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Color Atlas of Otoscopy

From Diagnosis to Surgery

Mario Sanna, MD

Professor of Otolaryngology

Department of Head and Neck Surgery

University of Chieti

Chieti, Italy

Istituto Scientifico Ospedale San Raffaele

Rome, Italy

Gruppo Otologico

Piacenza, Italy

Alessandra Russo, MD

Giuseppe De Donato, MD

Gruppo Otologico

Piacenza, Italy

with the collaboration of

Essam Saleh, Abdelkader Taibah, Maurizio Falcioni, Fernando Mancini

464 illustrations, most in color

Thieme

Stuttgart • New York 1999

Library of Congress Cataloging-in-Publication Data

Sanna, M.

Color atlas of otoscopy: from diagnosis to surgery / Mario Sanna,

Alessandra Russo, Giuseppe De Donato; with the collaboration

of Essam Saleh...[et al.].

p. cm.

Includes bibliographical references and index.

ISBN 3-13-111491-6 (hardcover)

1. Otoscopy-Atlases. 2. Ear-Diseases-Atlases. 3. Ear-Surgery-

Atlases. I. Russo, Alessandra. II. Donato, Giuseppe De. III. Title.

[DNLM: 1. Ear Diseases-diagnosis atlases. 2. Otoscopes.

Ear Diseases-surgery atlases. WV 17S228c 1998]

RF 123. S26 1998

617.8'07545-dc21

DNLM/DLC

for Library of Congress

98-35434

CIP

Mario Sanna, MD

Essam Saleh, MD

Professor of Otolaryngology, Head and Neck Surgery

Department of Otolaryngology, Head and Neck Surgery

University of Chieti, Chieti, Italy

University of Alexandria, Egypt

Gruppo Otologico

Piacenza, Italy

Alessandra Russo, MD

Abdelkader Taibah, MD

Giuseppe De Donato, MD

Maurizio Falcioni, MD

Fernando Mancini, MD

Important Note: Medicine is an ever-changing science. Re

Gruppo Otologico

search and clinical experience are continually expanding our

Piacenza, Italy

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12345 6

Foreword

The good fortune of otology resides in the fact that in

the necessary experience and subsequently to share it.

most cases a diagnosis can be established through

This is the reason for which I feel honored, as friend

careful otoscopic examination: the tympanic mem

and colleague, to preface this remarkable volume.

brane is the window to the middle ear.

Having perfectly mastered the technical problems,

Otoscopy constitutes the first phase in the exami

we note with real pleasure that Dr. Sanna and his col

nation of the patient. The initiation of the young otol

laborators offer us more than an "Atlas of Otoscopy",

ogist begins with this basic step. Colleagues of my gen

as the title of the volume modestly suggests. It is truly

eration will recall the long months of training which

a "Manual of Otology" in that it covers all aspects of

were necessary to understand and identify something

inflammatory, infectious, and tumor pathology of the

in the depths of a narrow, tortuous, and sensitive exter

ear, as seen through modifications of the otoscopic

nal canal, often obstructed by physiologic or patholo

image.

gic secretions. It was difficult to find good textbook

The reader, initially attracted by a book of pictures,

illustrations. There were only drawings and lengthy

will be further captivated by a concise text, where, with

pages of description not worthy of comparison with

style and precision, the principal pathologic conditions

the unparalleled iconography of Politzer or Toynbee

are described: definition, nature, pathogenesis, and

in the last century... Photographs were either absent;

classification accompanied by diagrams. The text indi

or when included, were of such mediocer quality, that

cates as well the complementary examinations indis

they were of limited interest. We experienced a feeling

pensable for diagnosis and available therapeutic

of frustration in that era of the electron microscope

options. Thus, radiographic images

(CT scan, MRI)

and of space probes bringing back photos of the earth

are juxtaposed with the otoscopic view when deemed

taken from the moon...

appropriate. All pertinent information conforms to

Modern optical systems, in particular the binocular

the most recently available sources and reflects the

microscope, have permitted an unfettered approach

consensus of the scientific community.

and the detailed observation of the tympanic mem

A particularly interesting and original aspect is

brane under optimal conditions of lighting and magni

represented by the last chapters which deal with the

fication. The addition of observer tubes and video

pathology of the skull base: cholesteatoma of the pe-

cameras have helped to further familiarize ourselves

trosa, glomus tumors, meningoencephalic herniations,

with the various pathologic conditions. However, the

areas in which Dr. Sanna has special experience which

tympanic membrane has long defended itself from

he shares with us.

photographic intrusion. Inclined in relation to the

The resident or practitioner desirous of an initia

three spatial planes, and of a diameter of 1 cm (while

tion into otology will find a presentation of auricular

the normal canal accepts only a 4 mm speculum), it is

pathology which is both general and detailed. Such a

only through progressive scanning that we view the

structure is thoroughly complementary to the knowl

totality of the surface. Our brain reconstructs the vir

edge acquired during his or her medical training. The

tual image. Thus, otoscopic photography faces a for

well-informed otorhinolaryngologist will find an

midable challenge: to reproduce not what one sees but

update of the most recent clinical, radiologic, and ther

what one imagines. The solution came with the intro

apeutic acquisitions in a field which is in constant evo

duction of the Hopkins optical system, which provides

lution.

wide angle capability through a narrow diameter

We thank and warmly congratulate the author and

endoscope, affording an enlarged field of vision and

his collaborators for this exceptional work which

greater depth of field with increased light transmis

reflects the level of their talent and experience. It

sion. The principle is simple; however, utilization of

clearly represents a significant advance in the field of

the equipment necessitates a certain degree of experi

Otology.

ence to obtain quality pictures with regularity.

Through my father, to whom I am indebted, I acquired

Dr. C. Deguine

a passion for photography, permitting me to acquire

Lille, France

Preface

Despite advances in diagnostic techniques and imag

seen in a giant petrous bone cholesteatoma. The man

ing modalities, otoscopy remains the cornerstone in

ifestation of an aural polyp can vary from a mucosal

the diagnosis of otologic diseases. Every otolaryngolo

polyp associated with chronic suppurative otitis media

gist, pediatrician, or even general practitioner dealing

to the much less common but more dangerous glomus

with ear diseases should have a good knowledge of

jugulare tumor. A small retrotympanic mass may rep

otoscopy.

resent an anomalous anatomy such as a high jugular

This atlas is based on 15 years of experience in the

bulb or an aberrant carotid artery. It may also repre

Gruppo Otologico in the treatment of otologic and

sent frank pathology such as facial nerve neuroma,

neurotologic disorders. It presents a vast collection of

congenital cholesteatoma, or even en-plaque menin

otoscopic views of a variety of lesions that can affect

gioma.

the ear and temporal bone. Many examples are given

In each chapter, a surgical summary that lists the

for each disease so that the reader becomes acquaint

different approaches for the management of the

ed with the variable presentations each pathology can

pathology dealt with is provided. Throughout the

have.

book, emphasis is on how the otoscopic view and the

While otoscopy alone can establish the diagnosis

clinical picture may affect the choice of treatment and

in some cases, parameters such as history, or audiolog-

the surgical technique.

