 revision tympanoplasties), with an average follow-up of 19 months. The diagnoses were chronic suppurative otitis media without cholesteatoma in 36 cases and cholesteatoma in 69 cases. The mean preoperative ABG was 34 +/- 15 dB, and the mean postoperative ABG was 20 +/- 14 dB (P < 0.001). Of the independent variables analyzed, the type of procedure (ie, OCR performed during second-look tympanoplasty vs canal wall up vs canal wall down), preoperative ABG, and status of malleus handle were predictive of the success of OCR. CONCLUSIONS Favorable prognostic factors in OCR include smaller preoperative ABG and the presence of an intact malleus handle.