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CHRONIC OTITIS MEDIA
Table 10.1 Grading systems for tympanic retraction for the pars accida (Tos system) and pars
tensa (Sade system)
Grade Pars accida Pars tensa
1 Retraction to neck of malleus, but airspace
visible
2 Retraction onto neck of malleus, no
airspace behind membrane
3 Retraction extends beyond malleus, but
full extent visible
4 Scutum eroded, full extent of retraction
not visible
Mild retraction
Retraction onto incudostapedial joint
Retraction onto promontory (not
adherent)
Adhesion of pars tensa to medial wall
Tympanic Perforation and CSOM
Some perforations are asymptomatic (inactive), whereas others will lead to repeated infections (active). Infection (leading to CSOM) may arise from water ingress, an upper respiratory
tract infection, or without obvious precipitant. In the United Kingdom, CSOM aects around
1% of adults, but on a global scale it has a high disease burden, aecting around 250 million
adults and children. Prevalence is higher in socioeconomically deprived regions and in indigenous populations.
Active infection should be treated with aural toilet (microsuction/ear wicking/iodine washout; Figure 10.2) and topical antibiotics. A mixed bacterial ora is typical of CSOM, including
Proteus, staphylococci, and Pseudomonas. Many advocate quinolone antibiotic drops as rst-
line treatment, because they are oen eective and are not known to be ototoxic. Advice on
correct ad ministration of drops is important (head ti lted to the side with tragal pumping to push
drops medially). Antifungal drops may be indicated if fungal infection is suspected or if spores
are seen, and in such cases prolonged therapy may be needed. In low-resource settings human
immunodeciency virus (HIV) infection may be a cause, or tuberculosis (TB; particularly if
there are multiple perforations of the tympa nic membrane). Fai lure of initial treatment warrants
microbial culture and sensitivity testing, regular aural toilet, and consideration of switching of
topical antibiotic class (or considering an antifungal), and possibly addition of oral antibiotics.
Patients with persistent or recurring infection may benet from tympanoplasty, which typically has a success rate of around 85%. Local anaesthetic tympanoplasty is an option for
selected patients, including those not suitable for general anaesthesia. Tympanoplasty is also
a treatment for those with hearing loss (air-bone gap greater than 20 dB) from a tympanic
perforation or CSOM. Hearing aids are an alternative option but increase the risk of infection. Tympanoplasty is covered in more depth in Chapter 11.
Cholesteatoma
Cholesteatoma aects 1 in 10,000 of the population per year. Once present, cholesteatoma
becomes an encapsulated but self-perpetuating mass, typically growing into the mastoid air
cells, and eroding surrounding bone. Super-added infection is common, and may increase
disease activity and patient symptoms. ere is a small risk of death from intracranial spread
of infection, estimated at 1 in 10,000 per year.
e only eective treatment for cholesteatoma is surgical excision through mastoidectomy.
In patients unt for surgery, aural toileting to debulk disease may be used, but it is unclear
if this is of any benet. Most surgeons will obtain a computed tomography (CT) scan of the
temporal bones prior to operating, to identify anatomical variants and bony erosion.
Mastoidectomy may be performed with either preservation or removal of the bone of the
superior and posterior external auditory canal (EAC). Where the EAC is preserved this is
termed a ‘wall up’ procedure, also known as combined approach tympanoplasty. Where the
EAC is removed this is a ‘wall down’ procedure, and it can be classied by the extent of dissection (atticotomy/attico-antrostomy/mastoidectomy).
58 e Ear
CHRONIC OTITIS MEDIA
(a)
(b)
(c)
Microsuction
ear
Vacuum
aspiration
Figure 10.2 Techniques for irrigation in active chronic suppurative otitis media. (a) Suction under
microscopic guidance (microsuction). (b) Washout with dilute iodine solution using a syringe.
