Lela Migirov

Acute mastoiditis — the antibiotic era: a multicenter study☆

OBJECTIVES To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics. METHODS A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. SETTING Nine secondary or tertiary academic or non-academic referral centers. RESULTS Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy). CONCLUSIONS Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.

Suprameatal approach: new surgical approach for cochlear implantation

The conventional technique for cochlear implantation is via a mastoidectomy and posterior tympanotomy. An alternative approach for cochlear implantation is hereto described. The middle ear is entered through a suprameatal approach (SMA) bypassing the mastoid cavity. This surgical approach shortens the duration of the procedure to approximately one hour. The introduction of the cochlear implant electrode array involves drilling in the suprameatal region and the osseous portion of the external auditory canal at a safe distance from the anatomical position of the facial nerve. This prevents possible injury by direct trauma or drill overheating of the chorda tympani or facial nerves. We report 15 consecutive patients who were operated on using the SMA technique. No complications were encountered as a result of this surgical technique but further experience may be necessary.

Otogenic intracranial complications: A review of 28 cases

Conclusions. Antibiotic treatment does not absolutely prevent the development of otogenic intracranial complications (ICC); however, their incidence is relatively low (0.36%).Various pathogens can be isolated in cultures of patients with these complications, but combinations of third- or fourth-generation cephalosporins with chloramphenicol, vancomycin, metronidazole or aminoglycosides can provide good results. Underlying cholesteatoma is common and is usually associated with intracranial abscess or sinus thrombosis. High morbidity rates warrant long-term follow-up. Objective. To evaluate the cause and nature of otogenic ICC in patients treated at 1 medical center over an 18-year period. Material and methods. This was a retrospective chart review of 28 patients admitted to Sheba Medical Center, Israel with otogenic ICC between 1984 and 2002. Results. Meningitis was the commonest complication (46.4%), followed by brain abscess, epidural abscess, sigmoid sinus thrombosis, subdural empyema, perisinus abscess and transverse and cavernous sinus thrombosis. Twelve patients (42.9%) had received antibiotic treatment prior to admission. Chronic otitis media, cholesteatoma and brain abscess were diagnosed mainly in adults, while acute otitis media and epidural abscess were more frequent in children. Twenty-one patients underwent mastoidectomy to eradicate the source of infection. The commonest finding at surgery was granulations (81%). Cholesteatoma was seen in 38.1% of cases. Cholesteatoma and brain abscess were usually associated with Gram-negative bacterial infection. Meningitis, however, was caused by Streptococcus pneumoniae in 40% of cases. CT showed a sensitivity of 92.75% for diagnosing otogenic ICC. There was no mortality. The morbidity rate was high (71.4%) and included hearing impairment, hemiparesis, hydrocephalus, mental retardation, polyneuropathy and epilepsy.

The suprameatal approach: an alternative surgical approach to cochlear implantation.

The suprameatal approach is an alternative method for performing cochlear implantation developed in the Sheba Medical Center in 1999. This technique eliminates the need for mastoidectomy and posterior tympanotomy. The middle ear is entered through a retroauricular tympanotomy flap, and the electrode is introduced into the cochlea via a tunnel drilled in the suprameatal region superior to Henles spine. The suprameatal approach is a simple and safe technique that does not endanger the facial nerve nor the chorda tympani. A wide exposure of the promontory enables exact determination of scala tympani and smooth introduction of the electrodes into the cochlea. This technique may also be used in malformed or ossified cochlea. Until now 140 patients were operated in our department and an additional 48 patients were operated on in the department of Otorhinolaryngology at the University of Vienna employing the suprameatal approach technique.

Exclusive endoscopic ear surgery for acquired cholesteatoma: preliminary results.

