Middle Ear

Middle ear effusion in adult ICU patients: A cohort study

August 21, 2013     Bradley W. Kesser, MD; Charles Ryan Woodard, MD; Nicholas G. Stowell, MD; and Samuel S. Becker, MD
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Abstract

We conducted a prospective study of 74 adults-34 men and 40 women, aged 18 to 90 (mean: 60.2)-to determine the prevalence of middle ear effusion (MEE) among patients in the setting of an intensive care unit (ICU) and to compare the findings with those of a control group of non-ICU hospitalized patients. Other goals were to identify risk factors associated with MEE in ICU patients and to evaluate any association with fever. Both groups included 37 patients. MEE was present in 19 patients (51.4%) in the ICU group, compared with only 2 patients (5.4%) in the control group (p < 0.01; odds ratio: 18.5; 95% confidence interval: 3.9 to 88.3). In the ICU group, there were statistically significant associations between MEE and both the use of mechanical ventilation (p = 0.03) and the use of sedation (p = 0.02). No significant relationships were seen in terms of length of stay, body position, the use of an endotracheal tube, the length of ventilation, and the use of a feeding tube. Fever was present in 8 ICU patients (21.6%) and 3 controls (8.1%), but none of the fevers was associated with MEE. We conclude that adult ICU patients have a high prevalence of MEE (51.4% in our sample) that is perhaps unrecognized. We believe that MEE in these patients is most likely related to altered consciousness, sedation, and mechanical ventilation. MEE was an unlikely cause of fever.

Degraded tympanostomy tube in the middle ear

July 21, 2013     Nitin J. Patel, MD; Joshua Bedwell, MD; Nancy Bauman, MD; Brian K. Reilly, MD
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Tympanostomy tubes can cause a foreign-body reaction that can lead to myringitis and the development of granulation tissue and polyps.

A study of persistent unilateral middle ear effusion caused by occult skull base lesions

April 17, 2013     John P. Leonetti, MD
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Abstract

The goal of this article is to review a series of patients with persistent unilateral middle ear effusion (MEE) and to suggest a more contemporary diagnostic algorithm. The author conducted a retrospective chart review of adults with persistent unilateral MEE and normal findings on physical and nasopharyngoscopic examinations whose MEE was eventually found to be caused by a variety of occult skull base lesions. The study population was made up of 79 patients-52 women and 27 men, aged 21 to 83 (mean: 54.8) at presentation-who had been referred to an academic tertiary care medical center between July 1, 1988, and June 30, 2008. Follow-up ranged from 9 months to 19.5 years (mean: 8.7 yr). Of this group, 50 patients (63.3%) had a malignant tumor, 26 (32.9%) had a benign tumor, and 3 (3.8%) had an internal carotid artery aneurysm. Eustachian tube occlusion had been caused by diffuse invasion in 33 patients (41.8%), by intracranial pathology in 24 (30.4%), and by extracranial-infratemporal lesions in 22 (27.8%). Nasopharyngoscopy cannot identify a variety of rare skull base lesions that cause eustachian tube compression or tissue invasion that ultimately leads to MEE. Therefore, patients with unexplained persistent unilateral MEE should undergo coronal magnetic resonance imaging or computed tomography to look for any intra- or extracranial lesions before undergoing ventilation tube placement.

Evolution of acute otitis media

April 17, 2013     Joseph A. Ursick, MD; Jose N. Fayad, MD
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Treatment for acute otitis media (AOM) ranges from watchful waiting to myringotomy with or without tube placement.

Retention cyst in chronic otitis media

March 24, 2013     Min-Tsan Shu, MD; Kang-Chao Wu, MD; Yu-Chun Chen, MD
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The retention cyst originates from the obstruction of a glandular structure and contains fluid, while the cholesteatoma contains keratinizing squamous epithelium.

Middle ear metastasis from dormant breast cancer as the initial sign of disseminated disease 20 years after quadrantectomy

March 24, 2013     Teresa Pusiol, MD; Ilaria Franceschetti, MD; Francesca Bonfioli, MD; Francesco Barberini, MD; Giovanni Battista Scalera, MD; Irene Piscioli, MD
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Abstract

We describe an unusual case of breast cancer metastatic to the middle ear in a 71-year-old woman. The metastasis was the initial sign of disseminated disease 20 years after the patient had undergone a quadrantectomy for her primary disease. Computed tomography (CT) demonstrated the presence of an intratympanic mass with a soft-tissue density that was suggestive of chronic inflammation. The patient underwent a canal-wall-down tympanoplasty. When a brownish mass was found around the ossicles, a mastoidectomy with posterior tympanotomy was carried out. However, exposure of the tumor was insufficient, and therefore the posterior wall of the ear canal had to be removed en bloc. Some tumor was left on the round window membrane so that we would not leave the patient with a total hearing loss. Our case highlights the limitations of CT and magnetic resonance imaging in differentiating inflammatory and neoplastic lesions.

Cerebrospinal fluid leak of the fallopian canal

March 24, 2013     Karen B. Teufert, MD; William H. Slattery, MD
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Abstract

Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are extremely rare, as only a few cases have been reported in the world literature. We describe a case of spontaneous CSF otorrhea through an enlarged geniculate fallopian canal. The patient was a 45-year-old woman who presented with a history of CSF rhinorrhea and otorrhea from the right ear. Myringotomy and tube insertion revealed CSF otorrhea. Contrast-enhanced computed tomography revealed that the geniculate fossa was smoothly enlarged (demonstrating remodeling of bone). A middle fossa craniotomy with temporal bone exploration was performed. Intraoperative inspection detected the presence of a fistula secondary to a lateral extension of the subarachnoid space through the labyrinthine segments of the fallopian canal. We discuss the management of this unusual finding, which involves sealing the fistula while preserving facial nerve function.

