The advantages and the hints and pitfalls of the canal wall down tympanoplasty for the acquired middle ear cholesteatoma were elaborated. The canal wall down tympanoplasty is a safe procedure for an ear having a risk factor for reformation of the retraction pocket of the tympanic membrane, especially for those with sniffing habit caused by insufficient closure of the eustachian tube. The mastoidectomy should be performed in a manner to saucerize the cortical bone and the tegmental border to expose the dural plate to ensure the complete removal of the cholesteatoma matrix and the pneumatic cells in this area. The horizontal portion of the facial nerve should be identified before taking down the posterior canal wall to prevent the injury to the facial nerve. The entrance of the external auditory meatus should be enlarged by removing a portion of the conchal cartilage to support the self-cleansing and the ventilation of the created cavity. In an ear with relatively good pneumatisation of the mastoid, the mastoid tip and the anterior end of the attic should be obliterated using a piece of cartilage or soft tissue materials, such as pedicled fascial flap or musculo-periosteal flap.
There are professional otologists in 126 college affiliated hospitals and large hospitals. These hospitals are distributed in the large cities all over China. The treatment of otological diseases was relatively confined to these cities. There are obvious differences in terms of level of clinical services provided and the equipment available in these hospitals. Every year patients with otological diseases account for 20.2%(275/1360) of all inpatients in the First Affiliated Hospital of China Medical University. Chronic simple suppurative otitis media and cholesteatoma represented 66.6% of all otological diseases. It implied that chronic suppurative otitis media was still the main disease of surgical treatment in otology. Attic cholesteatoma accounted for 66.5%; adhesion cholesteatoma accounted for 33.5%, the latter being associated with high morbidity of secretory otitis media and inadequate treatment. Morbidity of intracranial complications was 2%. Patients without intracranial complications were given Stage 1 or 2 tympanoplasty. There are 17, 700, 000 people with hearing disabilities in China. Hearing aids are widely used. Patients who had multi channel artificial cochlea implantation were very very few. High cost is the main obstacle to this technique. Aminoglycoside induced deafness was very rare. People will rather gradually pay much more attention to anti-cancer drugs induced sensorineural deafness.
Recently, low vacuum scanning electron microscope (nSEM) and scanning probe microscope (SPM) had been developed in order to avoid even slight changes in tissue. Employing this new technique, any process of treatment of the specimen is unnecessary, and contamination of artifact is considered to be minimum. The tectorial membrane is particularly known as soft tissue that easily sustains a damage under the process of preparation and fixation. The authors used untreated specimen (normal 15 guinea pigs 30 ears) and examined the tectorial membrane using nSEM and SPM. And also analyzed the surface of tectorial membrane using dispersion-typeαwave analyzer. The results are as follows, 1. The limbal zone of the tectorial membrane was observed as a meshed-like appearance (limbal net) and a structure of pillar was identified lying under it. 2. Covering net in the middle zone was not observed by nSEM, however, under the method of SPM it was detected morphologically and moisture was also content between the fibers of it. This may suggest amorphous substance that covers surface of the tectorial membrane, however, it seemed inconsistent. 3. Former studies reported the marginal zone as a band and ends free, however, it was observed as a pillar structure (marginal pillar) and was tightly attached to the surface of Hensen's cell both by nSEM and SPM. Strand-like substance was observed in the marginal hole by nSEM. The fibers were not confirmed under SPM, however, moisture was detected here. An unknown substance was considered to exist in the subtectorial membrane space. 4. The result of above was found through all turns of the cochlea. 5. The analysis using dispersion-typeαwave analyzer in three different portions of the tectorial membrane (limbal, middle, and the marginal zone) confirmed that there was no difference between each point, however, in comparison between the untreated specimen and treated tissue, a difference of composition in magnesium, potassium, sodium, phosphorus, sulfur and osmium was noticed. This difference was considered to be due to the treatment of the specimen and in addition, the existence of amorphous substance covering the surface of the tectorial membrane may be suggested. The authors also considered the function of new structures that have been found in this study.
Abnormal perilymph pressure (P. P.) has not been considered as a possible cause of sensorineural hearing loss compared with endolymphatic hydrops. This may mainly be due to the fact 1) that a method to measure or estimate P. P. is not available, 2) that there are few cases with sensorineural hearing loss suggesting abnormal P. P. However, considering that the membrane structure of the cochlea, and the cochlear function depends on electrolyte components in endo-and peri-lymph, it is possible to assume that the abnormal P. P. may cause sensorineural deafness. In this report, sensorineural hearing loss which may be caused by the abnormal P. P. was described and discussed.
Type III and modified type III tympanoplasties were performed in 87 ears in our department for 6 years. Successful hearing result in 87 ears was obtained in 79.3%, but postoperative hearing result less than 30dB was observed in only 22 ears. No significant difference in hearing results between chronic otitis media with and without cholesteatoma. Auricular cartilage was used for reconstruction of ossicular chain in 65 ears, and the hearing result was less than 80%. Ossicles were selected for the reconstruction in 15 ears, and successful hearing gain was observed in 14 ears.
We reported postoperative hearing results of 96 ears operated on by tympanoplasty type III with columella and 63 ears by type IV with columella between April 1994 and March 1999. The hearing result was considered as successful when the postoperative hearing level satisfied with at least one of three conditions as follows: 1) air-bone gap less than 15dB, 2) hearing gain more than 15dB, or 3) hearing level above 30dB. Success rates were 67.7% for type III and 58. 7% for type IV. Hearing results were analyzed according to preoperative bone conduction thresholds (≤30dB or>30dB), underlying diseases, prosthesis, staged procedure for cholesteatoma (one stage or two stage), and reconstruction methods of the external auditory canal for cholesteatoma.
We examined bacteria in aural discharge before and after surgery in 130 ears of 122 patients with chronic otitis media from 1997 to 1999. These ears consisted of 28 ears with cholesteatoma, 62 ears with chronic supprative otitis media (CSOM), and 40 ears with postoperative CSOM. Preoperatively, pathogenic bacteria were detected in 77.7% of all ears. Coagulasenegative staphylococci and gram positive rods were found most frequently.P. aeruginosawas isolated in 13 ears and MRSA in 3 ears. Postoperatively, bacteria were isolated in 47.7% of all ears, most frequently in ears with postoperative CSOM. Change of microbial flora was found in approximately 30% of ears with coagulase negative staphylococci and gram positive rods. These bacteria disappeared, but compromised pathogens appeared postoperatively. The majority of ears with infection ofP. aeruginosaand MRSA became uninfected 3 months after surgery. In ears with postoperative CSOM, two types of surgery were performed: total middle ear reconstruction and tympanoplasty without middle ear reconstruction. Bacteria were found in more than half ears of the two groups postoperatively, although almost all the cases in these groups became uninfected one year after surgery.
A 22-year-old male, complained of left hearing loss 4 months after head injury. CT scan revealed that the left external ear canal was totally obstructed with a soft tissue mass. Cholesteatoma existed medial to the connective tissue of the external ear canal during surgery. A 31-year-old female, complaining of pain and hearing loss in the left ear, had a history of traffic accident 13years ago. She had received left ear surgery twice. CT scan showed soft tissue in the external auditory canal, the middle ear, and the mastoid air cells. The inferior wall of the external ear canal was destructed. In both cases, cholesteatoma and scar in the ear canal were removed, and free skin graft was placed to cover the bony wall. Ear canal has been kept widely open and hearing was significantly improved.