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Data and Picture Interpretation Stations: Cases 1–45
Published in Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar, ENT OSCEs, 2023
Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar
Cholesteatoma is a disease of the middle ear in which a sac of keratinising squamous epithelium grows expansively and destructively. There is a strong association with eustachian tube dysfunction although cases can also be congenital or related to chronic tympanic membrane perforation. The diagnosis is made on clinical examination (looking with magnification is important) combined with audiometry which will usually demonstrate varying degrees of conductive hearing loss depending on how much of the middle ear has been eroded. Cases can still demonstrate normal hearing though, and if the inner ear is eroded in advanced disease then a sensorineural loss can result. A CT scan is standard to provide a surgical roadmap and information around hazards and complications. The treatment is tympanomastoid surgery which may be conducted in a number of different ways (canal wall up or down, with or without obliteration, with or without ossiculoplasty) based on surgeon preference and disease extent. The risks of surgery and complications of leaving disease untreated are both related to the surrounding anatomy, so an understanding of this will help answer such questions.
The Child with a Syndrome
Published in John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed, Paediatrics, The Ear, Skull Base, 2018
Thushitha Kunanandam, Haytham Kubba
Otological aspects of the disease include the following: persistent otitis media with effusion – hearing aids should normally be offered to children with Down syndrome who have hearing loss due to OME5narrow and waxy ear canals – ventilator tube otorrhoea and early extrusion can be more commonconductive hearing loss secondary to ossicular anomaliessensorineural hearing loss with increased labyrinthine dysplasia – inner ear dysplasia is common in children with Down syndromeincreased incidence of cholesteatomaanatomical abnormalities of the facial nerve – tympanomastoid surgery can be especially challenging. Hearing screening with behavioural testing throughout early childhood should be carried out to establish near-normal hearing with the use of amplification or ventilation tube insertion. Cholesteatoma should be suspected in continuously discharging ears.
Medical Negligence in Otorhinolaryngology
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
This is a rare complication and is probably sustained as a result of negligence in about 1 in 600–1500 major ear operations. In the author’s hospital there have been only two cases of permanent inadvertent iatrogenic facial nerve damage in middle ear surgery over a 20-year period, which gives an approximate incidence of 1 in 2000 cases of middle ear surgery excluding minor procedures, such as ventilation tube insertion and procedures on the external auditory canal (in which there were no palsies). In 1982, Wiet4 estimated the risk of iatrogenic damage as being 0.6–3.6% in the USA, which is considerably higher than in the UK, but not all cases of iatrogenic damage are due to negligence. It has been reported in operations such as stapedotomy, but is so rare that it was doubtful that even despite the devastating effect that a palsy has, it was not a requirement to warn patients as part of the consenting process. This may no longer be the case in this post-Montgomery era. In the UK in 2016 the patient should be advised about the risks to the facial nerve from cholesteatoma surgery even if the surgeon has evidence from personal audit that it is not a common risk in their hands.
Cholesteatoma in chronic otitis media secondary to pars tensa perforation
Published in Acta Oto-Laryngologica, 2023
Caili Ji, Xiaowen Zhang, Xudong Yan, Songli Cao, Tao Fu
We designed this study to explore factors related to the formation of cholesteatoma secondary to pars tensa perforation. We retrospectively recruited subjects with acquired cholesteatoma with pars tensa perforation in different sites. Patients should satisfy following conditions: 1) chronic otitis media with pars tensa perforation with or without adhesion in the perforation edge; 2) patients with ear discharge and earache as first symptoms other than hearing loss to identify from congenital cholesteatoma; 3) to distinguish from pocket retraction cholesteatoma, patients with retraction pockets in either pars flaccid or pars tensa, or with history of otitis media effusion were excluded from the study; 4) patients with history of middle ear surgery, nasopharyngeal tumor, and cleft palate were also excluded.
The impact of fusion imaging technique on middle ear cholesteatoma surgery: a prospective comparative study
Published in Acta Oto-Laryngologica, 2023
Edoardo Covelli, Valerio Margani, Andrea Romano, Luigi Volpini, Haitham H. Elfarargy, Alessandro Bozzao, Maurizio Barbara
Cholesteatoma confirmation was done clinically, radiologically, and surgically. Before the operation, the patient showed a hearing impairment and a history of a malodorous, continuous, or periodic ear discharge, non-responding to medical treatment. Otological examination revealed attic or marginal tympanic membrane retraction pocket or perforation, with keratin debris. Audiological evaluation revealed conductive or mixed hearing loss. On CT scans, cholesteatoma appeared as opacity in the middle ear cleft with or without bony erosions (scutum and ossicles). On non-EPI DW MRI, cholesteatoma appeared as a hyper-intense image. In the ‘fusion’ image, cholesteatoma appeared as a hyper-intense lesion confined within the CT bony configuration. During surgery, cholesteatoma appeared as a whitish sac containing keratin sheaths. Histopathological examination confirmed the nature of the lesion as cholesteatoma.
Proposal of a magnetic resonance imaging follow-up protocol after cholesteatoma surgery: a prospective study
Published in Acta Oto-Laryngologica, 2022
Edoardo Covelli, Valerio Margani, Chiara Filippi, Haitham H. Elfarargy, Luigi Volpini, Andrea Romano, Alessandro Bozzao, Maurizio Barbara
This prospective long-term study represents a proposal of a protocol for the postoperative follow-up to detect residual or recurrent CHO after primary surgery. This fixed-schedule protocol used non-echo planar DW MRI, whose sensitivity was confirmed by our surgical correlation. The one-month MRI follow-up was revealed to be useful in detecting residual cholesteatoma. From our clinical experience, it would be appropriate to extend the imaging control up to 5 years after the primary surgery. At least in our hands and via the described surgical techniques, this time limit would enable us not to miss any recurrent CHO. The proposed protocol showed to be very sensitive, specific, and accurate, with a low possibility of missing any lesion, and therefore advisable for CHO check over time after surgery.