Absent stapedial reflex: Otosclerosis or middle ear tumor?

February 25, 2013     Deb Biswas, FRCS-ORL, MS-ORL, MRCS, DOHNS; Ranjit K. Mal, FRCS
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Abstract

We present an unusual case in which a patient diagnosed as having otosclerosis on the basis of clinical and audiologic findings actually had a middle ear facial nerve schwannoma. To the best of our knowledge, this is the first reported case in English literature in which a facial nerve schwannoma presented with conductive deafness of gradual onset and absent stapedial reflex with a normally functioning facial nerve. We also include a review of the literature.

Recurrent post-tympanostomy tube otorrhea secondary to aerobic endospore-forming bacilli: A case report and brief literature review

February 25, 2013     James J. Jaber, MD, PhD; Matthew L. Kircher, MD; Eric Thorpe, MD; Ryan G. Porter Sr., MD; John P. Leonetti, MD; Sam J. Marzo, MD
article

Abstract

We report a unique case in which a 57-year-old man with an 8-year history of late recurrent post-tympanostomy tube otorrhea (PTTO) was found to harbor Bacillus subtilis, an aerobic endospore-forming bacillus that is typically resistant to chemical and physical agents because of its unique life cycle. Removal of the patient's tympanostomy tube resulted in complete resolution of his long-standing otorrhea. We also review the etiologies of and treatment strategies for early, late, chronic, and recurrent PTTO. We conclude that regardless of the etiology, a patient with persistent or recurrent PTTO should consider undergoing removal of the ventilation tube.

Complicated coexisting pyogenic and tuberculous otitis media affecting the temporozygomatic, infratemporal, and parotid areas: Report of a rare entity

January 24, 2013     Tripti Brar, MBBS, MS, DNB; Sumit Mrig, MBBS, MS, DNB; J.C. Passey, MS; A.K. Agarwal, MS; Shayma Jain, MD
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Abstract

We report an unusual case in which a 28-year-old woman presented with a long-standing history of ear discharge, hearing loss, facial weakness with ipsilateral facial swelling and cellulitis, a postauricular fistula, and an abscess of the temporozygomatic, infratemporal, and parotid areas. The pus stained positive for bacteria and acid-fast bacilli, and culture was positive for Proteus vulgaris and mycobacteria. Based on these findings, a diagnosis of tuberculous otitis media with complications was made. Computed tomography showed extensive destruction of the tympanic and mastoid part of the temporal bone, as well as lytic lesions in the skull. The patient was placed on antituberculosis drug therapy. Although her facial nerve palsy and hearing loss persisted, she otherwise responded well and did not require surgery.

Nontuberculous mycobacterial otomastoiditis: A case report

January 24, 2013     Li-Tai Tsai, MD; Ching-Yuan Wang, MD; Chia-Der Lin, MD; Ming-Hsui Tsai, MD
article

Abstract

Nontuberculous mycobacterial otomastoiditis is rare and can be easily confused with various different forms of otitis media. We describe the case of a 50-year-old woman who presented with left-sided chronic otitis media that had persisted for more than 1 year. It was not eradicated by standard antimicrobial therapy and surgical debridement. After appropriate antibiotic therapy for nontuberculous mycobacteria was added to the therapeutic regimen, the patient improved significantly and the lesion had healed by 6 months. Based on our experience with this case, we conclude that early bacterial culture and staining for acid-fast bacilli in ear drainage material or granulation tissue should be performed when standard antimicrobial therapy fails to eradicate chronic otitis media of an undetermined origin that is accompanied by granulation tissue over the external auditory canal or middle ear. Polymerase chain reaction testing is also effective for rapid diagnosis. Surgical debridement and removal of the foreign body can successfully treat nontuberculous mycobacterial otomastoiditis only when effective antimicrobial therapy is also administered.

Tympanomastoidectomy with otoendoscopy

December 31, 2012     Ryan M. Rehl, MD; Sepehr Oliaei, MD; Kasra Ziai, MD; Hossein Mahboubi, MD, MPH; Hamid R. Djalilian, MD
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Abstract

A cadaveric study was performed to test the hypothesis that intact-canal-wall mastoidectomy (ICWM) with otoendoscopy allows for equal or better visualization of the middle ear cavity structures when compared with canal-wall-down mastoidectomy (CWDM) with microscopy. Ten temporal bones were prepared with a reversible canal-wall-down tympanomastoidectomy technique. Five anatomic sites in each middle ear cavity (lateral epitympanum, posterior crus of the stapes, the sinus tympani, eustachian tube orifice, and round window niche) were marked with paint. Two otolaryngologists blinded to the purpose of the study viewed the temporal bones with the microscope. Following replacement of the posterior canal walls, the bones were then viewed with a 30° and a 70° otoendoscope. All visualized paint marks for each viewing were recorded and compared. We found that ICWM with 30° or 70° otoendoscopy provided significantly better visualization of the sinus tympani than did CWDM (p ≤ 0.001). There was no significant difference among the three methods in visualization of the lateral epitympanum, posterior crus of the stapes, and round window niche. With respect to the eustachian tube orifice, one of the observers reported significantly better visualization with CWDM (p = 0.036). With adjunctive otoendoscopy, it is not necessary to remove the posterior canal wall to adequately visualize or remove disease from various areas of the middle ear cleft. The use of otoendoscopy during cholesteatoma surgery may allow for more frequent preservation of the posterior canal wall and reduced rates of residual cholesteatoma, given the equal or better visualization of the middle ear cavity.

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