Ryuzaburo Nonaka

Residual Cholesteatoma: Incidence and Localization in Canal Wall Down Tympanoplasty With Soft-Wall Reconstruction

OBJECTIVE To compare the incidence and localization of residual cholesteatomas in canal wall down tympanoplasty with soft-wall reconstruction with results with the canal wall down and open tympanoplasty or canal wall up tympanoplasty. DESIGN Retrospective case-series study. SETTING Tertiary care university hospital. PATIENTS Eighty-five patients (85 ears) with fresh extensive cholesteatomas who underwent canal wall down tympanoplasty with soft-wall reconstruction as first-stage surgery and a second operation after 1 year to confirm residual cholesteatomas and perform ossiculoplasty. MAIN OUTCOME MEASURES The incidence and localization of residual cholesteatomas in the middle ear were compared between surgery using the canal wall down and open tympanoplasty and canal wall up tympanoplasty. Possible technical causes of the residua were reviewed in a retrospective videotape analysis of the first-stage operations. RESULTS Of the 85 ears operated on, 18 had residual cholesteatomas, for an overall incidence of 21%, with 1 residuum per ear. Six cholesteatomas were located in the epitympanum (33%), 3 in the sinus tympani (17%), 3 in the antrum (17%), 2 on the stapes (11%), 2 on the tympanic membrane (11%), 1 on the tympanic portion of the facial canal (6%), and 1 just under the skin of the external auditory canal (6%). The retrospective videotape analysis revealed that the main cause of residual cholesteatomas in the epitympanum and sinus tympani was incomplete removal of the matrix under an indirect surgical view because of insufficient drilling. Residual matrix in a bony defect in the middle cranial fossa or facial canal was the cause of residual cholesteatomas in the antrum or facial canal. Inappropriate keratinizing epithelium rolling during tympanic membrane or external auditory canal reconstruction was the cause of residual cholesteatomas in the tympanic membrane or external auditory canal. CONCLUSIONS The incidence of residual cholesteatomas in patients who underwent canal wall down tympanoplasty with soft-wall reconstruction was similar to that in patients who underwent surgery involving the canal wall down and open tympanoplasty or canal wall up tympanoplasty. In terms of localization, with canal wall down tympanoplasty with soft-wall reconstruction, there is the possibility of residua not only in the tympanic cavity but also in the antrum or mastoid cavity, as with the canal wall up method. Results of this study suggest that in patients with extensive cholesteatoma, canal wall down tympanoplasty with soft-wall reconstruction should be followed by a second procedure to detect any residual cholesteatomas in the tympanic cavity, antrum, or mastoid cavity.

Prognosis for Bell's palsy: a comparison of diabetic and nondiabetic patients

Conclusion. The present study indicates that recovery from Bells palsy in a diabetic group (DG) is delayed, and the facial movement score remains low in comparison with a nondiabetic group (NDG). More aggressive treatments, such as higher-dose corticosteroid administration and/or facial nerve decompression surgery, might be considered in diabetic patients with severe Bells palsy. Objectives. The purpose of this study was to reveal prognostic differences for Bells palsy in the DG and NDG. Patients and methods. The grades of facial palsy in 19 diabetic and 57 nondiabetic patients with Bells palsy were assessed using the House-Brackmann grading system (HB system). Recovery was defined as grade I. The average of HB system grades and recovery rates were compared in the DG and NDG at the start of the treatment, and 1 month, 3 months, and 6 months after onset. Results. There were no differences in the HB system between the DG and NDG at the start of treatment and at 1 month after onset. However, facial movement in the DG was poorer than that in the NDG at 3 months and 6 months after onset. In terms of the recovery rate, the rate in the DG (52.6%) was much lower than that in the NDG (82.5%) at 6 months after onset.

Postoperative aeration in the middle ear and hearing outcome after canal wall down tympanoplasty with soft-wall reconstruction for cholesteatoma.