ical and neuroradiological evaluation are required in

At the end of this atlas, a chapter on postsurgical

others. An important aspect of this atlas is that it jux

conditions is presented. The presence of previous

taposes, when appropriate, the clinical picture, radio

surgery poses special difficulties because of the dis

logical diagnosis, and intraoperative findings with the

torted anatomy. Moreover, the otologist should be

otoscopic findings of the patient. Needless to say,

able to distinguish between what is considered to be

every patient should be considered as a whole and in

normal postsurgical healing and complications that

some particular cases, the otoscopic findings might

need further intervention.

only be the "tip of the iceberg." Otalgia, otorrhea, and

The authors would like to thank Dr. Clifford

granulations in the external auditory canal are mani

Bergman, medical editor at Georg Thieme Verlag, for

festations of otitis externa, but when they persist, par

his excellent cooperation and help. Thanks also go to

ticularly in the elderly, they should arouse suspicion of

Paolo Piazza, neuroradiologist, for his continuous

malignancy. Otitis media with effusion can be a simple

cooperation and to Maurizio Guida for the illustra

disease when seen in children, whereas unilateral per

tions included in the book.

sistent otitis media with effusion in an adult may be

the only sign of a nasopharyngeal carcinoma. A small

Mario Sanna, MD

attic perforation in the presence of facial nerve paral

Alessandra Russo, MD

ysis and sensorineural hearing loss may be all that is

Giuseppe De Donato, MD

Contents

1 Methods of Otoscopy.

2 The Normal Tympanic Membrane

Anatomy

Histology

3 Diseases Affecting the External Auditory Canal

Exostosis and Osteoma

Pathologies Extending to the External

Furunculosis

Auditory Canal

Myringitis and Meatal Stenosis

Carcinoid Tumors

Otomycosis

Histiocytosis X

Eczema

Other Pathologies

Cholesteatoma of the External Auditory Canal

Carcinoma of the External Auditory Canal. . .

4 Secretory Otitis Media (Otitis Media wi th Effusion)

5 Cholesterol Granuloma

6 Atelectasis, Adhesive Otitis Media

7 Non-Cholesteatomatous Chronic Otitis Media

General Characteristics of Tympanic

Perforations Complicated by or Associated

Membrane Perforations

with Other Pathologies

Posterior Perforations

Tympanosclerosis

Anterior Perforations

Tympanosclerosis Associated with Perforation.

Subtotal and Total Perforations

Tympanosclerosis with Intact Tympanic

Posttraumatic Perforations

Membrane

8 Chronic Suppurative Otitis Media with Cholesteatoma

Epitympanic Retraction Pocket

Cholesteatoma Associated with Atelectasis...

Epitympanic Cholesteatoma

Cholesteatoma Associated with Complications

Mesotympanic Cholesteatoma

9 Congenital Cholesteatoma of the Middle Ear

10 Petrous Bone Cholesteatoma

11 Glomus Tumors (Chemodectomas)

Differential Diagnosis with Other Retrotympanic

Masses

VIII

12 Meningoencephalic Herniation

109

13 Postsurgical Conditions

115

Myringotomy and Insertion of a Ventilation

Myringoplasty

Tube

115

Tympanoplasty

References

142

Index

145

1 Methods of Otoscopy

A preliminary examination is carried out using a head

ear loop, Hartman auricular forceps, and suction tips

mirror or an otoscope.

(Fig. 1.1). In cases with a history of recurrent otitis, we

For proper otoscopy, the external auditory canal

prefer to clean the ear with the aid of a microscope

should be cleaned. Few instruments are used for this

(Fig.

1.2).

step, namely, aural speculi of different sizes, a Billeau

Fig.

1.1

Fig.

1.2

1 Methods of Otoscopy

The use of a rigid 0° 6-cm endoscope (1215AA-

Storz, Fig.

1.3) connected to a video system enables

the patient to see the pathology involving his/her ear

(Figs.

1.4 and

1.5 show the Endovision Telecam SL

20212001 and the Xenon Light Source

615-Storz).

With the help of a video printer connected to the mon

itor, instant photos of the pathology can be obtained.

The rigid

30° endoscope allows evaluation of attic

retraction pockets, the extent of which cannot always

be determined using the microscope or the 0° endo

scope

(Fig. 1.6 shows a series of rigid endoscopes

-Storz).

During the last few years, instant photography has

also been used in the operating room. A copy of the

important steps of the operation is given to the patient

while another copy is kept in the patient's chart. The

patient is also photographed during the follow-up visit.

Thus, for each patient pre-, intra-, and postoperative

photographic documentation is obtained.

All the photos in this book were obtained with an

Olympus OM 40 camera mounted to the endoscope

with a Storz 593-T2 objective. The focus is adjusted to

infinity and the diaphragm to

140. We use the TTL-

Computer-Flash-Unit Model 600 BA Storz (Fig. 1.7).

The film used is a Kodak Ektachrome

64T

Professional Film (Tungsten).

Methods of Otoscopy

Fig. 1.6

In all the cases, the examiner sits to the side of the

patient whose head is slightly tilted towards the contra

lateral side. The examiner holds the camera attached

to the endoscope with his right hand. With the ring and

middle finger of the left hand, the examiner pulls the

patient's auricle backwards and outwards to straighten

the external auditory canal. The endoscope is

advanced over the index finger of the examiner's left

hand into the patient's external auditory canal. In this

manner, any undue injury to the external auditory

canal is prevented (Fig. 1.8).

Fig. 1.8

2 The Normal Tympanic Membrane

• Anatomy

dle of the malleus. Most of the membrane circumfer

ence is thickened to form a fibrocartilaginous ring, the

The tympanic membrane forms the major part of the

tympanic annulus, which sits in a groove in the tym

lateral wall of the middle ear (see Figs. 2.1-2.3). It is

panic bone called the tympanic sulcus. The fibrocarti

thin, resistant, semitransparent, has a pearly gray color,

laginous ring is deficient superiorly. This deficiency is

and is cone-like. The apex of the membrane lies at the

known as the notch of Rivinus. The anterior and pos

umbo, which corresponds to the lowest part of the han

terior malleolar folds extend from the short process of

Figure

2.1 Right ear. Normal tympanic

membrane. 1 = pars flaccida; 2 = short

process of the malleus; 3 = handle of the

malleus; 4 = umbo; 5 = supratubal recess;

6 = tubal orifice; 7 = hypotympanic air cells;

8 = stapedius tendon; c = chorda tympani;

I = incus; P = promontory; o = oval window;

R = round window; T = tensor tympani;

A = annulus.

Figure

2.2 Right ear. Structures of the

middle ear seen after removal of the tym

panic membrane. 9 = pyramidal eminence;

co = cochleariform process; f = facial nerve;

= incudostapedial joint. See legend to

Figure 2.1 for other numbers and abbrevia

tions.

Normal Otoscopy

Figure 2.3 Right ear. Division of the tympanic membrane

into four quadrants: A.S. = anterosuperior; A.I. = anteroinfe

rior; P.S. = posterosuperior; P.I. = posteroinferior. This division

facilitates the description of different pathologic affections of

the tympanic membrane.

the malleus to the tympanic sulcus, thus forming the

inferior limit of the pars flaccida of Sharpnell's mem

brane. The membrane forms an obtuse angle with the

posterior wall of the external auditory canal. It also

Figure

2.4 Left ear. Normal tympanic membrane. Note the

forms an acute angle with the anterior wall of the

acute angle formed between the tympanic membrane and

canal. It is important to respect this acute angulation in

the anterior wall of the external auditory canal. The pars tensa

the myringoplasty operation to maintain as much as

with the short process of the handle of the malleus, the

umbo, the cone of light, the annulus, and the pars flaccida

possible the vibratory mechanism of the tympanic

are seen. Note also the presence of early exostosis in the

membrane and hence ensure maximum hearing

superior wall of the external auditory canal.

improvement.

