Tauno Palva

Immune Complexes in Middle Ear Fluid in Chronic Secretory Otitis Media

Data on 87 patients (113 ears) with chronic secretory otitis media (SOM) are reported. The bacteriological analysis of the middle ear fluid (MEF) revealed Streptococcus pneumoniae in 7% of ears, Hemophilus influenzae in 9%, opportunistic bacteria in 20%, while 64% of the samples showed no growth. Free capsular polysaccharide pneumococcal antigens were found in 5 % of the MEF samples using counterimmunoelectrophoresis (CIEP) with Omniserum containing 83 different pneumococcal polysaccharide types. Heating of the samples to disrupt the immune complexes increased the frequency of positive samples to 27%. These findings, together with the frequent occurrence of S pneumoniae and H influenzae in the nasopharynx, strongly support the opinion that chronic SOM in a considerable number of cases is an immune complex disease.

Surgical Treatment of Chronic Middle Ear Disease: II. Canal Wall Up and Canal Wall Down Procedures

Results of canal wall up (CWU) and canal wall down (CWD) tympanomastoid one-stage surgery were evaluated in 268 ears. In the CWU group of 121 ears, 50 ears (41%) had clinical cholesteatoma, whereas cholesteatoma was present in all 147 ears operated upon by the CWD technique. The disease was much less severe in the former group, which, for instance, showed no labyrith fistula, as compared with 17 (12%) in the latter group. Extensive disease also accounts for the larger number of complications seen in the CWD group. Average hearing levels postoperatively in the CWU group were significantly better than preoperatively. In the CWD group the preoperative levels were maintained. Recurrence of cholesteatoma was noted in 2% in the CWD group, while one implantation cholesteatoma occurred in the CWU group. Of the many surgical procedures available, the one offering the best means of curing the disease should of course be chosen. Ossicular repair with bone offers good prospects of a successful one-stage reconstruction.

Functional results of facial nerve suture after removal of acoustic neurinoma: analysis of 25 cases.

The facial nerve is sometimes severed during the removal of acoustic neurinomas, either intentionally to ensure complete removal, or unintentionally because of difficulties in identification. In such cases we have, if possible, sutured the nerve stumps microsurgically, either end to end or by use of an intervening nerve graft. We analyzed the outcome of 25 instances of facial nerve suturing in a series of 219 patients operated on for acoustic neurinoma from 1979 to 1987. The first signs of recovery appeared at an average of 12 months, and there was continued improvement for several years. Recovery was graded from 1 to 6. The anastomosis was successful in 24 of the 25 sutured nerves, in that at least some facial movement and tone were restored (Grade 5 or higher). In 11 of the 25 cases, facial appearance at rest and with movement was moderately good (Grade 2 or 3). A Grade 1 result, with no perceivable facial dysfunction, was never achieved. Typically, oral muscles showed the most improvement and frontal muscles the least. Facial appearance was better at rest than with movement, which was always complicated by some degree of synkinesis. Closure of the eye was so good in 13 of the 25 cases that neither tarsorrhaphy nor an eyelid spring was necessary. When the facial nerve is severed, intraoperative suture is recommended, because it provides a chance for moderately good restoration of facial appearance.

Surgical treatment of chronic middle ear disease: 1. Myringoplasty and Tympanoplasty

Results of myringoplasty or tympanoplasty were evaluated in 225 ears followed for at least one year after surgery. Repair of the tympanic membrane with an underlay connective tissue graft (fascia in 90%) was successful in 97% of the ears. One late perforation developed 3 years postoperatively. The average postoperative air-bone gap was 4.8 dB in 88 cases of myringoplasty, the series including three ears with a rigid footplate. Rigid incus and malleus should not be mobilized but subjected to resection and reconstruction. Poor tubal function caused adhesive changes in one ear (1%). In tympanoplasty the average postoperative air-bone gap was 11.3 dB in 100 ears with stapes present and 20.6 dB in 36 ears with only the footplate remaining. Of the 137 tympanoplasty ears, 10 (7%) showed prominent adhesive changes. In 36 ears with cholesteatoma there was one recurrence 3 years later (3%). An air-bone gap of less than 20 dB was postoperatively noted in 94% of the ears undergoing myringoplasty and in 69% of the ears undergoing tympanoplasty.

Lymphocyte morphology in mucoid middle ear effusions.

—Cytologically, the mucoid middle ear effusions could be divided into a lymphocyte-monocyte type and a type where the granulocytes predominated. By α-naphthyl-acetate esterase (ANAE) staining procedure the T lymphocytes were found to make up the majority of lymphocytes in the first type, often accompanied by large numbers of ANAE-positive macrophages. In the second type the relative and particularly the absolute numbers of T cells were smaller. The T lymphocytes in aural effusions, distributed in agreement with their normal distribution in blood, could be the basis of possible delayed hypersensitivity immune mechanisms in the middle ear, but definite proof, either demonstrating receptor molecules directed to antigens or a specific response by T cells, is still lacking.

Fate of the mesenchyme in the process of pneumatization.

