Ahmet Mutlu

An Unusual Presentation of Gout: Tophi in the Middle Ear.

Gout is a common metabolic disease and is characterized by episodic acute and chronic arthritis caused by the deposition of monosodium urate (MSU) crystals in joints and connective tissues. The most commonly involved joint is the first metatarsophalangeal joint. It may also present with nonspecific complaints caused by gouty tophi in unusual sites of the body such as the spine, bone, and middle ear. Such involvements can be disabling and impair the quality of life. In this report, we describe the case of a patient who had complaints of hearing loss and otorrhea. A 34 year-old male patient presented with complaints of recurrent otorrhea and hearing loss for several months. He had no history of joint pain or constitutional symptoms at the time of admission. An otoscopic examination of the left ear revealed subtotal tympanic membrane perforation, and white middle ear plaques were detected. The patient underwent intact canal mastoidectomy under general anesthesia, and middle ear sclerosis was determined as Wieling Kerr classification type 2. Postoperative histopathologic examination of the specimen revealed amorphous eosinophilic deposits within fibrous stroma and tophi containing negatively birefringent MSU crystals by polarized light. After the histopathologic diagnosis of gout, the patient was assessed for peripheral joint involvement. He had no radiographic abnormalities. The patient was administered a serum urate-lowering therapy, given a low purine diet, and followed with the diagnosis of tophaceous gout. Unusual localizations of gouty tophi have been reported in the literature. Gouty tophi should also be considered in the differential diagnosis of middle ear masses alongside common pathologies.

The protective effect of adrenocorticotropic hormone treatment against noise-induced hearing loss

OBJECTIVE NIHL is a common problem, and steroids are the most effective treatment option. In this study, we aimed to evaluate the protective effects of the synthetic adrenocorticotropic hormone (ACTH) analogues, which induce endogenous steroid secretion, against noise-induced hearing loss (NIHL) and to compare their effectiveness with that of steroid treatment. METHODS Twenty-four male Sprague-Dawley albino rats were divided into four subgroups as follows: group 1 (n=6) control, group 2 (n=6) saline, group 3 (n=6) dexamethasone (2mg/kg/day intramuscularly [IM]), group 4 (n=6) ACTH analogue (0,4mg/kg/day IM), respectively. Three groups (groups 2-4) were exposed to white noise (105dB SPL, 12h). All the rats were evaluated for hearing thresholds of 10kHz, 20kHz, and 32kHz via acoustic brainstem responses (ABR) measurement. After the basal threshold measurements, measurements were repeated immediately after the noise and on day 7 and day 21. RESULTS Both steroid and ACTH analogue groups showed significantly better hearing outcomes than the saline group on day 7 (p<0.001) and day 21 (p<0.001) after the noise exposure. No superior treatment effect was demonstrated in either the steroid or ACTH analogue group. None of the related intervention groups reached the basal hearing thresholds. CONCLUSION Steroids were effective drugs for the treatment of NIHL. ACTH analogues also demonstrated promising therapeutic effects for NIHL. Further studies to establish ACTH analogues as an alternative NIHL treatment option to steroids are needed.

A Comparison Study of Partial Ossicular Reconstruction Prosthesis (PORP) Placement under the Malleus or Tympanic Membrane Graft in the Presence of the Malleus

OBJECTIVE The aim of this study was to compare the hearing results of embedding the partial ossicular reconstruction prosthesis (PORP) underneath the malleus with the malleus relocation technique and tympanic membrane graft in the presence of the malleus. MATERIALS AND METHODS A retrospective review of patient charts and audiometric results in a tertiary referral center was conducted. In total, 83 patients who underwent intact canal tympanoplasty with mastoidectomy between 2010 and 2015 were included and divided into two different groups: malleus assembly to the stapes head (MASH) and tympanic membrane assembly to the stapes head (TASH). Pre- and postoperative audiometric results were assessed. The air-bone gap (ABG) and hearing gains were evaluated according to the groups. RESULTS In MASH, 86.1% (n=31) of the patients were received successful surgery and the postoperative average ABG was 10.41 dB. In TASH, 82.9% (n=39) of the patients were considered successful and the postoperative ABG was 13.27 dB. According to the overall data, MASH was more statistically successful than TASH, and hearing gains at 500 Hz (p<0.036), 2000 Hz (p<0.031), and PTA (p<0.22) were statistically significant better in the MASH group. CONCLUSION Malleus relocation is a successful technique with the presence of the malleus and provides better hearing outcomes than direct placement under the tympanomeatal flap. Both malleus- and tympanomeatal flap-linked groups were successful, but the malleus-linked group showed better ABGs.

