Recent advances in tympanoplasty have generally brought stable results of postoperative hearing. On the other hand, it is difficult to obtain improvement of postoperative hearing in cases of adhesive otitis media, chronic otitis media with cholesterol granuloma, or tympanosclerosis. In these special cases, the special considerations on combination of treatment is needed. Laterally located grafting at the primary stage operation and reconstruction of ossicular chain with tragal cartilage at the second stage operation are recommended for adhesive otitis media. For cholesterol granuloma otitis, combination of insertion of a ventilation tube in the eardrum and complete mastoidectomy with or without removal of the malleus head and the incus is effective as the surgical treatment. In general, the following points are important to prevent untoword problems in the postoperative hearing in, 1) local sterilization by non-toxic material to the inner ear, 2) use of a small chisel in atticotomy for prevention of inner ear damage caused by a touch of the rotating drill to the ossicles, 3) use of “slim columella” with a diameter less than 1mm, 4) a small fenestration on the foot plate of the stapes when a columella is put on it, 5) careful measurement of bone conduction before the operation when the opposite ear is involved.
Tympanoplasty was performed in one handred ears with tympanosclerosis during the period from 1987 to 1994 in our department. Surgical techniques for tympanosclerosis were presented on the representative cases. In the case with sclerotic tissue around the malleus, myringoplasty was performed after eradicating the tissue and a good postoperative hearing result was obtained. In the case with the sclerotic tissue around the incus and/or the stapes, the diseased tissue was eradicated following anterior attico-antrotomy and removal of the malleus head and the incus. Ossiculoplasty was performed following reconstruction of the ear canal using a mixture of temporal bone chips and pate. Good postoperative hearing result was obtained in most cases. Expected hearing gain was not obtained when the diseased tissue around the ossicles could not be removed completely. In the case with stapes foot plate fixation, small fenestra stapedectomy was performed in the second stage of the staged operation.
The surgical cases of adhesive otitis media (AdOM) were more uncommon (3.8%) than those of chronic otitis media (28%), cholesteatoma (20%) and the postoperative chronic otitis media (23%). Tympanoplasty of AdOM is one of the most difficult surgeries to obtain satisfactory hearing improvement. Missing ossicular continuity, loss of ossicules, hardness of ossicular reconstruction, postoperative re-adhesion and inflammation of the tympanic membrane are common in AdOM. Postoperative hearing results of forty-five ears with AdOM, treated at Niigata University Hospital between 1982 and 1992, were examined. The hearing level of speech frequencies (pure-tone average of 500Hz, 1000Hz and 2000Hz) improved by 6.4dB from 51dB to 46dB (p<0.01). An airbone gap closure of less than 20 dB was achieved in 51% of 23 ears. Tympanoplasty for AdOM is indicated in cases of recurrent otorrhea, deteriorating sensorineural hearing loss and progression to cholesteatoma. In elevating the adhesive tympanic membrane, every possible precaution should be taken to preserve squamous epithelium and mucosa. The tensor tympani tendon was cut to widen the middle ear cleft. Mastoid obliteration and ventilation tube insertion were performed to insure postoperative middle ear aeration and healing.
Cholesterin granuloma of the middle ear is one of the middle ear diseases difficult to be cured. At times, this disease could involve the inner ear resulting in sensorineural hearing loss, vertigo and facial palsy. Therefore, when the conservative treatment is not effective to suppress inflammation caused by granuloma, a surgical approach is recommended. Since 1991, we have applied atticoantrotomy along with tympanoplasty for the surgical treatment of cholesterin granuloma. The mastoid cavity is usually left wide open. This approach enables us to observe easily the cavity, and to perform an appropriate cleaning, if necessary, at the outpatient clinic. The final goal of the surgery would be to obtain pneumatization of the middle ear cavity. Therefore, we generally insert an elastic silicone tube through the Eustachian tube to ventilate the middle ear cavity. We do not attempt to remove granuloma adjacent to the stapes. Should the granuloma remained, a second operation is performed after the sufficient control of inflammation with the use of a tympanic tube.
Countermeasures against readhesion of the new ear drum after tympanoplasty in adhesive otitis are discussed. In 92 cases of adhesive otitis media, nine countermeasures were used: 1) no special procedure but separation of limitted adesion, 2) insertion of Gelfilm sheets, 3) insertion of Silicon paste, 4) transplant of mastoid antrum mucosa, 5) cartilage plate, 6) intentional lateral healing of new ear drum, 7) insertion of Gelfoam, 8) transplant of nasal mucosa, 9) total removal of ear drum and myringoplasty after mucosa regerenation. The favorable result was obtaind in the following order; transplant of antrum mucosa, cartilage plate, Gelfoam, Gelfilm, and Silicon paste, intentional laterale healing. Surgical procedure of transplantation of mastoid antrum mucosa was reported. A special case, in which hearing was improved after 6 times of tympanoplasty in only hearing ear was reported.
