Mario Sanna

Surgery of the 'only hearing ear' with chronic ear disease.

The management of chronic ear disease affecting the only hearing ear is a controversial subject. The relative scarcity of literature on the subject prompted us to prepare a questionnaire which was sent to European and American otologists and to review 19 cases operated at the ENT Clinic of the University of Parma, Italy, and 16 cases operated at The Baptist Memorial Hospital, Memphis, U.S.A. Surgery of cholesteatoma involving the only hearing ear is advised by all the interviewed otologists without exception, even in the presence of a labyrinthine fistula. The cases from the University of Parma were managed as follows: a classic modified radical mastoidectomy was performed in 10 cases, a staged intact canal wall tympanoplasty was done in four cases, an open tympanoplasty in three and a radical mastoidectomy in the remaining two cases. The cases from The Baptist Memorial Hospital were managed with an intact canal wall tympanoplasty (ICWT) in nine and with an open procedure in seven cases. All the otologists interviewed agreed that surgery of the only hearing ear requires particular attention and experience, and should be performed with extreme care by a very experienced surgeon.

Management of the labyrinthine fistula in cholesteatoma surgery

The presence of a labyrinthine fistula has remained one of the major problems in cholesteatoma surgery. Confronted with this problem, the surgeon may ultimately base his choice of procedure on four basic conditions: the size of the fistula, its location in the ear, the condition of the other ear, and the cochlear function. Our attitude has been changing, and currently we prefer to perform a staged closed tympanoplasty. When a closed technique is performed, we either remove the cholesteatoma matrix and then cover the fistula immediately or we leave the matrix in situ and re-explore the mastoid process 5 or 6 months later. The series consists of 88 cases out of a total of 701 patients with cholesteatoma operated on between January 1971 and June 1982. In 20 patients the matrix was left over the fistula at the first stage. The results suggest that a staged operation, i.e. closed tympanoplasty, is to be preferred even in cases with an extensive labyrinthine fistula.

Autologous fitted incus versus Plastipore TM PORP in ossicular cgain reconstruction

Hearing results and causes of failure with three types of ossicular reconstruction techniques over an intact stapes, during second-stage intact canal wall tympanoplasty, are reported herein. The three types of reconstruction are: fitted autologous incus (38 cases); Plastipore PORP with cartilage (41 cases); Plastipore PORP without cartilage (32 cases). A residual air-bone gap within 15 dB. was found in 63.2 per cent of fitted includes, in 41.5 per cent of PORPs with cartilage, and in only 37 per cent of PORPs without cartilage. Eighty-four per cent fitted incudes, 63 per cent PORPs with cartilage and 44 per cent PORPs without cartilage yielded a residual air-bone gap within 25 dB. Extrusion has been the main cause of failure among Plastipore prostheses.

Regenerated Middle Ear Mucosa after Tympanoplasty

The surgeons attitude towards the diseased middle ear mucosa during intact canal wall tympanoplasty has remained a controversial problem. Our approach consists of the complete removal of the irreversibly diseased mucosal lining. A planned staged operation has been carried out in most cases of tympanoplasty with the use of Silastic sheeting. At the time of the second operation, the middle ear and mastoid process appear to be lined by the regenerated mucosa and pneumatized. 54 mucosal biopsies taken during the second stage of the operation showed a normal flat, cuboidal and pseudostratified ciliated epithelium with functional features (secretory granules, microvilli and cilia). It is concluded that the diseased middle ear mucosa can be removed whenever necessary during staged closed-tympanoplasty operations because under the Silastic sheeting the mucosa will be regenerated within 12 months.

Regenerated Middle Ear Mucosa after Tympanoplasty. Part II. Scanning Electron Microscopy

The ultrastructural appearance of the regenerated middle ear epithelium, found at the second operation of staged ICWT with mastoidectomy, has been investigated herein with the scanning electron microscope. The regenerated epithelium consists of flat nonciliated cells, “elevated” nonciliated cells with microvilli, and ciliated cells. Secretory material is present on the surface of the “elevated” nonciliated cells surrounding the ciliated ones. Regeneration of the mucosa occurs following precise topographic differences that mimic the distribution of epithelial cells in the normal middle ear. It is confirmed that a morphologically normal middle ear epithelium regenerates to cover all denuded bone surfaces within 12 months—after first stage ICWT with mastoidectomy—when silicone rubber sheeting has been used to maintain an aerated middle ear and mastoid space.

Histology of extruded Plasti-Pore ossicular prostheses.

Twenty-three Plasti-Pore ossicular prostheses removed from the human middle ear following partial or total extrusion were investigated by light microscopy. No specific tissue reaction other than the ingrowth of histiocytic cells elicited from the porous Plasti-Pore was found. The only histologic feature typical of extruded prostheses was the presence of granulocytes in all parts extruded. In our opinion this finding was the inflammatory reaction following the ischemic necrosis of tissue grown inside the pores and the superimposed bacterial colonization. We concluded that no histologic feature supports a biologic cause of extrusion, and that extrusion instead is related to biofunctional characteristics.

Failures with Plasti-Pore Ossicular Replacement Prostheses

Plasti-Pore ossicular prosthesis failures found in our series of 246 patients with regular follow-up are reported and analyzed. Extrusions as well as poor functional results (postoperative air-bone gap greater than 25 dB) of the prostheses with and without cartilage on top have been reviewed. The overall extrusion rate was 9.3%: a higher extrusion rate occurred with prostheses without cartilage (18.4%) than with cartilage (4.4%). Thirty-six patients among those with poor postoperative hearing improvement have undergone revision surgery: the main causes of failure were a short prosthesis, a fixed stapes or footplate, adhesions of the prosthesis to surrounding structures, and the displacement of the prosthesis.

Vestibular Neurectomy for Dizziness after Head Trauma

28 patients with dizziness after head trauma were treated by vestibular neurectomy. Comparisons between the results of surgery and preoperative symptoms and findings showed that the best results were

Bilateral cerebellopontine angle lipomas

Cerebellopontine angle (CPA) lipomas are extremely rare lesions and usually unilateral. We describe a case of a 36-year-old man with bilateral aural fullness that was discovered to have bilateral CPA lipomas associated with an abnormal hindbrain segmentation appearance. The patient was evaluated with 3.0T magnetic resonance imaging (MRI) system. MRI demonstrated the presence of bilateral CPA masses partially extending into the internal auditory canals. These lesions were hyperintense on both T1- and T2 weighted images. Facial and vestibulo-cochlear nerves together with tortuous vascular structures and fibro-connective septa were identified on T2-weighted 3D Fast Imaging Employing Steady-state Acquisition (FIESTA) sequences as areas of lower intensity coursing through the masses. Gadolinium administration yielded no enhancement. Conservative management was adopted.

Regenerated Middle Ear Mucosa after Tympanoplasty. Part I. Transmission Electron Microscopy

The ultrastructural appearance of the regenerated middle ear mucosa—found at the second operation of staged intact canal wall tympanoplasty (ICWT) with mastoidectomy—has been evaluated with the transmission electron microscope. The regenerated epithelium showed all the morphologic characteristics of the normal middle ear mucosa: ciliated cells, noncillated cells, and secretory cells. All of these (Including goblet cells) have been found in the specimens. It is concluded that a normal middle ear mucosa regenerates to cover all denuded bone surfaces after the first operation of staged ICWT with mastoidectomy, when silicone rubber sheeting has been used to prevent adhesions and maintain an air-containing middle ear space.