The external surface of the tympanic membrane is

innervated by the auriculotemporal nerve and the

auricular branch of the vagus nerve, whereas the inner

surface is supplied by Jacobson's nerve, a branch of the

glossopharyngeal nerve.

The blood supply is derived from the deep auricu

lar and anterior tympanic arteries. Both are branches

of the maxillary artery.

• Histology

The tympanic membrane consists of three layers: an

outer epithelial layer continuous with the skin of the

external auditory canal, a middle fibrous layer or lam

ina propria, and an inner mucosal layer continuous

with the lining of the tympanic cavity.

The epidermis or outer layer is divided into the

stratum corneum, the stratum granulosum, the stratum

spinosum, and the stratum basale, which is the deepest

layer that rests on the basement membrane.

The lamina propria is characterized by the pres

ence of collagen fibers. In the pars tensa, these fibers

are arranged in two basic layers: an outer radial layer

Figure

2.5 Right ear. Normal tympanic membrane. In this

case, the drum is very thin and transparent. The handle and

that originates from the inferior part of the handle of

short process of the malleus as well as the umbo and cone of

the malleus and inserts in the annulus, and an inner

light are well visualized. Through the transparent tympanic

circular layer that originates primarily from the short

membrane, the region of the oval window, the long process

process of the malleus. Such a distinct arrangement,

of the incus, the posterior arc of the stapes, the incudostape-

however, is absent in the pars flaccida.

dial joint, the round window, and the promontory can be dis

The mucosal layer is formed mainly of a simple

tinguished. Anteriorly, at the region of the eustachian tube,

cuboidal or columnar epithelium. The free surface of

the tensor tympani canal and the supratubaric recess can be

the cells possesses numerous microvilli.

observed.

2 The Normal Tympanic Membrane

Figure

2.6 Left ear. Normal tympanic membrane. The han-

Figure

2.7 Right ear. Normal tympanic membrane. The

die of the malleus and cone of light are well visualized through

drum, however, is slightly thickened with an accentuated cap-

the tympanic membrane; the promontory, the area of the

illary network along the handle of the malleus. The increased

round window, and the air cells in the hypotympanum can be

thickness of the tympanic membrane obscures all the struc-

appreciated. The pars flaccida is visualized superior to the short

tures in the middle ear.

process of the malleus.

Figure

2.8 Left ear. A normal tympanic membrane that is

slightly thinned in the anterior quadrant and moderately

thickened posteriorly.

3 Diseases Affecting the External Auditory

Canal

• Exostosis and Osteoma

tion of wax and debris with subsequent otitis externa.

In such cases, and in cases in which a hearing aid is to

Exostoses are defined as new bony growths in the

be fitted, surgical removal of exostoses is indicated. In

osseous portion of the external auditory canal. They

some cases, surgery is technically difficult and special

are usually multiple, bilateral, and are commonly ses

care is taken to preserve the skin of the external audi

sile. They vary in shape, being either round, ovoid, or

tory canal. Other structures at risk are the tympanic

oblong. The condition is caused by periostitis sec

membrane and ossicular chain medially, the temporo

ondary to exposure to cold water. This explains the

mandibular joint anteriorly, and the third segment of

high incidence of exostoses among divers and cold-

the facial nerve posteroinferiorly. A postauricular inci

water bathers. Histologically, they are formed from

sion is preferred because it allows good exposure and

parallel layers of newly-formed bone. It is postulated

proper replacement of the skin of the external audito

that the periosteum stimulates an osteogenic reaction

ry canal to prevent postoperative scarring and stenosis.

with each exposure to cold water, thus causing this

Osteoma is a true benign neoplasm of the bone of

stratification.

the external auditory canal, usually unilateral and

When exostoses are small they are asymptomatic.

pedunculated. Histologically, it can be differentiated

Large lesions, however, can occlude the external audi

from exostosis by the absence of the laminated growth

tory canal and lead to conductive hearing loss or reten

pattern.

Figure 3.1 Right ear. Small exostosis originating from the

Figure

3.2 Right ear. A small asymptomatic exostosis of the

superior wall of the external auditory canal. Anterosuperiorly,

superior wall of the external auditory canal is observed. A

another exostosis is seen in the early phase of formation.

hump of the anterior wall precludes adequate visualization of

the entire tympanic membrane.

3 Diseases Affecting the External Auditory Canal

Figure

3.3 Right ear. Osseous neoplasm of the external

Figure

3.4 Exostosis of the superior wall of the left external

auditory canal. In this case, given the pedunculated narrow

auditory canal. The lesion prevents complete visualization of

base, an osteoma is a more probable diagnosis. This was con

the tympanic membrane.

firmed by pathological examination of the removed specimen.

Ample bone removal is performed in such cases to avoid

recurrence.

Figure

3.5 Same patient, right ear. Two exostoses are pre

Figure

3.6 Right ear. Exostosis of the posterior superior wall

sent in the superior wall of the external auditory canal. In

of the external auditory canal that precludes visualization of

addition, the anterosuperior wall shows an additional exosto

the pars flaccida. A bony hump is also present in the anterior

sis. The lesions allow only a limited view of the central part of

wall of the canal. In such a case, it is useful to photograph the

the tympanic membrane. In this case, a regular follow-up and

ear for further follow-up within 1-2 years.

evaluation is necessary because further growth of the lesion

could lead to accumulation of debris and cerumen, necessi

tating surgical intervention.

Exostosis and Osteoma

Figure 3.7a Left ear. Obstructing exostosis that causes

Figure

3.7b Computed tomography (CT) of the same case.

subtotal occlusion of the external auditory canal. The patient

The bony external canal is particularly narrowed.

complains of hearing loss and frequent episodes of otitis

externa secondary to retention of water and debris inside the

canal. A canalplasty under local anesthesia is indicated to

restore the size of the external canal.

Summary

Surgery in cases of exostosis is indicated only in cases

with obstructing stenosis with or without hearing loss

but with frequent otitis externa due to retention of

debris. Surgery can be performed under local anes

thesia, preferably using a postauricular incision. This

approach allows excellent exposure of the whole

meatus, thus minimizing the risk of injury to the tym

panic membrane. In addition, it enables the surgeon

to preserve the canal skin, thereby avoiding post

operative cicatricial stenosis. After dissecting the

posterior limb, the flap is retained by the prongs of

the self-retaining retractor. The skin of the anterior

wall is incised medial to the tragus and is dissected in

a lateral-to-medial direction. While drilling the exos

tosis, the skin of the canal is protected using an alu

minum sheet (the cover of surgical sutures).

Osteoma can be removed by using a curette. In case

of recurrence, a wide drilling of the bone around its

base is also indicated.

Figure

3.8 Obstructing exostosis of the external auditory

canal resulting in otitis externa due to accumulation of squa

mous debris inside the canal. Surgery is essential both to

avoid the formation of cholesteatoma and to improve hear

ing.

Diseases Affecting the External Auditory Canal

• Furunculosis

Furunculosis is pustular folliculitis caused by staphylo

coccal infection of a hair follicle. Infection occurs as a

result of microabrasion or of decreased immunity, as in

diabetics. It is characterized by severe pain. A tender

swelling is seen in the cartilaginous part of the external

auditory canal which may have a central necrotic part.