Objective: To present preliminary results in transmeatal exclusive endoscopic ear surgery. Study Design: Retrospective. Intervention: Rigid endoscopes were used for all procedures. A wide posterior tympanomeatal flap was elevated transmeatally, and the scutum was removed with a bone curette or was drilled until visualization of cholesteatoma extension and the mastoid antrum. The malleus and incus were removed when they were involved in the cholesteatoma or restricted access to it. When present, the stapes was left intact. Endoscopic accessibility was defined by no extension of the cholesteatoma beyond the level of the lateral semicircular canal. Scutumplasty was by with tragal cartilage, and tympanic membrane defects were reconstructed with the palisade technique and perichondrium. Results: Thirty patients, aged 9 to 75 years, underwent the exclusive endoscopic transmeatal cholesteatoma eradication between July 2008 and May 2010. There were no incidents of iatrogenic injuries to the facial nerve or ossicles. Closure of the tympanic membrane and good hygienic status (water tolerance and absence of inflammation) were achieved in all operated ears. Two patients had significant postoperative worsening of their sensorineural hearing loss: the cholesteatoma of one of them involved all 3 ossicles and oval window and the other patient experienced postoperative labyrinthitis. There was no residual disease in 18 patients who were followed for more than 1 year, and the non-echo-planar base diffusion-weighted sequence magnetic resonance imaging was negative in 3 patients. Conclusion: Our preliminary results indicate that the minimally invasive endoscopic ear surgery allowed complete eradication of cholesteatoma from the middle ear and its extensions, with minimal morbidity and good functional results.

Cochlear Implantation in Elderly Patients: Surgical and Audiological Outcome

Background: Deteriorated hearing affects speech perception and speech production, and negatively impacts on social interaction, employment, income, and, as a result, the quality of life of the elderly population. Lack of satisfaction with conventional hearing aids motivated part of them to turn to more sophisticated cochlear device systems. Objective: To investigate the outcome of cochlear implantation (CI) among elderly cochlear implant recipients. Methods: The medical records of 20 postlingual patients aged >65 years at the time of CI, who were followed up for a period of at least 12 months were retrospectively reviewed for age at the time of CI, the cause and duration of deafness, hearing aid experience, comorbidities, complications of the procedure and audiological outcome. Pre- and post-CI speech perception performance was tested using a battery of speech perception tests. Results: In addition to bilateral severe to profound hearing loss, all 20 patients had some comorbidities and 13 had more than 2 pathologies that are associated with hearing impairment. Major complications such as facial nerve paralysis and foreign body reaction were rare (n = 2). Minor complications such as disequilibrium (n = 5) and wound problems (n = 5) resolved spontaneously or were successfully managed conservatively. There were no complications associated with general anesthesia used during the CI procedure. Statistical analysis using the Wilcoxon Signed Rank Test showed significant differences (p < 0.01) between the pre- and postspeech perception categories. No significant correlations were found between the background data: unaided thresholds, aided thresholds, duration of profound deafness, duration of hearing aid use prior to CI, speech perception before CI and speech perception performance after CI using Pearson correlations. Conclusion: CI was found to be associated with significant hearing benefit in elderly candidates. However, every CI candidate must be informed about possible complications associated with the procedure, especially related to the vestibular system. At the same time, it should be made clear that life-threatening conditions are rare and that the surgery is usually safe.

Self-Reported Listening Habits and Enjoyment of Music Among Adult Cochlear Implant Recipients

Objectives: We sought to assess the associations between self-reported listening habits and enjoyment of music, and the following variables: Age at implantation, gender, prelingual versus postlingual deafness, duration of deafness, duration of cochlear implant (CI) use, type of CI, speech coding strategy, and speech perception abilities. Methods: A questionnaire on listening habits and enjoyment of music before the onset of deafness and after implantation was sent to 85 adult CI recipients who had been using the devices for at least 6 months. Results: Of the 53 responders, 39 (73.6%) listened to music after implantation. Listening to music was not significantly related to age at implantation, gender, duration of deafness, duration of CI use, type of CI device, speech coding strategy, or open-set speech perception abilities. The 14 nonlisteners were postlingually deafened. The ratings of enjoyment were the same for 22.6% of patients, improved for 26.4%, and worse for 50.9%. Only 2 of 13 patients who played a musical instrument and 14 of 24 patients who sang before the onset of deafness resumed their musical activities. Conclusions: Despite the decline in listening habits and in the enjoyment of music after cochlear implantation, most patients do listen to music. The changes in listening habits and enjoyment were not related to the selected background variables.

