C. Y. Joseph Chang

Efficacy of steroid injection on idiopathic sudden sensorineural hearing loss

Objective To evaluate the effectiveness of transtympanic steroid injection on patients with idiopathic sudden sensorineural hearing loss compared with patients who receive oral steroids alone. Study Design Retrospective chart review. Methods Patients with a history of ISSNHL and failed oral steroid therapy were included. Audiograms were performed and patients were included if SNHL of more than 20 dB occurred over less than 72 hours. Patients who received transtympanic steroid injection were compared with those who received oral steroids alone. Results Sixty-one patients met inclusion criteria and were included in the study. The number of patients with improvement in pure tone average in the injection group was 9 (30%) compared with 5 (17%) in the oral group. Twelve (38.7%) of the injected patients did have improvement in speech discrimination scores of greater than 15% compared with only 3 (10%) in the oral steroid group. Conclusion Our study revealed that patients with ISSNHL who have failed oral steroid therapy obtain better hearing results with transtympanic steroids in comparison to oral steroids. EBM rating: B-3b

Meningiomas presenting in the temporal bone: the pathways of spread from an intracranial site of origin.

Meningiomas comprise approximately 18% of all intracranial neoplasms. They are thought to arise from arachnoid granulations that are most commonly found along the major venous sinuses, cranial nerve foramina, and exits of spinal nerve roots. The growth rate of these tumors is generally slow, and patients can remain asymptomatic for many years until the tumor either enlarges to the point of causing significant brain or brainstem compression, or extends extracranially to sites such as the middle ear or neck. Meningiomas presenting within the temporal bone are rare, and only 77 cases have been reported since 1886. Meningiomas presenting within the middle ear or mastoid have numerous potential sites of origin. Secondary middle ear meningiomas are the most common form, and are defined as either intracranial tumors or tumors arising within a neural foramen, with extension into the middle ear cleft. Primary middle ear meningiomas are thought to arise from nests of ectopic, extracranial cells of origin. Another potential type is an intratemporal metastasis from an intracranial malignant meningioma, but we are unaware of any reports of this entity. Although a handful of cases of primary middle ear or mastoid meningioma has been reported in the literature, most cases have been of the secondary variety. 1-19 Because the temporal bone component of an intracranial meningioma may be the only symptomatic site, magnetic resonance imaging (MRI) with gadolinium, the most sensitive imaging modality currently available to detect an intracranial component, should be used. With numerous reported cases, an alleged primary middle ear meningioma was eventually shown to have an intracranial origin.4,7,8,10,12-14,18In addition, without evaluation with an enhanced MRI, some of our own cases, each of which had an intracranial origin, could have been misinterpreted as primary intratemporal tumors. Intracranial meningiomas can extend into the middle ear or mastoid via four pathways: the tegmen tympani, posterior fossa plate, internal auditory canal (IAC), and jugular foramen. We present five cases of primarily intracranial meningiomas with extension into the temporal bone, each demonstrating a pathway by which meningiomas can penetrate into the middle ear or mastoid.

Pressed scar tissue for tympanic membrane grafting in revision tympanoplasty.

OBJECTIVE Compare the efficacy of pressed scar tissue grafts to standard fascia and areolar tissue grafts for use in tympanoplasty. STUDY DESIGN A retrospective review of a prospective computerized database of tympanoplasty and mastoid surgeries at an academic, tertiary care practice was performed. Search parameters were set to find all patients who underwent tympanoplasty with or without mastoidectomy with use of various grafting materials for repair of tympanic membrane perforation from 1996 to 2002. All ages were included. Patients with cholesteatoma at the time of surgery were excluded. The short-term graft take rate was evaluated at 30 to 90 days to identify any differences in results using the standard fascia and areolar grafts vs. pressed scar tissue grafts. Other parameters that may have an influence on outcome were analyzed including mastoidectomy, infection, perforation size, perforation location, age of patient, primary vs. revision surgery, number of previous surgeries, postauricular vs. transcanal approaches, and medial vs. lateral grafting techniques. Hearing results were analyzed to see whether the use of scar tissue grafts resulted in equivalent outcomes compared to standard graft materials. RESULTS: There were no statistically significant differences in short-term tympanic membrane closure rates in subjects undergoing surgery using standard fascia/areolar tissue grafts and pressed scar tissue grafts. Hearing results were also statistically equivalent regardless of graft material used. The only parameter that was somewhat associated with successful closure of tympanic perforation was use of the postauricular approach compared to the transcanal approach. CONCLUSIONS Pressed scar tissue grafts are as efficacious as standard fascia and areolar tissue grafts when used to repair tympanic membrane perforations. Pressed scar tissue graft can be used successfully in cases such as revision tympanoplasty when standard tissue grafts are not available or difficult to obtain. EBM rating: B-3.

Aberrant carotid artery of the middle ear.

An 11-year-old girl had right conductive hearing loss and a mass on the tympanic membrane. She underwent exploratory tympanotomy, at which time the mass was noted to be on the promontory. This mass was not disturbed. A biopsy away from the mass near the incudostapedial joint was performed, and the ear was closed. The pathology report showed the presence of cholesteatoma. Two months later, she underwent a CT scan of the temporal bone, but the scans did not provide enough detail to allow a definitive diagnosis. The patient was then referred to our institution. The patient reported right hearing loss of several years’ duration. She had no history of tinnitus, vertigo, aural pressure, or otorrhea. Examination revealed a nonpulsatile, reddish mass behind an intact tympanic membrane on the right (Fig 1). A high-resolution CT scan of the temporal bones was obtained. This revealed an absence of the carotid foramen on the right. There was a vessel in communication with the horizontal petrous portion of the right internal carotid artery (ICA), which coursed along the promontory just inferior to the semicanal of the tensor tympani and proceeded inferiorly just anterior to the oval and round window niches. There appeared to be a thin bony covering over this vessel on the promontory. This vessel ended up in a small foramen just anterior to the jugular bulb and appeared to enter the jugular foramen near the pars nervosa. No angiograms were performed.