(c) Wicking the ear with spears made of tissue paper (which can be performed by the clinician,
patient, or carer.)
e Ear 59
CHRONIC OTITIS MEDIA
e canal wall up procedure risks leaving residual disease hidden in the mastoid, so there
needs to be subsequent follow-up with imaging (diusion weighted magnetic resonance
imaging [MRI]) and/or another operation to directly visualise (called a ‘second look’) the
mastoid, typically a year aer the rst procedure. A wall down procedure leaves a patient
with a mastoid cavity, which in some patients can cause problems with wax entrapment
(necessitating regular dewaxing) or infection. In the wall down technique, obliteration of
the mastoid cavity can reduce the risk of post-operative problems, and meatoplasty will aid
clearance of the cavity. In the wall up technique use of an endoscope to aid visualisation and
‘painting’ the cavity with laser can reduce risk of residual disease.
ere is debate about the relative merits of wall up or wall down procedures, and the choice
of procedure should be tailored to individual disease and patient factors.
As well as t he risk of residual or recurrent disease, mastoidectomy also carries a risk of worse
hearing (including a dead ear), persistent otorrhoea (usually from a failure of reconstruction leading to exposed mucosal epithelium), taste disturbance, nausea, vertigo, tinnitus,
or facial palsy.
Tympanosclerosis
Tympanosclerosis describes the deposition of calcium or bone at sites of previous middle ear
inammation. Usually it aects only the tympanic membrane (myringosclerosis) and is of no
consequence. Rarely it may be found to aect the ossicles, oen in an ear undergoing exploration for conductive hearing loss, causing xation of the ossicular heads (treated with partial
ossiculoplasty) or around the stapes footplate (usually causing surgery to be abandoned).
Complications
Complications of chronic otitis media occur from the erosion of surrounding structures.
is is most common in cholesteatoma but can also happen in persistent severe CSOM.
Within the temporal bone, erosion can occur of the facial canal (with a risk of facial palsy),
or into the labyrinth causing hearing loss or vertigo (typically with a stula of the lateral
semicircular canal). Treatment is by removal of infection/cholesteatoma. If an inner ear stula is present at surgery, the cholesteatoma sac over the stula may be marsupialised into
a mastoid cavity (associated with a low risk of iatrogenic hearing loss), or removed and the
stula repaired with bone pate (1 in 6 risk of dead ear).
Extra-temporal spread posteriorly or superiorly can lead to intracranial complications of
meningitis, sigmoid sinus thrombosis, or temporal lobe or cerebellar brain abscess, which
may present with fever and headache, or in advanced cases with altered mental state, seizures, or lateralising neurological signs. Lateral erosion can lead to mastoiditis or a mastoid
stula. Inferior spread can lead to neck abscess. Treatment of complications is with antibiotics, drainage of any abscess (either transcranial or transmastoid for intracrania l abscess), and
urgent mastoidectomy to treat the infection source. Many advocate adding anticoagulants in
cases of sigmoid sinus thrombosis.
KEY POINTS
• Chronic otitis media may manifest as glue ear, cholesteatoma, tympanic membrane
retraction, or tympanic membrane perforation (with or without infection).
• Aetiology likely relates to repeated bacterial ingress into the middle ear in early
childhood, leading to non-resolving inammation and tissue dysfunction in
predisposed individuals.
• Tympanic retraction or perforation may be treated with tympanoplasty if associated
with infection or hearing loss.
• Cholesteatoma is treated by mastoidectomy, with techniques divided by whether the
bony EAC is preserved or resected.
• Complications arise from bony erosion and spread of infection, and can be life-threatening.
60 e Ear
OSSICULOPLASTY AND MYRINGOPLASTY
Further Reading
1. Bhutta MF, ornton RB, Kirkham LS, Kerschner JE, Cheeseman MT. Understanding
the aetiology and resolution of chronic otitis media from animal and human studies.
Disease Models & Mechanisms 2017: 10, 1289–1300.
2. Bhutta MF, Monono ME, Johnson W. Management of complicated otomastoiditis in
resource constrained settings. Current Opinion in Otolaryngology and Head & Neck
Surgery 2020: 28(3), 174–181.