Adhesive otitis media is often accompanied by tubal dysfunction and pathological changes in the tympanic orifice of the eustachian tube, and the postoperative ear drum re-formation tends to undergo re-adhesion. Hence, it is not easy to reconstruct the tympanic cavity with good pneumatization. Moreover, due to proliferation of granulation around the auditory ossicles and others, mobility of the ossicles is impaired, resulting in poor hearing results. For these reasons, the purpose of tympanoplasty is not achieved in many cases. In the past, the improvement rate in cases with total adhesion was poor for a value of 46.4%. Today, in treatment of such cases with total adhesion of the ear drum, a transmeatal approach is employed without performing mastoidectomy. And we now employ a surgical method in which a ventilation tube is indwelled through fascia graft during tympanoplasty. A silicone sheet is inserted in some cases. When the cases were analyzed at least a half year postoperatively, and those cases showing no depression or adhesion of the reconstructed ear drum and maintaining good morphology accounted for about 70% of all cases. However, re-adhesion was observed in some cases. There was a tendency that many of these cases was in the group with poor eustachian tube function. Even though the above method was employed, postoperative hearing ability still remained at poor rate of 55%. One reason for this poor result was thought to be as follows. In operation of adhesive otitis media, bone surface of the promontory of the tympanic cavity was widely exposed as the result of abrasion of the adherent ear drum. Consequently, postoperative epithelization of the middle ear cavity was prolonged, the ciliary function of the, middle ear mucosa was impaired, and gas exchange in the mucosa was delayed. Therefore mucosa of the inferior turbinate had better be grafeted in the case with extensively exposed bone surface in the middle ear cavity.
Hearing results of 51 ears with tympnaosclerosis were reviewed. Postoperative air-bone gap was less than 10dB in 34 ears (66.7%) and less than 20dB in 46 ears (90.2%). There was no statistical difference in hearing results between type I and type III tympanoplasty. There was statistical difference in hearing results between the eras with and without tympanosclerosis of the stapes. In cases of stapes fixation, the ears with stapedectomy tended to have better hearing results than those without stapedectomy. But there were only 7 ears of tympanosclerosis of stapes, and the experince is needed to further discuss whether stapedectomy is useful or not.
The results of a comparative study of long-term and short-term ventilation tubes for treatment of otitis media with effusion (OME) in children were reported. Koken tube type B®was applied as a long-term ventilation tube and the straight tube was applied as a short-term ventilation tube. The Koken tube type B®was inserted into 299 ears of 167 children and the straight tube was inserted into 139 ears of 100 children between 1984 and 1989. The average intubation period was 15.9 months in the long-term study and 3.9 months in the short-term study. The recurrence rate of OME after the extubation was 15% in long-term intubation and 52% in short-term intubation. Complications occurred such as otorrhea, granulation and tympanic membrane perforation in 29% of long-term and in 5% of short-term intubation. Despite the significantly higher rate of the complications in the long-term group, there was no difference of the complications occurring per month between the longterm group and the short-term group. It was concluded that the long-term ventilation tube had an advantage of lower recurrence rate without repetitive insertion for the treatment of OME in children.
Microtia with aural atresia accompanied with cholesteatoma is extremely rare condition. A 20-year-old female student with microtia in the right ear was treated surgically in total four times between 1981 and 1987. She was complaining of right otorrhea on September 21st 1993. The fruncle was found in the central portion of the reconstracted auricle in the right ear and did not respond to systemic antibiotics therapy. Then, CT and biopsy detected the existence of external autiory canal cholesteatoma in her right ear. The lesion was removed and no recurrence has been found to date.
The reflectivity and the angle obtained with an acoustic otoscope with a 201 recorder were assessed in different age groups to evaluate changes with patient age. While no significant changes in the reflectivity or the angle with age were found in normal ears, significant (p<0.01) differences in reflectivity and angle were observed in patients with middle ear effusion in all age groups. The results of this study suggested that data from the acoustic otoscope alone were insufficient to differentiate middle ear effusion from other middle ear disorders such as tympanosclerosis. Hence the acoustic otoscope should be used in conjunction with otoscope. Test-retest reliability for the reflectivity and the angle was excellent, and thus the acoustic otoscope was a reliable instrument. The acoustic otoscope was then compared with tympanometry. The tympanometric criterion for identifying middle ear effusion had very good sensitivity but poor specificity. The acoustic otoscope was often used as well as tympanometry for detection of middle ear effusion. In conclusion, the acoustic otoscope is useful as a supplemental tool in detecting or confirming the presence of middle ear effusion.