Hypothesis This studys aim was to find histologic data that would indicate the mode of disappearance of the embryonal mesenchyme. Background The basic studies made during the first half of the 20th century concluded that mesenchyme disappears by regression and resorption. Recently, it was suggested that mesenchyme disappears by receding, spreading, and thinning to match the enlarging bony spaces. Methods We studied 11 serially sectioned temporal bones from newborns to adults and describe detailed findings in a 9-day-old newborn and in a 1.5-year-old infant. The temporal bones were sectioned to 20 &mgr;m and stained by hematoxylin and eosin. Results Histologic evidence of regression was found in the form of degenerating mesenchymal cells and fibers, in areas free of cells, and with empty spaces of varying size between the fibers. Vacuoles differing much in size appeared, and phagocytic cells were frequent. A rich capillary network allowed resorption of hemopoietic cells dispersed from the marrow spaces into the mesenchyme. From the lower lateral attic, from Prussaks space, and from the mastoid air cells, mesenchyme can disappear only by regression—there is no space where it could recede. Conclusion Pneumatization of the middle ear spaces occurs by regression and resorption with an individual speed under genetic guidance. The osteoclastic activity of the periosteum, intertwined with the nearest mesenchyme, is decisive in the mastoid air cell formation. Dispersion and reabsorption of hemopoietic cells is a normal phenomenon in this process. Underpressure in the middle ear spaces, caused either by a meconium-related foreign body otitis media in infancy or by chronic otitis media in childhood, are factors that may lead to a partial or full arrest of pneumatization.

Revision Surgery for Otosclerosis

The outcome of surgery was analyzed in 76 otosclerosis patients (82 operations) undergoing revisions during the period 1986–89. The ears were divided into 3 groups based on preoperative A–B gaps 1) larger than 25 dB, 2) between 10 to 25 dB, and 3) less than 10 dB. A final hearing gain of more than 11 dB was recorded in 76%, 40% and 10% of the ears in groups 1, 2 and 3, respectively. In the groups with conductive component none of the ears deteriorated. In the sensorineural group 2 patients suffered further loss of 10 and 29 dB, respectively, and one ear became deaf. At revision the most common causes of conductive impairment were found to be dislocation of the prosthesis, remnants of footplate or new bone growth. Fistula was suspected in 10 ears and verified in 5. Several reconstruction methods must be mastered.

Surgical Treatment of Chronic Middle Ear Disease: III. Revisions after Tympanomastoid Surgery

Revision surgery was performed in 185 ears which had earlier undergone a total of 276 tympanomastoid operations. An open cavity had been made in 98, obliteration in 44 and canal wall up surgery in 43 ears. All ears were now operated upon by the open method combined with ear canal reconstruction and mastoid obliteration. Mastoid cholesteatoma was found in 50% of the open cavities and in 63% of intact canal wall ears, while 80% of the obliterated ears showed mastoid retraction pockets with cholesteatoma. Semicircular canal fistulae occurred in all groups, most frequently in open cavities (11%). During the follow-up period after revision (average 5 years) 3% were reoperated upon because of a new cholesteatoma. In the whole series, average hearing levels were slightly better postoperatively and in 34% of the ears the A-B gap was 20 dB at most. The main reason for failure after primary surgery was inadequate mastoid and epitympanic bone work and failure to obliterate the medial parts of the cavity thoroughly.

Comparative Preoperative Evaluation of Eustachian Tube Function in Pathological Ears

On 100 pathological ears with tympanic membrane perforation, eustachian tube function was measured by using sonotubometry and the negative pressure equalization test in an attempt to compare these two methods. The pressure equalization test did not appear to be a reliable tool for preoperative clinical determination of tube function because sonotubometry showed tubal opening in 85 % (myringoplasty group) and in 49 % (radical surgery group) of pathological ears, which were not able to equalize negative middle ear pressure at all during swallowing. The negative pressure equalization test is considered to be unphysiological and may produce a locking phenomenon of the tube. Even a small negative pressure can act like a valve, producing an obstruction that muscle activity of the tube is no longer able to overcome particularly when mucosal changes are present in the tubal orifice. Sonotubometry is a physiological test and as such gives a reliable picture of the opening of the tube during swallowing. Data on tympanic aeration postoperatively will be reported later.

Mucosal Histochemistry in Secretory Otitis

Mucosal biopsies were taken from 20 ears with secretory otitis media (glue ear) and histochemical stainings were made for comparison with data obtained from biochemical analysis of the fluids. Acid phosphatase, lactate dehydrogenase (LD), and malate dehydrogenase (MD), the activity of which in the ear fluids was 20 to 30 times higher than in serum, were found to appear as strong precipitates in the middle ear epithelium, particularly in the top layer. Alkaline phosphatase activity was only exceptionally seen in the epithelium but appeared in the capillaries and histiocytes. Nonspecific esterase appeared irregularly in the epithelium and regularly in histiocytes. The latter two had lower activities in ear fluids than in serum. Epithelial secretory cells and subepithelial glands and cysts showed strong alcian blue (AB)-positive staining. Positive material appeared also in the cytoplasm of the epithelial cells and in the intercellular substance. Distinct PAS-positive staining appeared in the columnar epithelium and particularly in the free mucus on top of the epithelium but was less pronounced in the glandular structures and absent from the cysts.