Figure

3.9 A furuncle almost totally occluding the meatus.

Pain is caused by distention of the richly innervated skin. A

central necrotic part is seen.

• Myringitis and Meatal Stenosis

Myringitis is an inflammatory process that affects the

tympanic membrane. Three forms are recognized:

acute myringitis, bullous myringitis, and myringitis

granulomatosa.

Acute myringitis is usually seen in association with

infection of the external ear (otitis externa) or middle

ear (otitis media). It is characterized by hyperemia and

thickening of the tympanic membrane, as well as the

presence of purulent secretions

(Fig. 3.10). Therapy

consists of administration of general and/or local

antibiotics and local steroids.

Figure

3.10 Left ear. The tympanic membrane is character

ized by thickening and hyperemia. In this case, the skin of the

external auditory canal is also hyperemic. The tympanic mem

brane seems lateralized.

Myringitis and Meatal Stenosis

Bullous myringitis is commonly associated with

viral upper respiratory tract infection. It is character

ized by the presence of bullae filled with sero-

sanguineous fluid. The bullae are located between the

outer and middle layers of the tympanic membrane.

The patient complains of otalgia and hearing loss.

Therapy consists of antibiotics and steroids (Figs. 3.11,

3.12).

In granulomatous myringitis, the outer epidermic

layer of the tympanic membrane as well as the adja

cent skin of the external auditory canal are replaced by

granulation tissue. It is generally seen in patients suf

fering from frequent episodes of otitis externa. In

some cases, it may ultimately lead to stenosis of the

most medial part of the external auditory canal. It can

usually be cured, however, by removing the granula

tions in the outpatient clinic using the microscope.

This is followed by the administration of local steroid

drops for nearly 1 month. In refractory cases, however,

surgery in the form of canalplasty with free skin graft

is necessary.

Figure

3.11 Left tympanic membrane with a large bulla

anterior to the malleus and a smaller one posterior to it.

Figure

3.12 Right tympanic membrane with a large bulla

Figure

3.13 Granulomatous myringitis. The granulomatous

occupying the entire surface of the membrane. The malleus is

tissue has replaced the external skin layer of the tympanic

not visible.

membrane and part of the anterior wall of the external canal.

This case was treated by removal of the granulation tissue

under local anesthesia in the outpatient clinic. Local steroid

drops were then administered for 1 month.

3 Diseases Affecting the External Auditory Canal

administered for 1 month. On follow-up, stenosis was already

Figure

3.14 Postinflammatory stenosis of the right external

resolved and the granulation tissue in the external auditory

auditory canal of a 68-year-old woman. The patient com

canal was completely replaced by healthy skin.

plained of bilateral continuous otorrhea and hearing loss of 3

years' duration. The otorrhea in the left ear stopped 2 months

Figure

3.15 CT of the same case. The bony walls of the

before presentation. The granulations over the tympanic

external auditory canal are intact. The pathologic skin occu

membrane were removed in the outpatient clinic. A cello

pies the lumen of the external auditory canal.

phane sheet was inserted into the external auditory canal to

avoid the reformation of stenosis. Local steroid drops were

Figure 3.17 This CT scan demonstrates a similar lesion on

Figure 3.16 Same patient, left ear (see also CT in Fig. 3.18).

the contralateral side.

A canalplasty was performed on this side. After having

removed the granulation tissue, myringoplasty and canalplas

ty were performed. Next, the meatal flaps were repositioned.

Myringitis and Meatal Stenosis

Figure

3.18 Right ear. Case similar to that seen in Figure

Figure 3.19 The CT scan shows thickening of the tympanic

3.14. The patient complained of intermittent otorrhea and

membrane and normal bony canal.

hearing loss (see CT scan in Fig. 3.19).

Figure

3.20 Same patient, left ear. Two tympanolplasties

Figure 3.21 CT Scan of the previous case. The tympanic

were previously performed on this ear. Generally, revision

membrane is thickened and lateralized.

surgery is better avoided in patients who have undergone mul

tiple operations and present with canal stenosis associated

with lateralization of the tympanic membrane. (For postoper

ative stenosis of the external auditory canal, see Chapter 13.)

3 Diseases Affecting the External Auditory Canal

Summary

Postinflammatory stenosis of the external auditory

canal is a difficult pathology to treat. In early cases, in

which only granulation tissue is present, it is possible

to remove the pathologic tissue (under local anesthe

sia in the outpatient clinic). This is followed by the

insertion of a plastic (polyethylene) sheet to be left in

place for about 20 days during which regular lavage is

performed with 2% boric acid in 70% alcohol and

local steroid lotions are applied. Surgery is doubtful

in well-established cases with excessive cicatricial tis

sue leading to marked narrowing of the external audi

tory canal and lateralization of the tympanic mem

brane (secondary to thickening of the latter). In the

majority of cases, restenosis occurs following opera

tive interference. Therefore, it is preferable not to

operate in the case of unilateral postinflammatory

stenosis. In bilateral cases with marked hearing loss,

a hearing aid is prescribed. By contrast, postoperative

stenosis has a better prognosis and the results of

Figure

3.22

Right ear. Radical mastoid cavity

showing

treatment are more encouraging.

cholesteatoma with superimposed fungal infection.

Otomycosis

Otomycosis is more common in tropical and subtropi

include chronic otorrhea and the presence of epithelial

cal countries. In the majority of cases, the isolated

debris. Clinically, the patient complains of otorrhea,

fungi are of the Aspergillus (niger, fumigatus, flave-

itching, and hearing loss. Therapy consists of cleaning

scens, albus) or the Candida species. Otomycosis is

the ear to remove all debris and the instillation of local

more common in immunocompromised patients and in

antimycotic preparations as well as lavage with 2%

diabetics. Local factors that favor fungal infections

alcohol boric acid drops.

Figure

3.23 An ear with chronic suppurative otitis media

Figure

3.24 Another example of otomycosis in a radical

with cholesteatoma showing a superimposed fungal infec

mastoid cavity.

tion. The blackish fungal masses are easily recognized. They

should be removed before local antifungal solution is instilled.

Cholesteatoma of the External Auditory Canal

Eczema

Eczema is a dermo-epidermal process of reactive na

ture resulting from local or general factors. Local fac

tors include allergy, topical medical preparations, or

cosmetics, whereas general factors include hepatic or

gastrointestinal dysfunction. It manifests by itching, a

bur-ning sensation, vesication, and sometimes serous

otorrhea. Treatment consists of discontinuation the

suspected causative irritant, correction of the systemic

disturbances, as well as lavage with boric acid with

alcohol and steroid lotion.

Figure

3.25 Right ear. Chronic eczema of the external audi

tory canal. Squamous debris covering the skin of the external

auditory canal can be noted. Successfully treated by the use

of local steroid lotion.

• Cholesteatoma of the External

Auditory Canal

Cholesteatoma of the external auditory canal should be

differentiated from keratosis obturans. The latter

entails accumulation of desquamated squamous epithe

lium in the external auditory canal forming an occluding

cholesteatoma-like mass. The patient complains of pain

and hearing loss. Keratosis obturans is generally bilat

eral and occurs in young patients, whereas

cholesteatoma of the external auditory canal is usually

unilateral and occurs in the elderly. In about 50% of

patients, keratosis obturans is associated with

bronchiectasis and chronic sinusitis. Removal of the

mass is sufficient in keratosis obturans. However, in

cholesteatoma it may also be necessary to remove the

underlying bone followed by reconstruction of the

external auditory canal and its skin.

