The American journal of otology最新文献

Objective: To assess a new device intended to cover tympanic membrane (TM) perforations in an office setting.

Study design: Not all patients with TM perforations require or choose tympanoplasty surgery. Alternatives to surgery (e.g., paper and plastic onlay) have limitations that prompted a need for an alternative method. A new, simple device, designed to be inserted into the perforation, is made out of a very soft silicone in the shape of a sealed tympanostomy tube. The TM Patcher is self-stabilizing without adhesives.

Setting: An outpatient office.

Patients: Twenty-nine patients with 30 consecutive dry TM perforations, who volunteered to participate in the study. Patients with known cholesteatomas or persistent drainage were excluded.

Interventions: In the office, patients had the Patcher inserted into their dry TM perforation. No anesthetics were needed.

Main outcome measures: Hearing was tested before and after patching by conventional audiometry. The ears were assessed for Patcher position, perforation status, and infection.

Results: Patients with normal ossicular chains had immediate improvement of hearing. No patient experienced hearing loss. Twenty-six of 30 patients (87%) were free of infection. Two patients (7%) with persistent drainage were taken to surgery and were found to have mastoid disease (cholesteatoma or granulation tissue). Three patients (10%) had rare otorrhea after patching and were treated by drops or temporary removal of the Patcher. Two of these three ears subsequently became dry and then healed. Small perforations often healed or became smaller (46% of 3-mm perforations) despite failure of tympanoplasty or conventional office patching with a flat piece of paper or plastic. Perforations >5 mm did not heal; however, these patients simply continued wearing their Patcher and benefited by protection of their middle ear, typically with improved hearing and resolution of tinnitus. Occasional spontaneous lateralization was allowed to occur in the small perforations, which often later healed. In larger perforations, the Patcher was simply repositioned.

Conclusions: The Patcher is a safe and effective alternative for office patching of dry perforations when surgery is contraindicated or is refused by the patient. New materials should increase healing rates when applied to a Phase II Patcher.

Background: Cochlear ischemia is likely involved in sensorineural hearing loss after cerebellopontine angle (CPA) surgery.

Objective: To demonstrate the type of vascular damage to the cochlea, apart from arterial section, that can be induced by CPA surgery.

Methods: The effects on measures of both cochlear blood flow (CBF) and distortion-product otoacoustic emissions (DPOAEs) of partial or total mechanical compressions of the internal auditory artery (IAA) were compared in young adult rabbits.

Results: When preocclusion baseline activity was compared with postocclusion CBF and DPOAEs, it was clear in the majority of cases that total compressions lasting < or =7 minutes produced the same full recoveries for both measures as did the shorter obstructions of only a few minutes. By contrast, both short and long partial occlusions in which ischemia was interrupted by periods of poor reperfusion (<50% of the initial CBF value) resulted in delayed and prolonged recoveries. In addition, at times, full recovery was not achieved, particularly for DPOAEs, because of vasospasm-like activity.

Conclusion: Vasospasm of the IAA was induced by a systematic series of IAA compressions and releases that did not provide for full reperfusion. These data support the concept that vasospasm should be prevented whenever hearing preservation is attempted in CPA surgery.

Objective: To establish the incidence rate of vestibular schwannomas (VS) (acoustic neuromas) in Denmark.

Background: The worldwide incidence rates of VS vary from 1 to 20 cases per million population per year.

Methods: The nationwide and population-based age-specific, sex-specific, and calendar year-specific incidence rates of VS in Denmark between 1977 and 1995 are presented. Information on cases of VS was obtained from the Danish Cancer Registry and a clinical database situated at the University Hospital of Gentofte. A total of 795 cases were reported during the period of the study.

Results: The incidence rate increased from 5 cases per million population per year in 1977-1981 to 10 cases in 1992-1995; the increase was from 5 to 11 cases among women and 5 to 9 cases among men. The age-specific incidence rates show that VS is rarely diagnosed in persons under 30, but the incidence rate appears to increase among women after menopause.

