Edward K. Gardner

Prognostic factors in ossiculoplasty: a statistical staging system.

Objective To determine factors that predict hearing results using a standard prosthesis system. Study Design Retrospective chart review. Setting Tertiary referral center. Patients All patients undergoing ossiculoplasty with the Dornhoffer HAPEX partial and total ossicular replacement prostheses (PORP and TORP) from February 1995 to May 1999 who had documented postoperative follow-up and no congenital atresia or stapes fixation. A total of 185 patients (200 ears), 105 men and 80 women, were evaluated. Interventions Ossiculoplasty with the Dornhoffer prostheses. Main Outcome Measures Hearing results using a four-frequency pure-tone average air–bone gap (PTA-ABG). Multivariate statistical analysis determined the effect of mucosal status, ossicular chain status, and type of reconstruction techniques on hearing. Results The PTA-ABGs were 13.4 ± 8.1 dB and 14.0 ± 8.4 dB for the PORPs (n = 114) and TORPs (n = 86), respectively, which was not statistically different. When the malleus handle was present (n = 126), the PTA-ABG was 11.6 ± 6.2 dB, compared with 16.9 ± 10.1 dB when it was absent (n = 74), which was statistically significant (p < 0.05). Mucosal fibrosis, drainage, revision ear surgery, and type of surgical procedure had a significant detrimental impact on hearing. The type of pathologic process (perforation vs. cholesteatoma) had no significant impact on hearing results. Conclusions The revised staging system, the Ossiculoplasty Outcome Parameter Staging Index, more adequately predicts hearing outcome in this series of 200 cases.

Revision Chronic Ear Surgery

OBJECTIVE: To report results of revision chronic ear surgery following guidelines of the American Academy of Otolaryngology–Head and Neck Surgery and to establish expectations for infection and cholesteatoma control and hearing outcomes. STUDY DESIGN: Retrospective case review of all patients who underwent revision chronic ear surgery from January 1, 1990 to December 31, 2000. Revision chronic ear surgery included canal wall up and canal wall down procedures with ossicular chain reconstruction performed as needed. Cholesteatoma control, hearing improvement, and closure of middle ear space are main outcome measures. SETTING: Tertiary referral center. RESULTS: Cholesteatoma recurrence rate was 57% at 1 year after surgery and 14% in patients with a minimum of a 5-year follow-up. Disease control was achieved in 96% of patients. Hearing was significantly improved in all surgical groups. Closure of the air-bone gap for revision partial ossicular replacement prosthesis cases (PORP) to less than 20 dB occurred in 50% of patients. Closure of the air-bone gap to within 30 dB for revision total ossicular replacement prosthesis (TORP) occurred in 60% of patients. Canal wall down status had a significant impact on hearing results after PORPs and TORPs; patients with intact canal walls had significantly better hearing results. Diagnosis of cholesteatoma significantly impacted hearing results for TORPs but not PORPS. CONCLUSIONS: Cholesteatoma control rates after revision surgery are similar to primary cases. Significant improvement in hearing can be expected after revision chronic ear surgery. Hearing results after a revision surgery that requires a PORP is worse than primary cases and is canal wall status dependant. Closure of the middle ear space and creation of a safe dry ear can be expected after revision chronic ear surgery. SIGNIFICANCE: This is a review of a large series of exclusively revision chronic ear surgery. EBM rating: C-4