Postoperative

(iatrogenic) cholesteatoma of the

external auditory canal is generally located at the level

of the anterior angle of the tympanic membrane. It

usually originates from incorrect repositioning of the

Figure

3.26 Cholesteatoma of the external auditory canal

skin flaps at the end of the procedure.

that occurred as a result of incorrect repositioning of the skin

flaps in a previous intact canal wall tympanoplasty. This con

dition is to be differentiated from exostosis. A probe is used

to palpate the mass. If it is tender and of soft consistency,

cholesteatoma is diagnosed.

3 Diseases Affecting the External Auditory Canal

Figure

3.27 A case similar to that in Figure 3.26. The mass

Figure

3.28 Cholesteatoma of the inferior wall of the left

originating from the posterior canal wall inhibits the normal

external auditory canal being removed in the outpatient clin

process of epithelial migration towards the outside.

ic. In this case, the squamous debris led to erosion of the

underlying bone.

Figure

3.29 Same patient, a few months later. Note the

Figure

3.30 A case similar to the that in Figure 3.28. The

bone erosion caused by the cholesteatoma.

cholesteatoma occupies more than half of the external audi

tory canal and is in contact with the tympanic membrane. The

CT scan (Fig. 3.31) demonstrates partial erosion of the under

lying bone.

Carcinoid Tumors

A carcinoid tumor is an adenomatous neuroendocrinal

tumor of ectodermal origin. It has the same histologic

and histochemical characteristics as other carcinoid

tumors that involve different parts of the body. A car

cinoid tumor is suspected whenever an adenomatous

tumor of the middle ear has acinic or trabecular histo

logic features. The diagnosis is confirmed by electron

microscopy and immunohistochemistry to demon

strate the presence of serotonin and argyrophilic gran

ules. Surgical removal is indicated. To avoid recur

rence, removal of the whole tumor together with the

attached ossicular chain is essential.

Figure 3.31 CT scan of the same case, coronal view. The

cholesteatoma is clearly seen in the anteroinferior portion of

the external auditory canal with partial erosion of the under

lying bone.

Summary

Postoperative (iatrogenic) cholesteatoma can almost

always be removed in the outpatient clinic under

local anesthesia using an endomeatal approach. The

sac is opened and the cholesteatoma is aspirated. It is

advisable to insert a plastic sheet in the external audi

tory canal for about 3 weeks to prevent the formation

of adhesions that could lead to reformation of the

cholesteatoma pearl.

Cholesteatoma of the external auditory canal should

be surgically removed using a postauricular ap

proach. A wide drilling of the floor of the canal is

mandatory to avoid recurrences.

Figure

3.32 This patient complained of hearing loss in the

left ear and otalgia of 3 months' duration. Otoscopy revealed

a mass occupying the external auditory canal and originating

Pathologies Extending to the External

from its anterosuperior region. The inferior part of the tym

Auditory Canal

panic membrane, which is the only visible part, appears

whitish due to the presence of a mass in the middle ear. The

Some middle ear pathologies can extend into the

audiogram (Fig. 3.33) revealed the presence of an ipsilateral

external auditory canal

(e.g., cholesteatomas, glomus

conductive hearing loss. The tympanogram was type B. CT

tumors, meningiomas, carcinoid tumors, and histiocy

scan (Figs. 3.34, 3.35) demonstrated the presence of an iso-

intense soft-tissue mass occupying the middle ear and mas

tosis X). These cases are discussed here to underline

toid with extension into the external auditory canal. No ero

the importance of their inclusion in the differential

sion of the ossicular chain, nor of the intercellular septae of

diagnosis of "polypi" in the external auditory canal.

the mastoid air cells, was noted. Intraoperatively, a glandu

Moreover, taking a biopsy of these polypi in the out

lar-like tissue was found and a frozen section obtained. The

patient clinic without proper radiological study is

biopsy, confirmed by immmunohistochemical and electron

sometimes hazardous. For a detailed discussion of

microscopic studies, proved the presence of a carcinoid

these pathologies, the reader is referred to the relevant

tumor. A tympanoplasty was performed with total removal of

chapters.

the pathology and the involved malleus and incus.

3 Diseases Affecting the External Auditory Canal

125

250

500

16KHZ

Figure

3.33 The audiogram shows the presence of signifi

Figure 3.34 The CT scan demonstrates a soft-tissue mass

cant ipsilateral conductive hearing loss.

occupying the middle ear with extrusion through the tym

panic membrane.

Summary

Carcinoid tumors of the middle ear are very rare.

They are considered a subgroup of the adenomatous

tumors of the middle ear. Clinically, they manifest as

hearing loss, tinnitus, aural fullness, facial nerve

paresis, vertigo, and otalgia. These tumors require a

functional surgery that entails removal of the tym

panic membrane and ossicular chain together with

the mass. The tympanic membrane is grafted at the

same stage, whereas the ossicular chain is recon

structed at a second stage. This strategy ensures that

the condition is completely cured.

Figure

3.35 CT scan, axial view. Presence of glue in the

mastoid cells without erosion of the intercellular septae.

Histiocytosis X

• Histiocytosis X

Histiocytosis X refers to a group of disorders of the

reticuloendothelial system characterized by prolifera

tion of cytologically benign histiocytes. The disease

can present in three clinical forms, the most benign of

which is eosinophilic granuloma, which is usually

monostotic. A moderately aggressive form is known as

Hand-Schiiller-Christian disease. It is characterized

by multifocal lesions that are predominantly osteolyt

ic. The most severe form, Letterer-Siwe disease,

occurs in children under 3 years of age and presents

with diffuse multiorgan involvement. It has a mortali

ty rate of about 40% despite therapy with cytotoxic

drugs and corticosteroids. Survivors suffer from dis

eases such as diabetes insipidus, pulmonary fibrosis,

and vertebral column involvement.

Figure

3.36 A bulging of the posterosuperior wall of the

Figure

3.37 CT scan of the same case as in Figure 3.36. The

external auditory canal in a 4-year-old child. A similar picture

middle ear and mastoid are occupied by an isointense mass,

was also seen in the other ear (see CT scan in Fig. 3.37).

A frozen section obtained during surgery revealed the pres

ence of histiocytosis X. The patient was referred to a special

ized center for appropriate staging and therapy with cyto

toxic drugs and corticosteroids.

3 Diseases Affecting the External Auditory Canal

Other Pathologies

Figure 3.38 Polyp in the external canal in a child presenting

Figure 3.39 CT scan, axial view. The entire mastoid is occu

with continuous otorrhea and hearing loss. A CT scan (Fig.

pied by a soft-tissue mass. The intercellular septae of the mas

3.39) shows the presence of a soft-tissue mass eroding the

toid and the ossicular chain are absent.

intercellular septae of the mastoid and the ossicular chain,

suggestive of cholesteatoma. This was confirmed during

surgery.

Figure

3.40 Another example of chronic suppurative otitis

Figure

3.41 The otoscopic view is very similar to that in

media with cholesteatoma that manifests with an aural polyp.