11. OSSICULOPLASTY AND MYRINGOPLASTY
Myringoplasty
Myringoplasty is dened as surgical repair of the tympanic membrane (TM). is can
be performed to rectify a persistent perforation or reinforce a thin or retracted drum.
Tympanoplasty is dened as surgical repair of defects of the TM and middle ear ossicles. A
type 1 tympanoplasty is synonymous with myringoplasty
Etiology
Infection
•
Most common cause of acute perforation
•
Follows acute otitis media (AOM)
•
Spontaneously heals (70–80% within 30 days)
•
Negative healing inuences: tympanosclerosis, malleus injury, infection, large
•
perforations
Trauma
•
Direct trauma
•
– Foreign bodies (cotton buds, etc.)
– Barotrauma (air travel or diving)
Indirect (temporal bone fracture)
•
Iatrogenic
•
Following extrusion of ventilation tube (VT)
•
– 2.2% risk with short-term VTs
– Up to 16% risk with long-term VTs
Following middle ear surgery
•
Presentation
Perforations can be asymptomatic and found incidentally. However, discharge and hearing
loss (HL) are the main reasons for presentation.
Hearing Loss
HL is variable depending on the size and location of the perforation. Posterosuperior
perforations have larger conductive hearing loss (CHL) than other sites.2 Lower frequencies tend to be more aected than higher ones but, with increasing size, higher
e Ear 61
OSSICULOPLASTY AND MYRINGOPLASTY
frequencies are aected. More severe HL is associated with coexistent ossicular involvement or discontinuity; complete discontinuity can result in a maximal conductive HL of
around 60 dB.
Indications for Myringoplasty
1. Recurrent otorrhoea: More likely with hearing aid use.
2. Hearing loss: Greater than 25% perforation causes increasing HL as size increases.
3. Social: For example, desire to swim.
4. Retraction with risk of developing cholesteatoma.
Contraindications to Myringoplasty
1. Cholesteatoma: All squamous epithelium must be excised from the middle ear prior
to TM closure.
2. Contralateral dead ear (relative contraindication): The risk of HL is 1.5%.
3. Severe Eustachian tube (ET) dysfunction: There is an increased risk of HL and iatrogenic
cholesteatoma with elevating Sade grade IV retractions; recurrence of retraction can
occur.
4. Medical comorbidities: Chronic medical conditions (medications, obesity, smoking,
alcohol, etc.) can all negatively inuence success rate.
5. Social: Varying evidence of inuence of smoking on surgical outcomes.
3
Factors Inuencing Treatment Options
• Timing and age: Some advocate conservative management until after 7 years
of age due to ET maturity. State of the contralateral ear is an important guide
to this.
• Adenoidectomy: Conicting information regarding its contribution, with majority
of reviews suggesting prior adenoidectomy confers no benet to success.
• Infection: There is a differing opinion as to the inuence of infection at time of
surgery on outcomes; however, the majority of studies state infection does not
confer a negative inuence on outcomes.
• Other ear: Normal contralateral ear is a positive predictor of success. Conversely,
abnormal contralateral ear ndings are associated with poorer ipsilateral graft
uptake.
• Mastoid: Evidence of inuence of concurrent mastoidectomy with tympanoplasty is
subject to debate.
Graft Materials
• Paper onlay: Outpatient procedure; reasonable success for small perforations; may
need repeating.
• Autologous
• Temporalis fascia (TF): Most frequently utilised due to availability of abundant
tissue and ease of use.
• Perichondrium (tragus, concha): Easily accessible, long-term reliability, suitable
for permeatal approach.
• Cartilage (tragus, concha): Composite grafts (both cartilage and perichondrium in
the same graft) confer practicality and increased graft success, particularly in larger
perforations (>50%). Hearing results at 1 year equivalent to fascia/perichondrium.
• Other: Includes periosteum, fat, and fascia lata.
• Alloderm: Human allograft skin rendered immunologically inert for when TF not
available; success is 87.5%.