Success of Cartilage Grafting in Revision Tympanoplasty Without Mastoidectomy

Objective: Candidates for revision tympanoplasty have experienced at least one failed attempt at repair of the tympanic membrane and are, therefore, at higher risk for subsequent repair failure. The adjunctive use of mastoidectomy with tympanoplasty in those patients with noncholesteatomatous chronic otitis media is often used to decrease the risk for subsequent failure. However, at this institution, where we use cartilage tympanoplasty, mastoidectomy is rarely performed in the absence of cholesteatoma. Our objective was to assess outcomes in patients undergoing revision tympanoplasty without mastoidectomy using cartilage grafting. Study Design: We conducted a retrospective case review. Setting: Tertiary referral center. Patients: A total of 95 patients (42 female, 53 male; 5–81 yr of age) with a recurrent perforation who were treated surgically with cartilage tympanoplasty without mastoidectomy were included in the chart review. Patients must have undergone at least one previous tympanoplasty without mastoidectomy and had to have complete audiologic and chart follow up. Interventions: An underlay tympanoplasty technique using either a tragal cartilage–perichondrium island graft or palisaded concha cymba cartilage was used. Ossiculoplasty was performed as needed. Main Outcome Measure: Main outcome measures were incidence of reperforation of the grafted tympanic membrane, hearing result, and prevalence of other complications. Results: Successful closure without reperforation was obtained in 90 of 95 patients (94.7%). Average postoperative pure-tone average air–bone gap was 12.2 ± 7.3 dB compared with 24.6 ± 13.8 dB preoperatively (p < 0.001). Conclusions: Revision tympanoplasty with cartilage provided equivalent results to tympanoplasty with mastoidectomy. Thus, mastoidectomy may not be necessary in revision tympanoplasty in the absence of cholesteatoma if the repair is made with cartilage.

Oncogenic osteomalacia caused by phosphaturic mesenchymal tumor of the temporal bone

Oncogenic osteomalacia is a clinical condition characterized by radiographic evidence of inadequate bone mineralization and biochemical abnormalities including hypophosphatemia, hyperphosphaturia, elvated alkaline phosphatase activity, and low or inappropriately normal circulating levels of 1,25-dihydoxyvitamin-D3. These findings occur in association with a usually benign tumor of soft tissue and bone, comprised of primitive-appearing mesenchymal cells, prominent vascularity, poorly formed cartilaginous areas often with dystrophic calcifications, and multinucleated osteoclast-like giant cells. Approximately 100 cases have been reported in the literature, and occur most commonly in the extremities and head and neck region, including mandible, sinuses, and nasopharynx. We report here a case of phosphaturic mesenchymal tumor of the temporal bone that was originally diagnosed as a glomus tumor, and underwent two previous resections. To our knowledge, this is the first reported case of this tumor in the temporal bone. A 46-year-old woman presented for evaluation of a recurrent left temporal bone lesion. In 1995 she developed pulsatile tinnitus in her left ear and vertigo, and MR and CT imaging showed a tumor eroding the left jugular foramen. The radiographic findings were consistent with a glomus jugulare tumor. She also complained of rib pain, which was attributed to pulled muscles secondary to her active lifestyle as an avid golfer and hunter. She underwent excision of this tumor in 1995 at another institution, and again in 1997, at the same institution, after a recurrence. Pathologic examination of tumor from both operations was reported as a glomus jugulare tumor, although areas of ossification were seen with multinucleated giant cells reported. She did well for several years until she developed fullness

Tympanoplasty results in patients with cleft palate: An age-and procedure-matched comparison of preliminary results with patients without cleft palate

OBJECTIVE: Because of continued eustachian tube abnormalities, the presence of a cleft palate repair has been thought to be associated with poor outcomes after tympanoplastic surgery. However, little published data exist regarding the results of major otologic surgery in patients with cleft palate. The objective of this study was to review our results of otologic surgery in these patients and compare results with those of age- and procedure-matched controls. METHODS: Our otologic database was used to identify patients with a repaired cleft palate who underwent otologic surgery between March 1994 and December 1999. Two control patients were identified for each cleft palate patient. Results of hearing, graft take, and need for postoperative pressure-equalizing tubes were compared. RESULTS: No significant difference existed between patients with a repaired cleft palate and control patients with regard to postoperative air-bone gap (P = 0.6805), graft survival rate (P = 1.00), and need for postoperative intubation (P = 0.457). CONCLUSION: Results in patients with cleft palate appear to be similar to those in patients without cleft palate.