Figure 3.40. In this case, however, the diagnosis is that of an

Though cholesteatoma presents frequently in this manner, it

en-plaque supratentorial meningioma. An outpatient

is absolutely essential to abstain from taking a biopsy of the

polypectomy in this case might lead to excessive bleeding (see

polyp in the outpatient clinic without performing a CT scan of

MRI, Figs. 3.42 and 3.43).

the temporal bone (see Fig. 3.41).

Other Pathologies

Figure

3.42 MRI with gadolinium enhancement, axial view.

Figure 3.43 MRI with gadolinium, coronal view. The menin

The tumor (arrows) is located in the temporal fossa and reach

gioma displaces the temporal lobe upwards (arrows); pathog

es the area of the petrous apex and Meckel's cavity.

nomonic tails of the dura are visible.

Figure

3.44 Left ear. Glomus jugulare tumor with extension

Figure

3.45 Left ear. Another example of a glomus tumor.

into the external auditory canal. A biopsy of this lesion might

lead to severe and often difficult-to-control hemorrhage.

3 Diseases Affecting the External Auditory Canal

Figure

3.46 Pulsating neoplasm in the external auditory

Figure

3.47 MRI of the same case. A glomus jugulare

canal. MR I (Fig. 3.47) revealed the presence of a glomus jugu-

tumor engulfing the vertical portion of the internal carotid

lare tumor involving the vertical internal carotid artery.

artery is clearly visible.

• Carcinoma of the External Auditory

The tumor should be considered to be T3 or T4 if

Canal

there is infiltration of the posterior or middle cranial

fossae, or invasion of the jugular foramen or glenoid

Basal cell carcinoma is more frequent in the auricle, par

fossa. In such cases, whatever the modality of treat

ticularly in subjects with long exposure to the sun. On

ment, the prognosis is almost always poor.

the other hand, squamous cell carcinoma accounts for

Surgery consists of en-bloc removal of the tumor

about three quarters of invasive tumors of the external

and a trial to include a safety margin of the surround

auditory canal and the middle ear. In about

11% of

ing healthy tissue in the specimen. Postoperative

cases, cervical lymph node metastases are present at the

radiotherapy should be subsequently performed.

time of diagnosis. The most common symptoms include

otorrhea, otalgia, hearing loss, facial nerve paralysis, and

vertigo. An accurate microscopic examination is impor

tant for proper evaluation of the lesion extension.

Frequently, an exfoliative lesion is noted, whereas an

ulcer is present in other cases. Carcinoma should be sus

pected in the case of a persistent otitis externa charac

terized by pain and otorrhea that does not resolve ade

quately with medical treatment. A biopsy of the lesion

will clear any doubts. It is important to perform an accu

rate examination of the upper deep cervical, postauricu-

lar, and parotid lymph nodes (anterior extension of the

tumor). The cranial nerves are also evaluated. The facial

nerve is the most frequently involved. Involvement of

the mandibular nerve indicates tumor extension

towards the glenoid fossa. A high-resolution CT scan

(bone window) is the most important radiological inves

tigation as it permits the evaluation of bone erosion at

the level of the external auditory canal and middle ear.

MRI with gadolinium allows the evaluation of tumor

extension into the soft tissues.

Carcinoma of the External Auditory Canal

Figure

3.48 An exfoliative neoplasm that occupies the

Figure

3.49 CT scan demonstrates erosion of the antero

external auditory canal. The patient complained of otalgia

inferior wall of the external auditory canal. The glenoid fossa

and attacks of bloody otorrhea of 1-month duration. A biop

is not invaded.

sy was taken and pathologic examination revealed the pres

ence of squamous cell carcinoma. A CT scan (Fig.

3.49)

demonstrated erosion of the external auditory canal, particu

larly its anteroinferior wall, without breaking into the glenoid

fossa. En-bloc removal of the tumor was performed, togeth

er with a superficial parotidectomy. Radiotherapy was per

formed postoperatively.

Figure

3.50 Squamous cell carcinoma protruding through

Figure 3.51 CT scan. The carcinoma occupies all of the

the external auditory canal with extension into the glenoid

middle ear and the mastoid. The glenoid fossa and the mid

fossa and infiltration of the middle fossa dura (see CT scan,

dle fossa plate are eroded.

Fig. 3.51 and MRI, Fig. 3.52). Palliative surgery was performed

followed by radiotherapy.

3 Diseases Affecting the External Auditory Canal

Figure 3.52 MRI shows marked anterior extension of the

Figure

3.53 Squamous cell carcinoma with posterior exten

tumor into the infratemporal fossa.

sion. The mass ifiltrates the skin of the posterior wall of the

external auditory canal (see CT scan, Fig. 3.54) as a result of

which en-bloc resection and subsequent radiotherapy were

performed.

Figure 3.54 CT scan, axial view. The tumor has eroded the

Figure

3.55 Nasopharyngeal carcinoma extending into the

most lateral portion of the posterior bony wall.

middle ear and external auditory canal. A polypoid mass infil

trates the tympanic membrane and partially fills the external

auditory canal (see CT scan, Fig. 3.56 and MRI, Fig. 3.57). The

patient was considered inoperable and was referred to radio

therapy.

Carcinoma of the External Auditory Canal

Figure

3.56 The CT scan demonstrates marked infiltration

Figure

3.57 MRI with gadolinium confirms the infiltration.

of the nasopharynx, the pterygoid muscles, and the petrous

apex.

Summary

A carcinoma arising from the external auditory canal

to the level of the temporomandibular joint. The cav

is frequently confused with suppurative otitis.

ity can be exteriorized or obliterated with abdominal

Because of the high incidence of otitis externa and

fat and the external auditory canal closed as cul-de-

media and because these pathologies are frequently

sac. When indicated, the resection can include a

chronic, the diagnosis of carcinoma of the external

superficial parotidectomy, resection of the mandibu

auditory canal is almost always late. Diagnosis is

lar condyle, and/or neck dissection.

made by biopsy. A high-resolution CT scan and MRI

When the tumor has a deeper extension towards the

are necessary for proper evaluation. A high-resolu

middle ear, en-bloc subtotal resection of the tempo

tion CT scan determines the osseous erosion caused

ral bone is indicated. In such cases, a middle and pos

by the tumor, whereas MRI is superior to CT for the

terior fossa craniotomy is necessary. Bone removal is

evaluation of soft tissues. MRI shows the presence of

performed up to the level of the medial third of the

dural invasion, intracranial extension, as well as

petrous apex and the internal carotid artery. The

extracranial soft-tissue involvement. Until now there

facial nerve and inner ear are sacrificed.

has been no universally accepted system of staging,

A more extended procedure is total en-bloc resection

which is the basis for planning therapy and proper

of the temporal bone entailing, in addition, the sacri

treatment evaluation.

fice of the internal carotid artery, closure of the sig

Therapy for carcinoma of the external auditory canal

moid sinus and jugular bulb, and in some cases a total

is almost always surgical. Various degrees of resec

parotidectomy and neck dissection.

tion are utilized according to the extent of the pathol

ogy. Very small lesions can be managed by excision

biopsy with a safety margin and curettage of the

underlying bone.

