Roberto Gamoletti

The surgical management of childhood cholesteatoma.

The results of treatment of 124 cases of childhood cholesteatoma are reported in the present study and compared with an adult group of patients. Intact canal wall tympanoplasty was performed in over 90 per cent of cases in children and the procedure was staged in nearly 80 per cent of cases. The children had a 43.8 per cent incidence of residual cholesteatoma and an 8.8 per cent incidence of recurrent cholesteatoma in intact canal wall tympanoplasty cases. Intact canal wall tympanoplasty remains the technique of choice in our hands for the treatment of childhood cholesteatoma; pre-planned staging of the operation is mandatory for the detection and elimination of residual cholesteatoma which occurs more frequently in children.

Prevention of Recurrent Cholesteatoma in Closed Tympanoplasty

Recurrent cholesteatoma in a series of 534 staged intact canal wall tympanoplasties performed over a 10-year period has been reviewed for the present study. Overall detected incidence of recurrent cholesteatoma is 5.2% (28 of 534 operated ears). A steady decrease of recurrent cholesteatoma was found, however, in the second period of our surgical experience (1978 to 1982) when prevention techniques were adopted in all operations, resulting in a 1.07% incidence (four of 373 operated ears). Our present policy for prevention of recurrent cholesteatoma in intact canal wall tympanoplasties with mastoidectomy includes 1) the use of plastic sheeting with thick Silastic, 2) the repair of bony sulcus defects with cartilage shavings, 3) staging of the operation with preplanned reexploration of the middle ear and mastoid, and 4) transtympanic ventilation tube insertion in cases of refractory tubal insufficiency.

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.

Inner ear cholesteatoma and the preservation of cochlear function

Labyrinthine destruction by direct cholesteatoma invasion has always been considered a serious threat to the inner ear function. A number of reports in the literature have cited both patients who had preservation of hearing despite widespread erosion of the labyrinth by cholesteatoma and patients who had retained auditory function despite surgical removal of the matrix from the labyrinth. In most cases the vestibular portion of the inner ear was invaded but cases of cochlear involvement have been described as well. Twelve cases with pre-operative auditory function preservation despite extensive labyrinthine destruction treated at our Institution are reported. Seven cases retained cochlear function post-operatively. Possible explanations of this occurrence and implications of related with hearing preservation in the presence of widespread inner ear destruction by chronic inflammatory disease are discussed.

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.

Chorda Tympani Nerve Fibers in Man

Four normal human chorda tympani nerves were studied for quantitative data of nerve fibers. The average total number of nerve fibers was 5360 (range, 4941-6020). The average number of unmyelinated fibers was 1835 (range, 1518-2083), or 34% of the total. The diameters of myelinated fibers ranged from 1 to 7 microns, peaking at 2 microns. Most of the unmyelinated axons had a diameter between 0.5 and 2 microns. The importance of the quantitative evaluation of the chorda tympani nerve fibers is stressed in reporting structural changes.

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.