Warren Y. Adkins

Composite autograft for tympanoplasty and tympanomastoid surgery

In 1982, 40 composite cartilage perichondrial autografts performed to prevent recurrent cholesteatoma secondary to canal wall defects were reviewed. A follow‐up of those cases, plus 62 new cases, as well as the composite autografts for severe tympanic membrane retractions (55 cases) and selected tympanoplasties (22 cases) is presented. No recurrent cholesteatomas or retraction pockets developed at the graft sites, with one graft failure in the latter group.

Temporary threshold shifts in humans exposed to octave bands of noise for 16 to 24 hours.

Groups of human subjects were exposed in a diffuse sound field for 16--24 h to an octave-band noise centered at 4, 2, 1, or 0.5 kHz. Sound-pressure levels were varied on different exposure occasions. At specified times during an exposure, the subject was removed from the noise, auditory sensitivity was measured, and the subject was returned to the noise. Temporary threshold shifts (TTS) increased for about 8 h and then reached a plateau or asymptote. The relation between TTS and exposure duration can be described by a simple exponential function with a time constant of 2.1 h. In the frequency region of greatest loss, threshold shifts at asymptote increased about 1.7 dB for every 1 dB increase in the level of the noise above a critical level. Critical levels were empirically estimated to be 74.0 dB SPL at 4 kHz. 78 dB at 2 kHz, and 82 dB at 1 and 0.5 kHz. Except for the noise centered at 4.0 kHz, threshold shifts were maximal about 1/2 octave above the center frequency of the noise. A smaller second maximum was observed also at 7.0 kHz for the noise centered at 2.0 kHz, at 6.0 kHz for the noise centered at 1.0 kHz, and at 5.5 kHz for the noise centered at 0.5 kHz. After termination of the exposure, recovery to within 5 dB of pre-exposure thresholds was achieved within 24 h or less. Recovery can be described by a simple exponential function with a time constant of 7.1 h. The frequency contour defined by critical levels matches almost exactly the frequency contour defined by the E-weighting network.

Combined Extracranial-Intracranial Resection of a Maxillary Desmoid Tumor

Desmoid tumors are a locally infiltrative, nonmetastasizing form of fibromatosis. Wide en bloc extirpation is the therapy of choice, with a high recurrence rate reported for lesser resections. The first case of a desmoid invading intracranially is reported, and the combined intracranial-extracranial resection is described.

Upward spread of masking, hearing loss, and speech recognition in young and elderly listeners

Upward spreading of masking, measured in terms of absolute masked threshold, is greater in hearing-impaired listeners than in listeners with normal hearing. The purpose of this study was to make further observations on upward-masked thresholds and speech recognition in noise in elderly listeners. Two age groups were used: One group consisted of listeners who were more than 60 years old, and the second group consisted of listeners who were less than 36 years old. Both groups had listeners with normal hearing as well as listeners with mild to moderate sensorineural loss. The masking paradigm consisted of a continuous low-pass-filtered (1000-Hz) noise, which was mixed with the output of a self-tracking, sweep-frequency Bekesy audiometer. Thresholds were measured in quiet and with maskers at 70 and 90 dB SPL. The upward-masked thresholds were similar for young and elderly hearing-impaired listeners. A few elderly listeners had lower upward-masked thresholds compared with the young control group; however, their on-frequency masked thresholds were nearly identical to the control group. A significant correlation was found between upward-masked thresholds and the Speech Perception in Noise (SPIN) test in elderly listeners.

Congenital Cholesteatomas in the Tympanic Membrane

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3‐year‐old nor 14‐year‐old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.

Temporal bone showing polyarteritis nodosa, otosclerosis, and occult neuroma†

The clinical and general histopathologic manifestations of systemic vasculitis of the polyarteritis nodosa type are well known. Although hearing loss associated with polyarteritis nodosa has been reported, only two temporal bone studies are available. The findings in a 60‐year‐old man with well‐documented hearing loss who had rheumatoid arthritis, polyarteritis nodosa, and otosclerosis are presented. Polyarteritis nodosa extensively involved the subarcuate arteries and arteries of the facial canal. There were decreased nerve fibers to and sensory cells in the crista of the semicircular canals and macula of the utricle and saccule. Focal and diffuse atrophy of the stria vascularis and decreased cellularity in the spiral prominence and ligament were present. There was a loss of outer hair cells. Otosclerosis involved the left and right oval window niches (bilateral stapedectomy had been performed). There was a small Antoni type A neuroma of the superior division of the vestibular nerve on the left.

The use of pentoxifylline in a pig random skin flap model

Pentoxifylline, the first drug in a new class of rheologic agents, has enhanced skin flap survival in previous rat models. In an attempt to find an animal model more similar to the human, a trial using a pig skin flap model was undertaken. Experimental animals received oral pentoxifylline for 21 days. Random skin flaps were elevated on the 14th day, and flap viability was determined on the 21st day. Similar flaps were raised on control animals. Serum fibrinogen levels, platelet aggregation studies, and erythrocyte flexibilities were measured in both groups. No improvement in flap viability or rheologic properties of the blood were shown in the pentoxifylline‐treated animals. Although no enhancement of skin flap survival was demonstrated, future studies are warranted. Implications for future investigation and clinical application are discussed.

Canal atresia reconstruction with dental impression material

Medium-density viscosity dental impression material has recently been used after repair of an atretic canal to stent open the newly created external auditory canal for 2 weeks, followed by a hard acrylic stent. This may provide more benefits than traditional packing, but caution must still be used. We recently have used the dental impression material to help in the reconstruction of seven ear canals. The medium-viscosity impression material hardens quickly and provides a solid, nonmobile stent, which usually pulls out without difficulty. The stent that is removed may then be used by our prosthodontist to fashion a hard, acrylic, removable stent to be worn for the next few months. This hard stent is used to prevent further stenosis. As with any technique, complications may arise and, through experience, common mistakes that can hinder a good outcome can be avoided. We will report six cases with illustrated tips on how to avoid complications when using this technique.

Reduced Mastoidectomy Complications with an Open Meatoplasty Stent

Open-tube stents were compared with standard petroleum gauze packs in meatoplasties after canal-wall-down mastoid surgery to determine whether any difference existed in postoperative complications. Tube stents were associated with much lower incidences of postoperative meatoplasty stenosis and postauricular wound complications in this series.

Use of a Composite Autograft to Prevent Recurrent Cholesteatoma Caused by Canal Wall Defects

Recurrent cholesteatoma following atticotomy or combined-approach tympanoplasty remains a significant problem. The importance of closing defects created by surgery or disease in the posterosuperlor bony canal is recognized, and numerous materials and techniques have been advocated. Our experience with a composite autograft of tragal cartilage and perichondrium in 40 ears is presented after 1 to 6 years follow-up. The composite autograft performed satisfactorily in 38 cases. In no case did recurrent cholesteatoma develop at the site of a defect that had been obliterated by the autograft.