Conclusion: The overall incidence rate of VS increased linearly during the study period, probably owing to the introduction of more precise diagnostic procedures, increased awareness among physicians and patients of the symptoms of VS, improved registration of benign tumors in Denmark, and the use of data from two sources.

Objective: To characterize the incidence and complications resulting from venous insufficiency after neurotologic-skull base surgery.

Study design: Retrospective case review of >3,500 cases.

Setting: Tertiary referral center, inpatient surgery.

Patients: Six patients: four with complications related to chronic venous insufficiency and two with complications related to acute venous insufficiency.

Intervention(s): Medical (steroids, acetazolamide, hyperventilation, mannitol) and surgical (lumboperitoneal shunt, optic nerve decompression, embolectomy) interventions were undertaken.

Main outcome measure(s): Chronic venous insufficiency: nonobstructive hydrocephalus manifested by headache, disequilibrium, and papilledema with resultant visual loss. Acute venous insufficiency: acute nonobstructive hydrocephalus resulting in mental status abnormalities in the postoperative period.

Conclusions: (1) Incidence of 1.5 per 1,000 cases. (2) Acute and chronic forms with different pathogenesis. (3) Acute form presents postoperatively with change in consciousness and herniation, and may proceed to death. (4) Chronic form presents months or years postoperatively with headache, disequilibrium, and visual changes from papilledema. (5) Occurs almost solely in patients with preoperative abnormalities of the venous collecting system. (6) Causes mental status changes postoperatively.

Objective: Inner ear disorders are proposed to be affected by changes in inner ear hydrostatic pressure. In humans, the perilymphatic hydrostatic pressure can be assessed in a noninvasive way with the MMS-10 Tympanic Displacement Analyser. In this study, measurements were performed in patients with Ménière's disease and patients with idiopathic sudden sensorineural hearing loss (ISSHL), and the results were compared with those of normal hearing ears. The measurement technique has been evaluated as a possible additional diagnostic tool for Ménière's disease or ISSHL.

Study design: The hydrostatic perilymphatic pressure was measured noninvasively with the MMS-10 Tympanic Displacement Analyser.

Setting: Department of Otorhinolaryngology at the University Hospital.

Patients: Seventy-seven patients with Ménière's disease, 28 patients with ISSHL, and 50 normal hearing subjects.

Intervention: Diagnostic.

Main outcome measure: Significant differences of perilymphatic pressure measurement results, represented by the measurement parameters Vi and Vm, in affected, nonaffected, and normal hearing ears.

Results: On average, the measurement results showed no significant differences between affected (by Ménière's disease or ISSHL), nonaffected, and normal hearing ears.

Conclusions: In affected ears, perilymphatic pressure measured noninvasively did not differ significantly from the pressure in nonaffected and normal hearing ears. The tympanic membrane displacement technique cannot be considered an additional tool to confirm or reject the diagnosis of Ménière's disease or ISSHL.

Background: Conductive hearing loss is occasionally recognized in large vestibular aqueduct (LVA) syndrome; however, the incidence rate and the cause are not known.

Objective: To compare air and bone conduction levels between patients with LVA syndrome and those with idiopathic sudden sensorineural hearing loss, and to investigate the cause of the air-bone gap.

Study design: Retrospective study.

Setting: The patients were treated at a tertiary referral center.

Patients: Twenty-eight ears of 15 patients with LVA syndrome and 28 ears of patients with idiopathic sudden sensorineural hearing loss were examined. The latter patients were selected from a computerized database to match the former patients in air conduction levels.

Main outcome measures: Pure-tone audiometry, multiple frequency tympanometry, acoustic reflex, otoacoustic emission, vestibular evoked myogenic response.

Results: The air-bone gap in patients with LVA syndrome was always larger than that in patients with idiopathic sudden sensorineural hearing loss with the same air conduction level. The resonant frequency in patients with LVA syndrome was rather low compared with that in normal control subjects, in contrast to the finding that resonant frequency was significantly high in patients with otosclerosis.

Conclusions: An air-bone gap exists to some degree in almost all patients with LVA syndrome. The air-bone gap may not be associated with the movement restriction of the stapes as it is with otosclerosis.

