Otology

Editors Picks

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.

Chondromyxoid fibroma of the mastoid portion of the temporal bone: MRI and PET/CT findings and their correlation with histology

April 17, 2013     Noeun Oh, MD; Azita S. Khorsandi, MD; Sophie Scherl, BA; Beverly Wang, MD; Bruce M. Wenig, MD; Spiros Manolidis, MD; Adam Jacobson, MD
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Abstract

We report a very rare case of a chondromyxoid fibroma of the mastoid portion of the temporal bone in a 38-year-old woman who presented with left-sided hearing loss. Magnetic resonance imaging identified an expansile mass in the left mastoid bone with a heterogeneous hyperintense signal on T2-weighted imaging and peripheral enhancement. Subsequent positron emission tomography/computed tomography identified erosive bony changes associated with hypermetabolism. The patient underwent an infratemporal fossa resection with a suboccipital craniectomy/cranioplasty. We briefly review the aspects of this case, including a discussion of the differential diagnosis and the correlation between histologic and imaging findings.

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.

Cavernous hemangioma of the external auditory canal

April 17, 2013     Min-Tsan Shu, MD; Kang-Chao Wu, MD; Yu-Chun Chen, MD
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The differential diagnosisfor cavernous hemangioma of the external auditory canal includes attic cholesteatoma with aural polyp, glomus tumor, arteriovenous malformation, granulation tissue, and carcinoma of the EAC.

Endolymphatic sac tumor

April 17, 2013     Lester D.R. Thompson, MD
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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.

Behcet disease as a cause of hearing loss: A prospective, placebo-controlled study of 29 patients

March 24, 2013     Ozgur Kemal, MD; Yucel Anadolu, MD; Ayse Boyvat, MD; and Ahmet Tataragasi, AuD
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Abstract

We conducted a prospective, placebo-controlled study to determine the incidence and severity of inner ear involvement and hearing loss in patients with Behçet disease. Our study population was made up of 29 patients with Behçet disease and 28 healthy controls. Audiometric pure-tone thresholds and transient evoked otoacoustic emission (TEOAE) levels were determined in both groups. The main outcome measures were pure-tone audiometry (PTA) levels and TEOAE levels in the two groups. PTA detected a sensorineural hearing loss in 10 of the 29 patients (34.5%). The difference in audiometric findings between the two groups was statistically significant at 1, 2, 4, and 8 kHz (p ≤ 0.0498). A comparison of TEOAE levels revealed that the difference in sound-to-noise ratio between the two groups was not significant at 1, 1.5, 2, and 3 kHz, but it was significant in 4 kHz (p = 0.02), and the difference in reproducibility between the two groups was significant at 2 and 4 kHz (p ≤ 0.03). We conclude that all patients with Behçet disease should be screened for hearing impairment and subsequently treated if an impairment is discovered.

Mastoid osteoma: A case report and review of the literature

March 24, 2013     Jeffrey Cheng, MD; Roberto Garcia, MD; Eric Smouha, MD
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Abstract

We describe the case of a 22-year-old woman who presented with a slowly growing osseous lesion of the mastoid cortex. On computed tomography, the lesion was found to involve the mastoid cortex, with which it demonstrated similar attenuation. The indications for treatment in this case were the patient's sensation of a mass effect, the encroachment of the mass onto the external auditory meatus, and a cosmetic deformity. The tumor was removed in its entirety via a postauricular approach. Findings on histopathologic examination were consistent with a compact osteoma. Mastoid osteomas are rare, benign tumors. If their growth significantly occludes the meatus, they may cause cosmetic deformities, conductive hearing loss, and recurrent external ear infections. Several other osseous lesions of the temporal bone should be considered in the differential diagnosis. The etiology of mastoid osteomas is poorly understood. Surgical management can be undertaken with minimal postoperative morbidity.

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.

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.

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
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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.

Idiopathic incus necrosis: Analysis of 4 cases

February 25, 2013     Leyla Kansu, MD; Ismail Yilmaz, MD; Volkan Akdogan, MD; Suat Avci, MD; Levent Ozluoglu, MD
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Abstract

We evaluated ossicular chain reconstruction in patients with idiopathic incus necrosis who have conductive hearing loss and an intact ear drum. The study included four patients (3 women and 1 man; the ages of the patients were 22, 31, 35, and 56 years, respectively) with unilateral conductive hearing loss, no history of chronic serous otitis media, an intact ear drum, normal middle ear mucosa, and necrosis of the long processes of the incus. On preoperative pure tone audiometry, air-bone gaps were 24, 25, 38, and 33 dB. Bilateral tympanometry and temporal bone computed tomography results were normal. All 4 patients underwent an exploratory tympanotomy. During the operation, the mucosa of the middle ear was normal, with a mobile stapes foot plate and malleus. No evidence of any granulation tissue was found; however, necrosis of the incus long processes was seen. For ossicular reconstruction, we used tragal cartilage between the incus and the stapes in 1 patient; in the other 3 patients, glass ionomer bone cement was used (an interposition cartilage graft also was used in the patients who received the glass ionomer bone cement). In all patients, air-bone gaps under 20 dB were established in the first year after surgery. In the ossicular disorders within the middle ear, the incus is the most commonly affected ossicle. While, the most common cause of these disorders is chronic otitis media, it may be idiopathic rarely. Several ossicular reconstruction techniques have been used to repair incudostapedial discontinuity.

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