Effect of verapamil on cholesteatoma migration in vitro

OBJECTIVES It was previously shown that cholesteatoma migration in vitro is influenced by the calcium concentration of the culture medium. This study was designed to determine whether the calcium channel blocker verapamil affects cholesteatoma migration in vitro. METHODS Cholesteatoma cells harvested from patients with chronic ear disease were grown in culture and were exposed to culture medium containing verapamil. The migration rate of the verapamil-exposed cells was compared with control rates. RESULTS Verapamil at 300 μg/L caused marked reduction in the rate of migration compared with control values. The migration rate returned to normal within 48 hours after verapamil was removed from the culture medium. Higher verapamil concentrations (500 μg/L) caused complete detachment of the epithelial cells from the substrate within 24 hours. CONCLUSION Our findings suggest that cholesteatoma migration in vitro is calcium channel dependent and can be reduced with calcium channel blockers such as verapamil. (Otolaryngol Head Neck Surg 2000;122:91–5.)

Migration of intradural epidermoid matrix: embryologic implications.

The migratory behavior of acquired cholesteatoma matrices (those arising from the tympanic membrane) has been described previously. This tissue is derived embryologically from the first branchial groove and represents the only migratory epithelium arising from the branchial groove system. If the matrix from a cerebellopontine angle (CPA) epidermoid tumor exhibits migratory behavior similar to that of acquired cholesteatomas, a first branchial groove site of origin for CPA epidermoids would be supported. Intradural CPA epidermoid cells were grown in a—minimum essential medium. The cultures were examined daily, and cell mass migration rates were measured. It was observed that intradural epidermoid tumor matrix harvested from the CPA exhibited migration in vitro. Its migratory properties were indistinguishable from those of acquired cholesteatomas, which are embryologically derived from the first branchial groove. These data support the theory that purely intradural epidermoids are derived from cells of the first branchial groove.

Stapedectomy Effects on Tinnitus Relationship of Change in Loudness to Change in Severity

Objective To relate poststapedectomy change in tinnitus loudness to change in tinnitus severity. Study Design Prospective, within-subjects. Setting A single otology and neurotology subspecialty referral practice. Subjects and Methods Forty-nine subjects undergoing stapedectomy completed the study between January 2012 and October 2013. Tinnitus instruments, audiometric data, and demographic information were collected prior to and 1 and 6 months after surgery. Tinnitus loudness was assessed using an 11-point (0 = none; 5 = conversation level; 10 = jet engine) visual analog scale, and severity was measured using the validated Tinnitus Functional Index. The relationship between change in tinnitus loudness and change in tinnitus severity was evaluated using linear regression and receiver operating characteristic (ROC) analyses. Results A linear regression model of change in tinnitus loudness averaged for both ears on a visual analog scale (ΔVASavg) versus change in Tinnitus Functional Index score (ΔTFI) showed a strong correlation (ΔTFI = 9.35 ×ΔVASavg; R = 0.64; P < .001). An ROC analysis identified ΔVASavg between 1.5 and 2.0 as the optimal threshold for predicting a clinically significant change in tinnitus severity (ΔTFI ≥ 13), with sensitivity and specificity of approximately 0.62 and a positive predictive value (PPV) of 0.64. Conclusion For poststapedectomy patients, a VAS loudness change by 1.5 to 2.0 points averaged for both ears in bilateral tinnitus or ~3 points in unilateral tinnitus has a PPV ~0.64 for a clinically significant change in tinnitus severity.

Cartilage Interposition Grafts in Ossicular Chain Reconstructions

Abstract Problem: Hydroxyapatite ossicular implants were designed to be placed directly on the tympanic membrane. The rate of prosthesis extrusion may be reduced by placing cartilage over the prosthesis head. This study evaluated the effects of cartilage interposition grafts in ossicular chain reconstructions (OCR) on hearing results, hearing stability, and prosthesis extrusion. Methods: Patients were identified using a prospective patient database containing all tympanoplasty and tympanomastoid surgeries performed by the senior author at an academic tertiary care practice. Patients who underwent OCR between June 1995 and June 2003 were analyzed. A retrospective chart review augmented data collected prospectively. Patients were stratified into those who underwent OCR with cartilage placed between the ossicular implant and the tympanic membrane and those who did not have cartilage placed. All ossicular implants were hydroxyapatite. The initial hearing results, hearing stability over time, and extrusion rates were analyzed. Results: A total of 243 cases of OCR were identified and analyzed. There were only 3 episodes of extrusion, and all of these extrusions occurred when there was no cartilage interposition. The short-term and long-term hearing results were similar whether or not a cartilage interposition graft was used. Hearing improvement after surgery was greater for those with larger preoperative conductive hearing loss. Hearing results were better for PORP reconstructions than for TORP cases. Conclusion: The use of cartilage grafts in OCR has a neutral effect on hearing results and hearing stability over time. The overall rate of hydroxyapatite prosthesis extrusion rate is low. The use of cartilage grafts could reduce the extrusion rates even further. Significance: In OCR, the use of cartilage grafts between the implant and tympanic membrane can lower the incidence of prosthesis extrusion. Cartilage interposition grafts in OCR do not decrease the hearing results and do not appear to have any effect on hearing stability over time. Support: None reported.