Objective: Canal wall down (CWD) tympanoplasty with soft-wall reconstruction (SWR) is a unique technique for cholesteatoma surgery. The external auditory canal shape after surgery-retracted like a radical mastoid cavity or preserved intact-depends on postoperative aeration in the mastoid cavity. However, the relationship between postoperative middle ear aeration and hearing outcome with this procedure is unknown. We characterized this relationship and propose an ideal state of middle ear aeration to obtain satisfactory postoperative hearing after CWD tympanoplasty with SWR. Study Design: Retrospective case series. Patients: Seventy-eight patients (78 ears) with fresh cholesteatomas treated surgically at our hospital by planned 2-stage CWD tympanoplasty and SWR were included. Main Outcome Measures: Postoperative middle ear aeration was scored 1 year after second-stage surgery by computed tomography. The patients were divided into 4 bins according to postoperative audiometric air-bone (A-B) gaps: 0-10, 11-20, 21-30, and greater than 30 dB. Results: Postoperative middle ear aeration was significantly greater in the smaller gap bins (0-10 and 11-20 dB) compared with the larger A-B gap bins (21-30 and >30 dB). In contrast to the larger A-B gap bins, those with smaller A-B gaps showed reaeration of the antrum and mastoid cavity. No significant differences were observed in postoperative middle ear aeration or hearing outcome between the 2 cholesteatoma types. Conclusion: Promoting postoperative aeration of the entire middle ear is necessary to achieve better hearing outcome in patients undergoing CWD tympanoplasty and SWR for cholesteatoma.

Canal wall-down tympanoplasty with soft-wall reconstruction using the pedicled temporoparietal fascial flap: technique and preliminary results.

Objectives: We compared the use of the pedicled temporoparietal fascial flap (TPFF) with the use of free deep temporal fascia (DTF) in soft-wall reconstruction after canal wall–down tympanoplasty. Methods: In the TPFF group (6 ears), the pedicled TPFF that includes the superficial temporal artery and vein was raised ipsilaterally and rotated into the eradicated mastoid cavity. The tympanic membrane and external auditory canal (EAC) were reconstructed by gluing one side of the TPFF to the mucosal layer of the tympanic membrane and the reverse side of the posterior EAC skin. In the DTF group (21 ears), reconstruction was performed similarly with free DTF. The postoperative period for epithelialization of the tympanic membrane and EAC skin, postoperative complications, and reaeration in the middle ear revealed by computed tomography were reviewed in both groups. Results: In the TPFF group, the mean (±SD) period to epithelialization was 25.5 ± 2.8 days versus 38.4 ± 12.0 days in the DTF group; the two groups differed statistically (Welchs t-test, p = 0.0002). No postoperative complications occurred in the TPFF group, whereas 2 patients in the DTF group underwent graft necrosis with infection. Three of the 6 patients in the TPFF group showed reaeration not only in the tympanic cavity, but also in the mastoid cavity. However, no statistical differences between the two groups were observed in terms of postoperative complications or reaeration of the mastoid cavity. Conclusions: Our preliminary findings suggest that the pedicled TPFF has positive effects on quick epithelialization. Further prospective studies are needed to reveal the superiority of the pedicled TPFF over free DTF with regard to postoperative infection and recovery of mastoid aeration.

A new method for measuring compound muscle action potentials in facial palsy: A preliminary study

To establish a simple, reproducible procedure for studying facial motor nerve conduction (MNC), we determined the optimal electrode position to record evoked compound muscle action potentials (CMAPs) from perioral muscles in normal subjects. We examined three new electrode positions in which the electrode connected to the one input of the amplifier was placed on the mental protuberance, and the one connected to the other input was placed on the skin over the orbicularis oris muscle (the philtrum, mouth angle, or lower lip). We then compared the morphology and amplitudes of the CMAPs, right–left differences, and the reproducibility of CMAP amplitudes with recordings taken from the standard electrode position in which one electrode was placed on the nasolabial fold closely lateral to the ala nasi, and the other was placed on the skin over the orbicularis oris. Percutaneous supramaximal electrical stimulation was applied to the main trunk of the facial nerve. All three of the new recording positions showed greater amplitudes and more obvious biphasic CMAPs than the standard method. Positioning the electrode connected to the negative input on the philtrum was optimal in terms of right–left differences and the reproducibility of CMAP amplitudes. Therefore, this midline recording is a simple, reproducible method for calculating the CMAP amplitude ratio. However, prior to clinical use of this procedure, analyses of patients with facial palsy are required. Muscle Nerve 37: 764–769, 2008