Background: Matrix metalloprotease-9 (MMP-9) plays an important role in the degradation of extracellular matrix (ECM). In cholesteatoma there are significant changes in the composition of the ECM, supporting the view of a disturbed cell-ECM interaction. It has been reported that in cholesteatoma tissues, MMP-9 is expressed in epithelial cells but not in stromal cells. In this study, we report conflicting results regarding the identity of the cholesteatoma cells that express MMP-9.

Methods: An immunohistochemical assay was performed to examine the expression of MMP-9 in 25 cases (formalin-fixed paraffin-embedded sections) of cholesteatoma, using an MMP-9-specific monoclonal antibody.

Results: In all cholesteatomas examined, MMP-9 was expressed in the stromal cells but not in the epithelial cells. MMP-9 immunostaining was undetectable in external auditory meatal skin (n = 5) and tympanic membrane (n = 3).

Conclusions: These results suggest that the MMP-9 expressed in stromal cells may be involved in the disturbed cell-ECM interaction associated with the process of cholesteatoma formation.

Hypothesis/background: Endotoxin can induce morphologic changes to middle ear epithelium, which can disturb the mucociliary clearance system (MCS) and lead to otitis media with effusion (OME). The bactericidal/permeability-increasing (BPI) protein is a major component of neutrophil granules and binds with high affinity to endotoxin. In this study, the capacity to inhibit the effects of endotoxin by rBPI21, a recombinant amino-terminal analog derived from BPI, was investigated on cultured human middle ear epithelium using light microscopy and scanning- and transmission electron microscopy.

Methods: Human middle ear epithelium was air-exposed cultured on a collagenous underlayer with different additions of endotoxin and rBPI21 to the culture medium. The tissue specimens were inspected after 4 weeks for the number of ciliated and secretory cells, thickness of the mucosal layer, and cell size.

Results: The morphologic changes induced by endotoxin were increased thickness of the mucosal layer and increased number of secretory cells. These changes were significantly diminished or even absent when endotoxin was added with rBPI21 to the culture medium.

Conclusion: rBPI21 can inhibit morphologic changes in the middle ear epithelium due to endotoxin. Hence, the authors believe that rBPI21 can be a new therapeutic agent in the treatment of OME.

Objective: To determine the incidence of tinnitus and associated handicap after unilateral sudden sensorineural hearing loss (SSNHL); in addition, to determine the hearing handicap experienced as a consequence of such a loss.

Study design: Identification of patients and determination of demographic and audiologic data by retrospective case review; determination of handicap and distress by postal questionnaire.

Setting: Teaching hospital department of otolaryngology.

Patients: Thirty-eight patients were identified as having been treated for a unilateral sudden sensorineural hearing loss in the period 1988 through 1997. Of those, 21 (55.3%) replied to the questionnaire.

Main outcome measures: Audiometric data at admission and at 4-week follow-up, Tinnitus Handicap Inventory (THI), visual analogue scales of tinnitus loudness and distress, Hearing Handicap Inventory in Adults (HHIA).

Results: The questionnaire responder group did not significantly differ from the questionnaire nonresponder group on demographic nor audiometric variables, and hence were considered to be a representative sample. Tinnitus was present in 14 patients (67%). Hearing handicap was found in 86% of patients (of the 21 questionnaire responders) and tinnitus handicap in 57% (of the 14 with tinnitus). Correlations were found between tinnitus loudness, distress, and handicap. There was no correlation between time elapsed since SSNHL and tinnitus or hearing handicap, nor was there a correlation between the extent of audiometric loss and hearing or tinnitus handicap. A strong negative correlation was, however, found between recovery in audiometry in the first 4 weeks after onset and tinnitus and hearing handicap. The audiometric status of the contralateral ear correlated with hearing handicap.

Conclusions: A majority of patients after unilateral SSNHL have a perceived handicap associated with tinnitus and hearing. Although this condition is an otologic emergency, careful thought should be given to the audiologic rehabilitation of this patient group.