Hearing results with a hydroxylapatite/titanium bell partial ossicular replacement prosthesis

Objectives/Hypothesis To study the preliminary hearing results in patients receiving a hybrid hydroxylapatite/titanium bell partial ossicular replacement prosthesis (PORP) and compare these with a cohort of patients receiving a HAPEX PORP. We hypothesized that the design of the hybrid PORP would enhance its acoustic properties. In particular, the titanium bell, which allows the prosthesis to be freestanding, would obviate the need for Gelfoam, preventing fibrosis.

Photoacoustic effects of carbon dioxide lasers in stapes surgery: quantification in a temporal bone model.

Hypothesis The use of the CO2 laser in stapes surgery creates sound waves that could damage hearing. Background The application of a laser to any medium has absorption, reflection, and thermal effects. To date, the majority of research on the safety of CO2 laser stapedotomy has focused on the thermal effects of the laser alone. Because of the properties of the CO2 laser, its absorption also presents some risk to the inner ear. This absorbed energy can be converted to photoacoustic or photochemical effects. The goal of this paper is to measure these photoacoustic effects (sounds) produced by the CO2 laser. Methods Using a variety of settings, a Sharplan 150 XJ Laser and a Contour model Erbium:YAG laser were applied to the oval window of human temporal bones. Perilymph was simulated by fixing the temporal bone in a normal saline bath. Photoacoustic waves were measured by a hydrophone 2 mm beneath the oval window. Measurements were made with and without a simulated tissue seal over the window. Results No detectable sounds were created below 4 watts (continuous mode) or 60 mJ (superpulse mode). Above those settings, intensities of 90 dB sound pressure level and higher were detected when the laser was applied directly to the perilymph. With the tissue seal in place, no detectable sounds were identified. The accuracy of this model was confirmed by comparing these results with previously published results using the Erbium:YAG laser. Conclusions Below 4 watts in continuous wave mode and below 60 mJ in superpulse mode, any sound generated by the laser is small. Above these thresholds, however, impact sounds are produced that could result in threshold shifts with repeated applications.

Preoperative appearance of facial muscles on magnetic resonance predicts final facial function after acoustic neuroma surgery.

Objective: Several previous studies have shown that muscle appearance on magnetic resonance is a sensitive indicator of muscle denervation. Previous attempts at determining preoperative indicators of final facial function after acoustic neuroma removal has been mostly unsuccessful. The goal of this study was to determine if the appearance of the facial muscles on preoperative imaging is predictive of final facial function after surgical removal of vestibular schwannomas. Study Design: We conducted a retrospective chart and magnetic resonance review. Setting: This study was conducted at a tertiary referral center. Patients: We included all patients who underwent vestibular schwannoma removal between January 1, 1997, and December 31, 2001, with available preoperative magnetic resonance images and a minimum of 12 months follow up. Interventions: We used translabyrinthine, middle fossa, and suboccipital approaches for tumor removal. A neuroradiologist, blinded to preoperative or final facial function after tumor removal, retrospectively reviewed preoperative magnetic resonance images. Main Outcomes Measures: Facial muscles were evaluated on magnetic resonance and classified as symmetric or asymmetric. Facial function was graded using the House-Brackmann scale. Preoperative facial function was noted on the preoperative physical examination. Final function was determined at least 12 months postoperatively. Results: A total of 247 patients underwent tumor removal during the study period. One hundred thirty-two patients had adequate preoperative magnetic resonance images. Patients with preoperative facial muscle asymmetry seen on preoperative magnetic resonance indicating muscle atrophy had significantly worse final facial function, regardless of tumor size. Conclusion: The preoperative appearance of facial muscles provides valuable insight into the physiology of the facial nerve in the presence of vestibular schwannomas. Patients with pre-operative facial muscle symmetry have significantly better facial function than those with atrophy.