Lateral en-bloc petrosectomy is the treatment of

choice in the majority of carcinomas of the external

auditory canal. It entails excision of the external

auditory canal

(bone and soft tissues), tympanic

membrane, and ossicular chain with preservation of

the facial nerve. Anteriorly, bone removal extends up

4 Secretory Otitis Media (Otitis Media with

Effusion

Secretory otitis media is characterized by the presence

treatment

(myringotomy and ventilation tube inser

of middle ear effusion composed of a transudate/exu

tion), the reader is referred to Chapter

13 on post

date of the mucosa of the middle ear cleft that is

surgical conditions.

formed behind an intact tympanic membrane.

Classically, the tympanic membrane is retracted,

immobile, dark yellowish or bluish, and thickened. At

times, it may be transparent with a hairline

(liquid

level) or air bubbles visible through it.

The causes are generally: eustachian tube obstruc

tion secondary to mucosal edema due to infection

(sinusitis, nasopharyngitis) or allergy; extrinsic pres

sure on the cartilaginous portion of the eustachian

tube due to hyperplasia of glandular or lymphoid tis

sue or, rarely, due to tumors; malfunction of the tubal

muscles as in children with cleft palate, or malforma

tion of the tube itself as in Down's syndrome. Other

factors that may contribute include: bacteriologic,

immunologic, genetic, socioeconomic status, seasonal

variation, as well as lack of transmission of specific

immunoglobulins in non-breast-fed infants. All these

factors cause tubal dysfunction or occlusion leading

to negative middle ear pressure due to oxygen

absorption by the mucosa of the middle ear cleft.

Normally, the tendency of the tubal walls to collapse

at the level of the isthmus can be overcome by an

Figure

4.1

Conductive hearing loss. Bone conduction

increase in the nasopharyngeal pressure. A negative

normal. Air conduction is on an average of 35 dB.

middle ear pressure up to -25 mm Hg can be thus cor

rected. On the other hand, with edema of the tubal

mucosa, the same increase in the nasopharyngeal

pressure cannot overcome a negative middle ear

pressure less than -5 mm Hg.

In children, hyperplasia of the adenoid tissue is the

most common predisposing factor, and nasopharyngi

tis is the most frequent cause of secretory otitis media.

In adults, the condition is much less common and the

presence of persistent unilateral otitis media with effu

sion can be due to a nasopharyngeal tumor that

occludes the tubal opening, or a neoplasm that com

presses or infiltrates the tube along its course.

In cases that do not resolve despite proper med

ical treatment

(nasal and systemic decongestants,

mucolytics, and antibiotics) or in cases with persistent

conductive hearing loss

(see Figs. 4.1 and

4.2), the

insertion of a ventilation tube is indicated. In chil

dren, adenoidectomy is also performed. Surgery aims

at alleviating the conductive hearing loss avoiding the

sequelae of otitis media with effusion. Sequelae

-200

-100

+100

+200

include recurrent otitis media, tympanosclerosis,

adhesive otitis media, retraction pockets with eventu

Figure

4.2

Tympanogram type B, typical of middle ear effu

al cholesteatoma formation, and in some long-stand

sion.

ing cases the formation of cholesterol granuloma (see

Chapter 5). In this chapter, some typical cases of oti

tis media with effusion will be shown. For the surgical

Secretory Otisis Media (Otisis Media with Effusion)

Figure 4.3 Right ear. Secretory otitis media. Air bubbles can

Figure 4.4 Left ear. Secretory otitis media. Middle ear effu

be seen anterior to the handle of the malleus and also in the

sion having a reddish color inferiorly and a yellowish color

posteroinferior quadrant.

superiorly. In this case, the differential diagnosis includes glo

mus tympanicum. If doubts still exist after microscopic exam

ination, medical treatment is administered for several weeks

and the patient is reexamined.

Figure 4.5 Left ear. Secretory otitis media with an appar

Figure 4.6 Right ear. The presence of glue in the middle ear

ently dense transudate that gives the tympanic membrane the

leads to bulging of the tympanic membrane. In the posterior

characteristic dark yellow color. An air-fluid level can be

quadrant, a thinned area of the drum is visualized through

appreciated at the posterosuperior quadrant. The tympanic

which the yellowish color of the effusion is visible. This area

membrane is diffusely hyperemic. If the condition is not

would probably be the site of a future perforation.

resolved by medical treatment, a ventilation tube should be

inserted.

4 Secretory Otitis Media (Otitis Media with Effusion)

Figure 4.7 Right ear. Seromucoid effusion in the middle ear.

the presence of a tumor (later proven to be a trigeminal neuri

Air bubbles can be seen in the anterior quadrants of the tym

noma) with an intra- and extracranial extension. The tumor

panic membrane. The patient is a 53-year-old woman who

compressed the eustachian tube and resulted in the middle

presented with a signs of right otitis media with effusion caus

ear effusion. Total removal of the tumor was performed in a

ing conductive hearing loss and ipsilateral paraesthesia of the

single-stage operation using an infratemporal type B approach

maxillary and mandibular nerves, followed by episodes of

with orbitozygomatic extension (Fig. 4.10).

trigeminal neuralgia and diplopia in the last few months.

Computed tomography (CT) scan and magnetic resonance

Figure 4.8 MRI, axial view, showing the extension of the

imaging (MRI) with gadolinium (see following figures) revealed

giant trigeminal neurinoma.

Figure

4.9 MRI, sagittal view, confirms the intra-

and

Figure

4.10 Trigeminal neurinoma removal using an

extracranial extension of the tumor.

infratemporal type B approach with orbitozygomatic exten

sion.

Secretory Otisis Media (Otisis Media with Effusion)

Figure 4.11 Postoperative CT scan showing total tumor

Figure 4.12 A different case similar to the one in Figure 4.7.

removal.

This 64-year-old woman complained of right nasal obstruc

tion and a sensation of right ear fullness of 1 year duration.

One month before presentation the patient began to suffer

from neuralgic pain in the region of the maxillary nerve. The

tympanic membrane looks yellowish due to the presence of

middle ear effusion (see following figures).

Figure 4.13 Right nasal cavity, same case. A mass is visual

ized in the middle meatus. A biopsy proved it to be a neuri

noma.

4 Secretory Otitis Media (Otitis Media with Effusion)

Figure 4.14 MR I of the same case. A huge trigeminal neuri

Figure 4.15 A single-stage, total removal was accom

noma with intra- and extracranial extension can be seen.

plished using a preauricular infratemporal subtemporal

orbitozygomatic approach.

Figure 4.16 Postoperative CT scan showing total tumor

Figure 4.17 Left ear. An air-fluid level is seen in a young

removal. The floor and the lateral wall of the orbit have been

patient with a juvenile nasopharyngeal angiofibroma.

reconstructed.

Secretory Otisis Media (Otisis Media with Effusion)

Figure 4.18 MRI of the same case. The angiofibroma occu

Figure 4.19 Left ear. Secretory otitis media. The tympanic

pies the nasopharynx, pterygopalatine fossa, and infratempo

membrane is thickened. Catarrhal fluid can be seen through

ral fossa on the left side. Removal was accomplished via an

the relatively thinner anteroinferior quadrant.

infratemporal fossa approach type C according to Fisch.

Figure 4.20 Right ear. Secretory otitis media. The effusion is

Figure

4.21 Right ear. Secretory otitis media with tym

visible through two thinned areas of the tympanic membrane

panosclerosis and epitympanic erosion. The tympanic mem

lying anterior and posterior to the handle of the malleus.

brane shows areas of tympanosclerosis alternating with areas

of atrophy. Glue is present in the middle ear.

