Mark J. Levenson

A review of twenty congenital cholesteatomas of the middle ear in children.

Cholesteatomas, arising within the middle ear space behind an intact tympanic membrane, have been detected more frequently in recent years. This article reviews 19 children (with a mean age of 4.3 years) who underwent surgery over a 7-year period for removal of cholesteatomas from behind intact tympanic membranes. Most of these children were referred by pediatricians who had detected an asymptomatic whitish middle ear mass. Many had histories of treatment for otitis media. Patients with similar histories were excluded from the series if there had been a prior perforation, myringotomy, or otologic surgery. In the series, one fourth of the children had associated congenital malformations, and there were 3 times as many boys as girls. In two thirds of the cases, the cholesteatoma was manifested as an anterior-superior middle ear mass that seemed to arise from the processus cochleariformis, undersurface of malleus area. Many could be removed via an extended anterior tympanotomy operative approach. The results of surgery are reviewed. The possible origins of these localized cholesteatomas are considered. Are they congenital defects that arise from misplaced keratinizing epithelium? Do they arise from mesenchymal cells whose differentiation is stimulated by inflammatory changes within the middle ear?

Ciprofloxacin: drug of choice in the treatment of malignant external otitis (MEO).

Ciprofloxacin, a fluorinated quinolone with high efficacy against Pseudomonas aeruginosa, was used in the treatment of 10 consecutive patients with malignant external otitis. All patients had skull base osteomyelitis documented by nuclear and computed tomography (CT) scans. Dosages of 1.5 g of ciprofloxacin daily were used for a mean average of 10 weeks. All patients were considered cured with a minimum follow‐up of 18 months after completion of therapy. A new classification of malignant external otitis (MEO) is presented.

Laryngeal tuberculosis: Review of twenty cases.†‡§

Despite a dramatic reduction in incidence of laryngeal tuberculosis over the last three decades, tuberculous involvement still has to be considered in the differential diagnosis of laryngeal lesions. The majority of the 20 cases in our series consists of patients in whom the working diagnosis of carcinoma of the larynx was initially made. These patients presented with the chief complaint of hoarseness of several months duration, frequently associated with dysphagia, but in most cases with chest symptoms that were not prominent despite the fact that most of these patients had far advanced pulmonary tuberculosis.

Methods of Teaching Stapedectomy

Objectives: Establish a better method of teaching residents stapes surgery, with the goal of improving surgical outcome.

Beta-2 transferrin: limitations of use as a clinical marker for perilymph.

Beta‐2 transferrin is a protein marker that can be used in the clinical setting to reliably identify the presence of cerebrospinal fluid (CSF). Recent literature has suggested that beta‐2 transferrin can also be used as a clinical marker for perilymph. This study investigates the use of a beta‐2 transferrin assay as a method to identify the presence of perilymph. Twenty‐two patients were enrolled in the study. Fluid samples were obtained intraoperatively and tested for the presence of beta‐2 transferrin. As expected, four CSF samples collected were positive for beta‐2 transferrin; however, four known perilymph samples collected from patients undergoing cochlear implantation were negative for beta‐2 transferrin, seven of nine known perilymph samples obtained during stapedectomies were negative for beta‐2 transferrin, and four of five samples collected during middle ear explorations for fistula were negative for beta‐2 transferrin. With current methodology beta‐2 transferrin does not appear to be a reliable clinical marker for perilymph in the operative setting.

Complications of Acute Streptococcal Otitis Media: A Resurgence

Severe invasive infections caused by group A streptococcus (GAS) have been reported with increasing frequency since 1985. This recent resurgence of aggressive GAS infections recalls an entity now rarely seen in otolaryngology, acute necrotizing otitis media (ANOM). We report two cases of acute otitis media (AOM) due to GAS resulting in life-threatening intratemporal and extratemporal complications. Both patients were treated with oral antibiotics for AOM. A lateral semicircular canal fistula and epidural abscess subsequently developed in our first patient; acute streptococcal meningitis developed in our second patient. In both cases, mastoidectomy and drainage were performed, and intravenous antibiotics were administered, with resolution of infection. The bacteriology, pathophysiology, and appropriate treatment of AOM, ANOM, and severe invasive GAS infections will be reviewed.

Round Window Reinforcement for Superior Canal Dehiscence

Objective: To evaluate the outcome of round window (RW) with or without oval window (OW) tissue reinforcement in the management of superior canal dehiscence (SCD). Method: Chart reviews were perfomed for patients with symptomatic SCD that underwent this window reinforcement procedure. Preoperative and postoperative audiometry, vestibular myogenic evoked potentials (VEMP), and presence of a positive Tullio and Hennebert’s sign were recorded. Patient questionnaires were administered to assess symptomatic relief following the procedure. Results: Twenty-five chart reviews from 5 tertiary centers revealed that most patients experienced reduction of symptoms and were satisfied with the results. A comprehensive analysis will be presented. Conclusion: Tissue reinforcement of the windows(s) may reduce some of the symptoms associated with SCD, perhaps by mitigating some of the presumed “third window” effect of the dehiscence. Most patients were grateful for the benefits provided by the procedure and the avoidance of a craniotomy or mastoidectomy.

Management of External Ear Canal Diseases

Educational objectives: To understand rationale for management of infections and inflammations of the external auditory canal and to prescribe appropriate primary and secondary therapy for infections of the external auditory canal.