There have been several attempts to investigate the relationship between tinnitus and otoacoustic emissions. Although SOAEs were suggested to be an objective correlate of tonal tinnitus, such cases were generally proved to be very rare. Another possibility exists, however, that SOAEs and tinnitus could both be manifestations of a common underlying pathology and/or mechanism. On the other hand, there are few reports about the relationship between tinnitus and EOAEs, except the prolonged “oscillating” or “ringing” evoked emissions. Thus, in an effort to gather more data about the correlation between tinnitus and EOAEs, we investigated the change occurring in tinnitus and EOAEs after glycerol administration in Menere's disease patients. While we foung EOAE change in nine out of 15 patients with Meniere's disease (60%) whose tinnitus changed after glycerol administration, we discovered such change in four out of 30 patients (13.3%) whose tinnitus did not change following administration of this drug. This result suggests that there could be some relationship between the mechanism of tinnitus change and cochlear micromechanics.
A 45-year-old man complained of right complete hearing loss, right tinnitus and dizziness. At surgical procedure using translabyrinthine approach, tumors were observed in the utricle and the internal auditory canal (IAC). A bony partition between the vestibule and IAC was intact without tumor invasion. Enhanced MRI before the operation indicated isolated tumors in basal turn of the cochlea as well as in the vestibule and IAC. These data suggested that the neurilemomas had multiple origins and that they derived from the vestibule, cochlea, and IAC, respectively.
We performed histologic studies on the temporal bones of four patients who had lapsed into a state of brain death and became “respirator patients” of varying duration before the systemic (somatic) deaths. At autopsy, diffuse liquefaction necrosis of the brain, the last stage in the “respirator brain”, was noted in two of four cases in which the mass of cerebrum almost poured away from the base of the skull. Severe swelling and softening of the brain tissue were also observed in the other two cases and brain death was eventually confirmed pathologically in any of the four cases. Histologic examination of the temporal bones revealed fairly good morphologic preservation of the hair cell populations of the cochlear and vestibular sense organs as well as the cells of the stria vascularis and the cochlear and vestibular neurons in three of four cases. In one remaining case, the histologic details of the sensory epithelia could not clearly be identified because of severe postmortem autolysis. The autolytic change in this case wsa more advanced than that of specimens acquired during similar time lapses after death, including the findings observed in the other three cases. These histologic findings lead the following conclusions: 1) It is unlikely that autolytic change or so-called “in vivo autolysis” of the sensorineural structures in the inner ear could occur during the period of brain death before systemic death, as has recently been proposed by Kaga and his coworkers, since these strutures in the inner ear were histologically well preserved among the temporal bones that were acquired and fixed within a short period of time (2 to 4 hours postmortem), regardless of the duration of brain death or the extent of brain necrosis in each case. In other words, these findings might support the idea that an anterograde neural degeneration pattern (from central to peripheral direction) in the afferent nervous system is also unlikely, thereby indicating that measurement of the auditory brainstem responses for determining brain death in the respirator patients is valid as one of the adjunctive diagnostic criteria for this condition.2) It appears also evident that cases dying of such a specific disease process as brain death tended to show much greater postmortem change in the membranous labyrinth than in that of other case specimens that were removed during similar time lapses between death and fixation, indicating that, in addition to time delay from death to fixation and temperature, cause of death or specific dying process is another important determinant of the magnitude of postmortem alteration.
The patients with noises in the head were studied and compared with those who have monaural or binaural tinnitus. The subjects were 299 patients, from September 1993 to October 1994, with sensorineural hearing loss with tinnitus. They were divided into three groups. Group A: 20 (9 males and 11 females) patients with noises in the head. Group B: 70 (45 males and 25 females) patients with binaural tinnitus. Group C: 209 (96 males and 113 females) patients with monaural tinnitus. The results were as follows, 1) The mean age in group A was more than 10 years higher than that in group B and group C. 2) There was no difference in the average hearing level between three groups. 3) The audiograms in group A showed a high tone gradual loss more than those in group B and group C. 4) There was no significant difference in the mean age and average hearing level between group B and group C. As the results above, noises in the head were somewhat different from tinnitus and were often found in the elderly people. So it is likely that noises in the head have something with degenerative changes with aging.