• Xenogenous: Equine and bovine pericardium have poorer success rates compared
with TF. Basic broblast growth factor (FGF) in combination with atelocollagen, on
Gelfoam or as drops has shown very encouraging results.
62 e Ear
OSSICULOPLASTY AND MYRINGOPLASTY
Technique
e ‘underlay’ technique is briey described below:
Local anaesthetic injection into skin incision site (if applicable), ear canal, and
•
graft site.
Approach may be permeatal, endaural, or post-auricular. e latter is useful in narrow
•
ear canals and for anterior perforations.
Freshening of perforation edges.
•
Elevation of tympanomeatal ap.
•
Harvesting of gra and placement medial to TM, supported either by a dissolvable
•
dressing in the middle ear or by using the elevated tympanic annulus to hold the gra
in place.
Replacement of the TM and packing of the ear canal to support the TM.
•
Other techniques include the following:
‘Push-through’ technique: Variant of the underlay technique, avoids elevation of the
•
TM, and is used for small perforations. A dissolvable dressing is placed through the
perforation into the middle ear; the gra is then pushed through the perforation so
that it is held laterally against the TM.
‘Buttery’ technique: Utilises a disc of cartilage with a circumferential groove cut into
•
it; this splays the edges of the cartilage, which ‘snaps’ into place within the perforation. Suitable for smaller perforations <6 mm in size. Mild myringitis occurs in 11%,
resolving within 3 months.
‘Overlay’ technique: Steps similar to the underlay technique, except that the epithelial
•
layer of the TM alone is elevated, with placement of the gra between the collagen
(unelevated) and epithelial (elevated) layers. Repair outcomes are similar for overlay
and underlay techniques.
Complications
• For reperforation rates, the literature shows success rates 60–99% in adults;
35–94% in children. Success falls over time (85% at 1 year, 78% at 10 years). Most
failures are in the early post-operative period.
• Retraction can occur in up to 10%.
• Anterior blunting is a risk for underlay and overlay techniques.
• Iatrogenic cholesteatoma can be as high as 4.4%.
• Myringitis can occur but generally resolves within 3 months with topical treatment.
Ossiculoplasty
Aetiology of Conductive Hearing Loss
Congenital: 1:15,000 births
•
Minor: Just middle ear (stapes xation is the most common)
•
Major: Also involve external auditory meatus (EAM) and TM
•
– Surgery more challenging
– Consider bone conduction hearing device or middle ear implant
Acquired: Secondary to chronic suppurative otitis media
•
Erosion incudostapedial joint (ISJ) More common
Long process of incus
Stapes superstructure
Malleus Less common
e Ear 63
OSSICULOPLASTY AND MYRINGOPLASTY
Classication of Defects
Table 11.1 Austin Kartush classication of ossicular status
Group Ossicular status Abbreviation Prevalence (%)
A Malleus handle and stapes superstructure present M+ S+ 60
B Malleus handle present, stapes superstructure
absent
C Malleus handle absent, stapes superstructure
present
D Malleus handle and stapes superstructure absent M− S− 8
E Ossicular head xation
O Intact ossicular chain
F Stapes xation
Prognostic Factors for Successful Surgery
e Middle Ear Risk Index (MERI) (Table 11.2) provides a measure of severity of middle ear
disease and has been correlated with ossiculoplasty hearing outcomes. It includes ossicular
status as per the Austin Kartush classication and the Belluci classication of otorrhoea
(Table 11.3).
