Heikki Puhakka

Epidemiology and Aetiology of Middle Ear Cholesteatoma

A total of 500 patients with cholesteatoma diagnosed and operated during 1982-91 in the region of Tampere University Hospital and Mikkeli Central Hospital in Finland were analysed retrospectively. The mean annual incidence was 9.2 per 100,000 inhabitants (range 3.7-13.9) and during the study period the annual incidence decreased significantly. The incidence was higher among males under the age of 50 years. There was no accumulation of cholesteatoma diseases in lower social groups. The majority (72.4%) of cholesteatoma patients had suffered from otitis media episodes. Tympanostomy was carried out in 10.2% and adenoidectomy or adenotonsillectomy in 15.9% of all cholesteatoma ears prior to cholesteatoma surgery. Cholesteatoma behind an intact tympanic membrane with no history of otitis media was verified in 0.6% of patients and in cleft palate patients in 8%. In this study, 13.2% of patients had ear trauma or ear operation in anamnes.

Diagnostic value of tympanometry in infants in clinical practice

One hundred and twenty-one visits of 58 infants (2-11 months of age) were evaluated in the Finnish Otitis Media Vaccine Trial. Infants were examined with tympanometry (Grason-Stadler GSI 38 Autotymp) and pneumatic otoscopy by one study doctor. Diagnosis of otitis media was verified by myringotomy in 74% of cases. Tympanometry was technically successful in 94% of ears. The success rate was statistically significantly higher (P < 0.05) among infants less than 7 months of age than those above 7 months. The sensitivity of tympanometry (type B) to detect ears with middle ear fluid was 0.70 and the specificity 0.98 with a positive predictive value of 0.93 and negative predictive value of 0.94. The sensitivity was somewhat lower in the younger age group (0.61); specificity and positive and negative predictive values were good in both age groups. The high success rate and high negative and positive predictive values of tympanometry make it a useful aid for assuring the correct diagnosis of otitis media in infants in routine clinical practice.

Short-term use of amoxicillin-clavulanate during upper respiratory tract infection for prevention of acute otitis media☆☆☆★★★♢

We performed a randomized, double-blind, placebo-controlled study to determine whether acute otitis media could be prevented by antibiotic therapy initiated promptly after the appearance of symptoms of upper respiratory tract infection. One hundred four children aged 1 to 4 years received a 7-day course of either amoxicillin-clavulanate or placebo. Acute otitis media developed in 9 (18%) of the 50 children receiving amoxicillin clavulanate and in 12 (22%) of the 54 children receiving placebo (p = 0.59).

Rhinovirus in Otitis Media with Effusion

We studied rhinovirus in the middle ear fluid of 61 children with subacute or chronic otitis media with effusion. Rhinovirus was recovered from the middle ear fluid of 5 children with subacute otitis media with effusion. The minimum duration of effusion was 32 to 60 days. Additionally, 1 patient had middle ear fluid that was positive for adenovirus. Bacterial pathogens were cultured from the middle ear fluid of 20 of 61 patients. Our finding that rhinovirus can be isolated from middle ear fluid after an asymptomatic period of several weeks suggests its possible role in the development of otitis media with effusion.

Myringotomy in the Treatment of Acute Otitis Media in Children

The treatment of acute otitis media was studied in 158 children. All children (mean age 4 years) received penicillin orally 80 000--100 000 IU per day for 10 days. Myringotomy was performed on 68 children at the time of the diagnosis. The other 90 children were treated with penicillin and ear drops. The bacteriological findings from the nasopharynx at the time of diagnosis were equivalent in both groups. After 2 weeks, 42% of the children without myringotomy and 71% of the children with myringotomy were cured. The children who were not cured were treated with amoxicillin for 10 days. Four weeks after diagnosis 71% and 90% of the children respectively were cured. The differences between the two groups are significant. The observations indicate that myringotomy clearly accelerates the recovery from acute otitis media.

Globus hystericus: globus syndrome?

In a double-blind study, 22 patients with typical globus symptoms were investigated by both otolaryngological and odontological methods. All the patients underwent thorough hematological, endoscopic and radiological examinations. They were randomly divided into a treatment group and a placebo group and underwent either simple occlusal adjust or mock adjustment, respectively. The result of occlusal adjustment was assessed immediately after completion of treatment. The effect of treatment on globus symptoms was assessed 2 to 3 months later in a double-blind study. Binomial tests showed that there was a significant association between the success of occlusal adjustment and disappearance of the globus symptom. A new name for this disease is proposed: the globus syndrome.

Diphenylpyraline (Lergobine®) in the Treatment of Patients Suffering from Allergic and Vasomotor Rhinitis

In a double-blind study, diphenylpyraline (Lergobine®) was given to 63 patients whose main symptoms were stuffiness of the nose, increased secretion of mucus, snuffling, sneezing and redness of the eyes. Fifty-seven patients were given placebo for identical symptoms. Diphenylpyraline was found to have a better effect on all the symptoms than placebo. The difference was statistically significant in respect of the discharge of mucus and redness of the eyes, and when the total symptoms were considered as a whole. In atopic patients the better effect of diphenylpyraline was highly significant.

Virtual endoscopy imaging of the middle ear cavity and ossicles

Ten cadaver temporal bone blocks were studied with high-resolution computed tomography (HRCT) in order to produce topographic images, which are more informative than ordinary CT slices. Virtual endoscopic images were produced with separate, commercially available software, paying attention to the middle ear cavity and ossicles. Four major viewing locations for virtual endoscopy (the ear canal, hypotympanum, attic and eustachian tube) developed images acceptably. The malleus and incus were visualized properly. Small structures such as the lenticular process and the stapes sometimes failed to have good imaging. The eustachian tube and attic virtual views, which are usually not receptive to ordinary endoscopy, gave proper visualization of middle ear structures. Even the smallest structure, the stapes, can produce a virtual image.Virtual endoscopic images, or topographic images, of the middle ear and ossicles contribute to the understanding of the anatomy of the middle ear, thus enhancing the chances for successful surgery.

Tympanoscope-Assisted Myringoplasty

Thirty ears of 29 patients with different sized perforation of the tympanic membrane were operated on with the aid of rigid otoendoscopes. The technique has a significant novel feature: endoscopy of the tympanic cavity through a perforation with small tympanoscopes 1.7 mm in diameter with a 0%. The postoperative air-bone gap was less than 10 dB in 90% of the ears. It was concluded that tympanoscope-assisted myringoplasty is a reliable and simple procedure with the benefit of minimal trauma in healthy tissue and that it is a feasible approach for day-case surgery with an ordinary success rate of tympanic membrane closure and hearing results.

Endoscope-guided round window fistula repair.

Objective Endoscope-guided round window membrane repair was performed to evaluate whether the approach is feasible in the treatment of a round window fistula. Study Design Retrospective case review. Setting Tertiary care academic center. Patient A 27-year-old man had been scuba diving 6 days previously in the Australian Great Barrier Reefs. He had poor hearing with tinnitus in the left ear and a vertiginous sensation. Intervention A myringotomy was incised, and a tympanoscope was introduced into the middle ear cavity. With the patient under general anesthesia, the middle ear and the oval and round window areas were examined with a tympanoscope. In endoscopic visualization, a round perforation could be seen in the round window membrane. After detection of the round window perforation, a small piece of temporal fascia was obtained to seal the membrane perforation. Results One month after the operation, the patients hearing was significantly better. The myringotomy had healed. Conclusion A transmyringeal endoscopic procedure for round window fistula repair is feasible and combines the best features of minimally invasive surgery and aural endoscopy.