Otolaryngologic Clinics of North America最新文献

The diagnosis of skull base cerebrospinal fluid (CSF) leaks remains challenging and requires a multidisciplinary approach. Clinical evaluation and targeted endoscopic examination are essential, but laboratory confirmation with beta-2 transferrin or beta-trace protein provides the most reliable noninvasive evidence. Imaging modalities such as high-resolution computed tomography (CT), magnetic resonance cisternography, CT cisternography, and radionuclide studies complement detection and localization, guiding surgical planning. Intraoperative fluorescein enhances defect identification. Each diagnostic tool offers unique strengths and limitations, and their judicious combination enables accurate detection, localization, and management of CSF leaks.

While the motivation to pursue middle ear surgery is frequently related to establishing a safe, dry ear due to the presence of chronic otitis media or cholesteatoma, a highly prioritized secondary outcome is improvement in hearing. Compounding the task of precise recapitulation of middle ear mechanics is the accurate measurement of hearing changes before and after surgery. Here, we will review the basics of the audiometric assessment of ossicular chain function, summarize clinical audiometric outcomes associated with ossiculoplasty, and discuss the limitations of both the surgical technique and our ability to quantify ideal hearing outcomes.

Cerebrospinal fluid leaks are a complex clinical challenge with variable causes and management. Conservative therapy focuses on lowering intracranial pressure through bed rest, sinus precautions, antiemetics, bowel regimens, and lumbar drainage. Leaks persisting beyond 1 week may require surgical repair due to meningitis risk. Iatrogenic, postoperative, and spontaneous leaks rarely resolve without surgery, while small traumatic leaks tend to have the highest chance of resolution. Prophylactic antibiotics remain controversial. Management should be tailored to etiology, location, and patient-specific factors.

Computed tomography (CT) of the temporal bone can identify causes of hearing loss that can be addressed with ossiculoplasty. Careful investigation with CT and MRI can ensure the correct diagnosis and management of various temporal bone pathologies. In this article, we review critical imaging findings related to conductive hearing loss.

Ossicular chain defects are commonly encountered in otologic practice. The search for the ideal ossicular psosthesis is an ongoing debate. In this article, we describe our experience with the use of autologous cartilage tympanoplasty. Septal floor cartilage is harvested via the Killian incision and remodelled to fit the various ossicular defects identified in the middle ear. We describe the procedure from harvesting of cartilage through to ossiculoplasty. Different scenarios are described, as encountered intra operatively. We have not experienced extrusion when using this material. The cartilage remains sturdy even in the setting of recurrent disease. Audiological outcomes with the use of this technique are comparable to other ossiculoplasty material in the literature.

The middle ear amplifies sound waves transmitted through air, allowing for sufficient sound pressure to be received in the cochlea through a few interesting mechanisms of the tympanic membrane and ossicular chain, which is composed of the malleus (hammer), incus (anvil), and stapes (stirrup). We discuss how these structures serve as an acoustic conduit, alleviating the large impedance mismatch between air and fluid; and we provide an overview of the anatomy, physiology, and biomechanics of the middle ear, which are important concepts relevant to ossiculoplasty. By combining surgical expertise with scientific innovation, ossiculoplasty remains a cornerstone of middle ear surgery.

The surgical approach for ossiculoplasty, also known as ossicular chain reconstruction, is chosen based on the extent of concomitant middle ear or mastoid disease, such as chronic otitis media or cholesteatoma. The primary objective of the surgical approach is to adequately expose the middle ear ossicles, diagnose the ossicular chain pathology, and facilitate reconstruction. Surgeons may employ microscopes and/or endoscopes for visualization and access the ossicular chain through a variety of surgical corridors including the transcanal, endaural, transmeatal, postauricular, and transmastoid/transfacial recess approaches. Endoscopic approaches allow enhanced visualization of the middle ear and demonstrate comparable hearing outcomes to microscopic approaches.

Erosive middle ear disease (EMED) involves a spectrum of otologic conditions that involve chronic inflammatory processes, including chronic otitis media with or without cholesteatoma, that contribute to osseous erosion of the middle ear and ossicular chain. Treatment of EMED involves the eradication of the disease followed by ossicular chain reconstruction to optimize hearing outcomes. There are many challenges regarding ossiculoplasty in EMED, including the potential for microscopic residual disease, variability of ossicular chain status following disease eradication, and concern for recurrent disease processes.

Most traumatic ossicular chain injury results from blunt head trauma associated with temporal bone fracture, though penetrating, barotraumatic, and iatrogenic causes are also encountered. Dislocation of the IS joint is the most common lesion, followed by IM separation and a stapes superstructure fracture. Management depends on the mechanism and severity. High-resolution temporal bone computed tomography aids in localizing disruption and identifying delayed ossicular fixation. Surgical reconstruction with autologous or artificial materials typically achieves postoperative air-bone gaps of 10 to 20 dB. Long-term hearing stability depends on prosthesis position, eustachian tube function, and the integrity of the stapes superstructure.