Surgical and medical complications following cochlear implantation : Comparison of two surgical approaches

Our study was designed to evaluate the complication rate of cochlear implantation (CI) and to compare two different surgical approaches that are currently being used for implantations in our department. This retrospective study was conducted on the patients who underwent CI in our center between 1989 and 2003 and who were followed-up for at least 18 months. The patients were divided into two groups according to the surgical technique that had been used for the implantation: the mastoidectomy with posterior tympanotomy approach and the suprameatal approach (without mastoidectomy). The incidence of complications following CI was compared between the two groups and between children and adults. Facial nerve paralysis, electrode misplacement, injury to the chorda tympani nerve and mastoiditis occurred only in the mastoidectomy with posterior tympanotomy approach group. Acute middle ear infection with or without mastoiditis emerged as the most common complication in both groups, followed by vestibular and wound problems. Disequilibrium was significantly more common among the adults than among the children (p < 0.0001). The suprameatal approach was demonstrated as being a good alternative technique to the classical surgery for CI.

A longitudinal study of electrical stimulation levels and electrode impedance in children using the clarion cochlear implant

Conclusions. Electrical stimulation levels and electrode impedance values (EIVs) in children using the Clarion cochlear implant (CI) programmed with CIS strategy stabilized after 3 months of implant use. The data presented here may be useful as a general guideline for the programming of infants and young children and may further be of help for the identification of patients who fall outside the “average” range. Objectives. The purpose of the present study was to evaluate changes in electrical stimulation levels, i.e. threshold (T) levels, comfortable (M) levels, dynamic range (DR), and EIVs during the first 18 months of implant use, in children using the Clarion CI. Materials and methods. The maps of 18 pre-lingual children (mean age at implantation 4.2 years; range 1–8), using the Enhanced Bipolar 1.2 or Bipolar standard electrode with the S-Series speech processor programmed with CIS strategy, were examined at five time points: connection, and 3, 6, 12, and 18 months post-initial stimulation. T levels, M levels, DR and EIVs were analyzed according to four cochlear segments: apical, apical-medial, medial-basal, and basal. Results. During the first 3 months of implant use T levels increased to some extent, whereas M levels and DR increased significantly. From 3 months and through the entire follow-up, T and M levels as well as DR were stable. EIVs of current carrying electrodes decreased significantly from connection to the 3-month visit; thereafter a stabilization of values was evident. Electrical stimulation levels and EIVs did not differ among the cochlear segments during the entire follow-up.

Influence of coexisting myringosclerosis on myringoplasty outcomes in children

OBJECTIVE To obtain information on the success rate of tympanoplasty with concomitant myringosclerosis. METHODS The medical records of 40 children with myringosclerosis (23 girls, 17 boys; age range six to 16 years, mean age 9.85 years) who had undergone primary tympanoplasty were retrospectively studied. Surgical success was defined as the perforation remaining closed 12 months post-operatively. RESULTS Sclerotic plaques occupied whole remnant eardrums in 17 patients, and were located in various parts of the eardrum in 23. Tympanosclerosis associated with myringosclerosis was present in six patients. The success rate of primary tympanoplasty was 92.5 per cent. All three surgical failures were observed in girls with marginal perforations. These children underwent successful revision procedures for their residual perforations, variously at four, eight and 10 months after the initial surgery. CONCLUSION Appropriate freshening of the perforation edges, with removal of sclerotic plaques, can result in a high rate of successful closure of perforated tympanic membrane with coexisting myringosclerosis.