A novel electroneurography method in facial palsy

CONCLUSION The novel midline electroneurography (ENoG) method may have advantages over the standard method in terms of ease of electrode setting, and the ENoG value may be a useful prognostic factor. OBJECTIVE We compared ENoG performed in patients with facial palsy using two different methods--the new midline method and standard method--in terms of the amplitudes of the compound muscle action potentials(CMAPs) and relationship between the ENoG value and clinical course. METHODS A total of 64 patients with facial palsy were enrolled. CMAPs were recorded using the midline method, in which the recording electrodes were placed on the mental protuberance and philtrum over the orbicularis oris muscle, and the standard method, in which the recording electrodes were set close to the nasolabial fold. Percutaneous electrical stimulation was applied to the main trunk of the facial nerve.The amplitudes of the CMAPs and the relationship between the ENoG value and the period to full recovery from the facial palsy were compared. RESULTS The midline method had larger CMAP amplitudes on both sides and a stronger negative correlation in the relationship between the ENoG value and period to full recovery from palsy than the standard method statistically.

Enlarged bony portion of the eustachian tube in oculoauriculovertebral spectrum

The patulous eustachian tube (ET) has been reported as the cause of cholesteatoma, otitis media, and tinnitus. Almost all reports on the patulous eustachian tube mentioned the patulous lumen in cartilaginous portion of the ET and atrophy of peritubal tissue, especially fat tissue. In contrast, enlarged bony portion of the ET is rare (1) and its pathophysiology remains unknown. Radiological studies are extremely useful to detect this anomaly. In this case of oculoauriculovertebral spectrum (OVAS), the multi-detector row computed tomography (1-mm collimation, 1-mm interval) reveals the enlarged bony portion of the left ET (Figs. 1 and 2). The width of the bony portion of the ET, which is closed to the junctional portion of the ET (2), is 7 mm and is much wider than that in normal children (1.5 mm) as reported by Suzuki et al (3) (Fig. 1). Huge bony dehiscence is recognized in the carotid canal (Fig. 2). Moreover, underdeveloped vestibule and semicircular canals, complete absence of the cochlea (Fig. 1 and 2), and anomalous ossicles are observed. In the right ear, which has a normal aspect in the middle ear and inner ear, the shape and width (1.3 mm) of the bony portion of the ET are normal (Fig. 3). Embryologically, the tubotympanic recess and primary tympanic cavity are derived from the expanding terminal end of the endoderm-lined first pharyngeal pouch and probably the second pharyngeal pouch (4). The endoderm of the tubotympanic recess approached the surface that comes in contact with the ectodermal membrane of the first branchial groove. Near the end of the second month, the tubotympanic recess undergoes a bottleneck constriction, then the medial constricted portion lengthens and becomes the ET (4). The bony portion

Posterior meatal wall reconstruction using the temporoparietal fascia flap

Objectives: There are some general principles of tympanoplasty: complete removal of lesion, hearing improvement, quick epithelialization, and prevention of postoperative complications. Additionally, recovery of mastoid aeration is desirable. In the present study, we used the temporoparietal fascia flap (TPFF) for posterior meatal reconstruction for the open cavity to achieve these principles. Methods: The TPFF was used in 6 patients with cholesteatoma or cholesterol gramuloma for reconstruction of the posterior meatal wall. The skin of the posterior half of the external auditory meatus was elevated from the bony wall. After canal wall down tympanoplasty and mastoidectomy, the pedicled TPFF including the superficial temporal artery was raised ipsilaterally and rotated into the middle ear. The posterior meatal wall was reconstructed by gluing one side of the TPFF to the reverse side of the preserved posterior meatal wall skin. Results: Mean time to complete epithelialization of the meatal skin in these 6 patients was shorter than that of 27 patients who underwent the meatal reconstruction using the free deep temporal fascia (26 days vs 37 days) statistically. No postoperative infection in operated ears occurred. CT scans performed 1 year after the surgery revealed that recovery of mastoid aeration was observed in 2 patients despite thorough removal of the mucosa in the mastoid cavity Conclusion: The TPFF can provide optimal blood supply to the middle ear and external meatal skin. It is possible that the TPFF works positively not only for quick epithelialization and prevention of postoperative infection, but also for recovery of mastoid aeration.