Surgical Materials
Autogras: Incus, cortical bone, cartilage
•
Homogra: From donor, used widely in Belgium but not in the United Kingdom
•
(Creutzfeldt–Jakob disease [CJD] risk)
Alloplastic: Solid plastics, e.g. polyethylene
•
Porous plastics, e.g. Plasti-pore®(inammatory reaction risk)
•
Ceramics, e.g. hydroxyapatite
•
Metals, e.g. stainless steel, titanium (newest and most common)
•
M+ S− 23
M− S+ 8
64 e Ear
Table 11.2 Middle Ear Risk Index 2001
Otologic factor Maximum score
Otorrhoea 3
Perforation 1
Cholesteatoma 2
Ossicular status 4
Middle ear granulation 2
Previous surgery 2
Smoking 2
Table 11.3 Belluci classication of otorrhoea
Otorrhoea Risk value
Dry ear 0
Occasionally wet 1
Persistently wet 2
Persistently wet + cleft palate
OSSICULOPLASTY AND MYRINGOPLASTY
Principles: To try to reconnect inner ear to TM with a piston-like arrangement with rigid
material and good coupling at both sides, covered with cartilage if touching TM, low tension,
but good stability.
Specic Defects
1 Erosion of LPI
Autologous bone: dicult to fashion, may be unstable
•
ISJ prosthesis: xation dicult as incus remnant tapering
•
Bone cement: easy to use but expensive, and variable results
•
Removal of incus and partial ossicular replacement prosthesis (PORP)
•
2 M+S+ (see Table 11.1)
Refashioned incus interposed between malleus and stapes head
•
Refashioned malleus head interposed between drum and stapes head
•
Cartilage interposed between drum and stapes head
•
PORP - malleus to stapes (stability dependent on anteroposterior relation of
•
malleus and stapes)
– TM to stapes (Clip-type prostheses to stapes head maybe more stable)
3 M+S−
Autologous incus (TM to footplate)
•
Total ossicular replacement prosthesis (TORP)
•
– TM to footplate ± footplate shoe for stability, long-term stability and hear-
ing dicult to achieve
4 M−S+
TM to stapes head assembly as in M+S+, although some advocate neomalleus
(metal malleus prosthesis that can be xed to the attic)
5 M−S−
TORP as in M+S−
General Considerations
e presence of stapes superstructure is the most important predictor of success. Overlong
prosthesis can increase tension, causing inferior results. Two type of cholesteatoma surgery
include the following:
Primary reconstruction: May not need second operation, will need diusion-weighted
•
magnetic resonance imaging (MRI), may need redoing if residual/recurrence.
Delayed reconstruction: Period of poor hearing (concern in children), requires two
•
operations.
KEY POINTS
• Recurrent otorrhoea and HL are main indications for myringoplasty.
• Presence of cholesteatoma is an absolute contraindication to myringoplasty.
• Autologous graft materials are the most commonly used with a success rate of 85%
after 1 year.
• Presence of stapes superstructure is the most important predictor of success of
ossiculoplasty.
• In cholesteatoma surgery, primary ossicular reconstruction can be achieved, though
delayed reconstruction may be appropriate in certain cases.
e Ear 65
OTOSCLEROSIS
Further Reading
1. Saliba I, Abela A, Arcand P. Tympanic membrane perforation: size, site and hearing
evaluation. Int J Pediatr Otorhinolaryngol 2011; 75(4): 527–531.
2. Bellucci RJ. Cochlear hearing loss in t ympanoplasty. Otolaryngol Head Neck Surg 1985;
93(4): 482–485.
3. Austin DF. Ossicular reconstruction. Arch Otolaryngol 1971; 94: 525–535.
12. OTOSCLEROSIS
Denition
Otosclerosis is a localised disorder of bone metabolism of the otic capsule that is characterised by disordered resorption and deposition of bone. It is thought to result from increased
pathologic bone remodelling, and the basic lesion consists of areas of bone resorption by
osteoclasts and new bone formation by osteoblasts, accompanied by vascular proliferation.
Many patients with otosclerosis are asymptomatic and clinical otosclerosis with associated
hearing loss only occurs when the lesions involve the stapes footplate, or much more rarely
the round window causing a conductive hearing loss. Sensory hearing loss is thought to
occur when lesions involve the cochlear endosteum.
e most common site of otosclerosis is the cochlear wall just anterior to the stapes footplate.