Doppler ultrasonography can be useful to determine the etiology of idiopathic sudden sensorineural hearing loss

OBJECTIVE This study aims to evaluate clinical features of both carotid and vertebral arteries in the idiopathic sudden sensorineural hearing loss (ISSNHL) patients and healthy individuals to contribute additional knowledge on vascular compromise theory. METHODS This study was designed as a retrospective case control study in a tertiary referral center. 55 patients for ISSNHL and 35 healthy participants (70 ears) are involved to the study. All of the patients were evaluated for the systemic disorders and excluded other possible causes (autoimmune diseases, acoustic schwannoma, drug toxicity, etc) of ISSNHL. The carotid and vertebral arteries were assessed with Doppler USG; in fact, the vascular diameter (VD), intima media thickness (IMT), peak systolic velocity (PSV), blood flow (BF) and resistive index (RI) were evaluated. Related parameters were compared with the control groups. RESULTS In carotid artery system; common carotid artery intima-media thickness (CC-IMT) (p<0.001), and internal carotid artery intima-media thickness (IC-IMT) (p<0.001) were found significantly increased. Otherwise; PSV, VD and BF were not differed significantly. In vertebral artery system; VD (<0.001), PSV (<0.002) and BF (<0.001) were decreased significantly but vertebral artery RI was statistically increased (<0.001). CONCLUSION In our study, we found the carotid artery thickening on vascular wall. We also demonstrate the vascular compromise on vertebral arteries. The Doppler USG may lead to determine the etiology of ISSNHL and further investigations are needed to define the exact results. LEVEL OF EVIDENCE III b.

A Simple Closure Technic for Tracheoesophageal Puncture Failures

AbstractTracheosephageal puncture is the one of the most favorable methods, and widely used by physicians for voice reconstruction after total laryngectomy. Intractable leakages from the tracheosephageal punctures are the most common complication, and management of these fistulas is still troublesome for the patients and physicians. Local surgical sutures, rotational flaps, injections are reported previously, but in this report the authors aimed to mention on a very simple method with silicone septal button. Insertion of a temporary silicone septal button may be well tolerated by patients and can help to manage this complication easily on exact indications. The authors discussed indications and long-term results of this method with different patients.

Superglue (Cyanoacrylate) Drop in Perforated Tympanic Membrane

We present an unusual case of a 37-year-old womanwith normal intelligence who used superglue (cyanoacrylate) as aneardrop into her perforated tympanic membrane and her treatment.The37-year-oldwomanwithnormal intelligenceappliedear noseand throat clinic with pain and obstruction of the right external audi-tory canal via a white rubberlike material was dropped into the earas an eardrop (Fig. 1). No bleeding was detected. Earlier to this com-pliant, she experienced right ear otomycosis and a central perforationof the tympanic membrane. Otomycosis was treated by 1% ofciclopirox olamine solution. The patient accidentally instilled cya-noacrylate drop and waited for 5 minutes in supine position. Shehad not realized misusing until feeling the rubberlike material onher ear. On her first application, she was hospitalized to reveal thedepth of the glue. Considering the possibility of damaging the tym-panicmembrane,somepart of the rubberlike materialwas removedgently usingcurettewithotomicroscopy. Obstructionof the tympanicmembrane andbase oftheexternal auditorycanalwas observed byexpansionoftheforeignbody.Ontherightside,amoderatemixed-type hearing loss was detected on pure tone audiometry (air, right[R] = 63 dB and left [L] = 21 dB; bone, R = 31 dB and L = 20 dB).Computerized tomography was performed to see the connection be-tween the glue and the middle ear bone structures and to determinepossible accompanying pathologies.The superglue foreign body could not be removed under localanesthesia; therefore, anexploratorytympanoplasty in generalanes-thesia was planned and performed. After the removal of a piece ofdried rubberlike glue material from the outer ear canal, we testedwhether these removed materials would dissolve in the acetone so-lution invitro and observed that theydid not dissolve in 30 minutes.Wethoughtthattheacetonesolutionwillnothelpustodissolveandre-move the glue, and also, the acetone may have toxicity on the cochleaand vestibulocochlear nerve; thus, we decided not to use the solution.Instead, we decided to remove the superglue foreign body by drillingand removing it piecemeal. The whole foreign body was separatedand removed from the external ear canal and tympanic membrane witha little part of it. After the removal of the part of tympanic membrane,surroundingglueonthelongcrusoftheincusandontheheadandneckof the stapes is revealed. Influenced parts of the bones are resected. Inaddition, fixation of the stapes footplate to ovalwindow was observed.Hearingreconstructionofthebonefixationwasleftforthesecondlookin case of the ototoxicity, and the operation ended with the tympano-plasty with temporal muscle fascia.In the 10-week follow-up with no complaint, the oto-microscopicexamination showed that the tympanoplasty graft was intact, andhearing was detected using pure tone audiometer (L, 23 dB; R, 35dB; mild mixed-type hearing loss, bone, 23 dB). At 24 weeks, controlsecond-look hearing reconstruction operation is discussed with the pa-tient and then refused by the patient.Cyanoacrylateisaveryeffectiveglueandcanstronglybondtosofttissue as well. It may be difficult for surgeons to remove the adheredmaterial from the epithelia of outer ear canal, tympanic membrane,and middle ear structures in case of destruction risk of vital parts.