Aetiology
e aetiology of otosclerosis remains obscure. ere is a clear familial history of hearing loss
in approximately half of patients. e measles virus has been suggested as a possible cofactor in the development of otosclerosis, but the available evidence remains conicting and a
number of recent studies have cast doubt on this link.
Genetics
Otosclerosis occurs in familial and non-familial forms. e familial form accounts for
25–50% of cases and has an autosomal dominant inheritance pattern with incomplete penetrance. Whilst a number of gene associations have been noted in aected families, the genetic
cause of otosclerosis remains largely unidentied.
Incidence
Histological otosclerosis in a random series of temporal bones harvested in Belgium showed
histological evidence of otosclerosis in 3.4% of the bones. e British National Study of
Hearing showed the clinical prevalence is around 2% in adults. is increased with age to
3% in the 60- to 80-year-old age group (Table 12.1). Only 10% of those patients had sur-
gery, which explains the lower incidence reported in clinical series. Interestingly this study
showed similar prevalence in men and women but that the women had more severe hearing
loss, which may account for the nding, commonly reported in clinical series, that otosclerosis is more common in women by approximately 2:1.
Clinical Findings
Otoscopy is usually normal; however, some patients may have di lated arteries on t he medial
wall of the middle ear due to increased vascularity of the otosclerotic foci. is gives the
middle ear seen through the drum a reddish appearance and is known as a amingo ush
or Schwartze’s sign. e patients have a conductive hearing loss usually with a negative
66 e Ear
OTOSCLEROSIS
Table 12.1 Population prevalence per 100 of the presumptive diagnosis
of otosclerosis
Overall 2.1 1.5, 2.7
Age (years)
18–40 1.6 0.6, 2.6
41–60 2.2 1.3, 3.1
61–80 3.0 1.7, 4.3
Sex
Women 2.0 1.3, 2.7
Men 2.2 1.2, 3.2
Occupational group
Non-manual 1.5 0.8, 2.2
Manual 2.7 1.9, 3.5
1
Otosclerosis (%) 95% CI
(bone conduction better than air conduction) Rinne test. Pure-tone audiometry will conrm the conductive hearing loss, which is usually worse at lower frequencies. e bone
conduction is frequently reduced at 2 kHz (Carhart’s notch), possibly due to the ossicular
chain being xed. If the cochlea is involved patients may have a mixed hearing loss. Pure
sensory hearing loss from cochlear otosclerosis with no involvement of the ossicular chain
is rare. In cases where there is sensory hearing loss speech audiometry can be useful. If
the maximum speech reception score is less than 60% and the other ear is normal, then
the benet of surgery may be limited. Tympanometry may show reduced compliance due
to xation of the ossicular chain but is typically normal. Stapedial reexes are normally
reduced or absent.
History
e classic history is of progressive hearing loss in a young adult. e majority will have
bilateral hearing loss, but the loss is oen asymmetric and sequential. About half of patients
have a positive family history of otosclerosis. Tinnitus is present in two-thirds of cases.
Factors such as onset of hearing loss in childhood, history of ear or head trauma, and associated pain and/or discharge should make the clinician suspicious of other causes, as should
extensive tympanosclerosis on the tympanic membrane.
Differential Diagnosis
In a patient with the classic history described above approximately 95% will have otosclerosis. However, superior semicircular canal dehiscence, malleus head xation, incus erosion,
tympanosclerosis, and osteogenesis imperfecta all can on occasion cause diculties in
reaching the correct diagnosis.
Investigations
A high-resolution or cone beam computed tomography (CT) scan can frequently conrm
the diagnosis with the appearance of a lucency in the area anterior to the oval window
Figure 12.1. It can also show other possible diagnoses such as superior semicircular dehis-
cence or xation of the malleus. CT scanning is also useful in predicting possible surgical
diculties such as an obliterative footplate or dehiscence of the facial nerve.
Natural History
Although no perfect studies are available, the average air-bone gap typically deteriorates
about 1 dB per year. is is in addition to a sensory hearing deterioration of another 1 dB per
year. Clearly in many cases the deterioration is signicantly quicker.
e Ear 67
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