4 Secretory Otitis Media (Otitis Media

Effusion)

Figure 4.22 Left ear. Otitis media with effusion and a

Figure 4.23 Left ear showing a pulsating air-fluid level in a

whitish retrotympanic mass in the posterior quadrant at 3

patient operated 1 year previously to remove a lower cranial

o'clock can be observed. The presence of congenital

nerve neurinoma using a petro-occipital trans-sigmoid approach

cholesteatoma was considered in the differential diagnosis.

(POTS) (see preoperative MRI, Fig. 4.24 and postoperative CT

Exploratory tympanotomy showed only "glue" in the middle

scan, Fig. 4.25). The patient complained of a sensation of ear

ear that was particularly dense in the posterior mesotympa-

blockage and watery rhinorrhea on leaning forwards. The mid

num.

dle ear is full of cerebrospinal fluid (CSF) passing through open

hypotympanic air cells that communicate with the subarachnoid

space. The CSF rhinorrhea was treated by obliterating the

eustachian tube and middle ear with the temporalis muscle and

by closure of the external auditory canal as cul-de-sac.

Figure 4.24 MRI of the same case showing a schwannoma

Figure 4.25 Postoperative CT scan shows the petro-occipi

of the lower cranial nerves (T).

tal craniotomy and the surgical cavity with preservation of the

inner ear.

Secretory Otisis Media (Otisis Media with Effusion)

Figure 4.26 Right ear. Otitis media with effusion in a 47-

Small nasopharyngeal carcinomas can miss detection on MRI.

year-old female patient who complained of right hearing loss

Therefore, adults with unilateral otitis media with effusion,

and a sensation of ear fullness of 1 year duration. Naso

even with normal radiologic examination, should undergo

pharyngeal examination was doubtful. MRI (see Figs. 4.25

biopsy of the nasopharynx under local anesthesia.

and 4.26) demonstrated the presence of a neoplasm at the

level of the right Rosenmuller fossa. A biopsy was performed

Figure 4.27 MRI. Small neoplasm at the level of the

in this region and revealed the presence of an adenoid cystic

Rosenmuller fossa (arrow).

carcinoma. The patient was operated on through an infratem

poral fossa type C and then referred for radiotherapy.

Summary

Otitis media with effusion in children is generally

bilateral. If it does not resolve despite appropriate

medical treatment for a sufficient period, a myringo

tomy and the insertion of ventilation tubes are indi

cated. If necessary, adenoidectomy is also performed

at the same setting.

In all adult cases of unilateral prolonged otitis media

with effusion, nasopharyngeal examination is obliga

tory to exclude nasopharyngeal carcinoma. In these

cases it is often advisable to take a biopsy under local

anesthesia. Biopsy is still indicated even if the radio

logic examination proved normal. A biopsy should

not be attempted, however, during endoscopic exam

ination of the nasopharynx if the mass appears

macroscopically vascular. Profuse hemorrhage can

occur and may be difficult, to control.

Figure 4.28 MRI. Effusion in the omolateral mastoid is

clearly visible (arrow).

5 Cholesterol Granuloma

Cholesterol granuloma is a histologic term used to

of glomus tumors causing destruction of the jugular

describe a foreign body, giant cell reaction to choles

hypotympanic septum with an irregular "moth-eaten"

terol crystals, and hemosiderin derived from ruptured

contour.

erythrocytes. Cholesterol granuloma is thought to

In the initial phases, before cholesterol granuloma

arise from obstructed drainage and insufficient aera

is formed, it might be sufficient to insert a ventilation

tion of cellular compartments of the temporal bone.

tube, thus preventing further development of the gran

This leads to reabsorption of air, negative pressure,

uloma. When the granuloma has already been formed,

mucosal edema, and hemorrhage. It can be present in

it is necessary to perform a tympanoplasty with mas

the middle ear, mastoid, or petrous apex. Generally,

toidectomy that opens the intercellular septae with

patients with tympanomastoid cholesterol granuloma

subsequent aeration of the middle ear and mastoid.

have a long history of recurrent otitis media or otitis

media with effusion. They also complain of conductive

hearing loss, and on otoscopy the tympanic membrane

appears bluish in color. In some cases, where granula

tion tissue is more prevalent, cholesterol granuloma

can present as a retrotympanic reddish-brown mass

that may cause bulging of the tympanic membrane,

thus mimicking a glomus tumor. In these cases, a com

puted tomography (CT) scan is sufficient to clear any

doubts. A cholesterol granuloma rarely causes bone

erosion. On the contrary, bone erosion is characteristic

Figure 5.1 Right ear. Typical blue tympanum caused by cho

Figure

5.2 Blue tympanum caused by cholesterol granulo

lesterol granuloma. The blue color is due to hemosiderin crys

ma. An epitympanic retraction due to eustachian tube dys

tals. The granuloma involves not only the middle ear but gen

function is also present.

erally extends into the mastoid air cells.

Cholesterol Granuloma

Figure

5.3 Cholesterol granuloma associated with an

Figure

5.4 Characteristic blue color of the tympanic mem

inflammatory polyp that leads to bulging of the tympanic

brane caused by a cholesterol granuloma.

membrane.

Figure

5.5 Axial CT of the case described in Figure 5.4. The

Figure

5.6 Coronal CT scan of the same patient.

granuloma and the effusion are present in the middle ear and

mastoid without causing any bony erosion. The ossicular

chain (malleus and incus) is intact and the intercellular septae

in the mastoid are preserved.

5 Cholesterol Granuloma

Figure

5.7 Left ear. A 17-year-old male patient complained

Figure

5.8 CT, coronal view. Involvement of the nasophar

of conductive hearing loss of 1 year duration accompanied by

ynx and the sphenoidal sinus.

left nasal obstruction. Otoscopy revealed the presence of a

left cholesterol granuloma. Rhinoscopy showed the presence

of a nasopharyngeal swelling that extended into the left nasal

cavity. The swelling was suggestive of a juvenile nasopharyn

geal angiofibroma.

Figure

5.9 Magnetic resonance imaging (MRI) of the same

Figure

5.10 MRI of the same case, sagittal view, showing

case, coronal view, showing the extension of the angiofibro

the extension of the tumor from the ethmoid to the

ma.

rhinopharynx pushing the soft palate.

Cholesterol Granuloma

Figure

5.11 MR I of the same case, axial view. Involvement Figure

5.12 The angiofibroma was removed, after being

of the middle ear and mastoid by the cholesterol granuloma

embolized, using a midfacial degloving approach,

can be observed.

Figure

5.13 Postoperative CT (1 year) confirming the total

tumor removal.

6 Atelectasis, Adhesive Otitis Media

Adhesive otitis media is characterized by complete or

mainly the posterior part of the tympanic membrane,

partial adhesions between the thin retracted and

usually without retraction of its anterior half.

atrophic pars tensa and the medial wall of the middle

Histologically, the tympanic membrane is atrophic

ear. Necrosis of the long process of the incus or the

due to thinning or even absence of the lamina propria.

stapes' suprastructure can also occur with a resultant

It can be hypothesized that the negative middle ear

natural myringostapedopexy. It should be differentiat

pressure caused by eustachian tube dysfunction or per

ed from atelectasis and from simple drum retraction in

sistent secretory otitis media leads to atrophy of the

which the tympanic membrane is mobile with the

elastic fibers of the pars tensa. An occasional episode

Valsalva or Toynbee maneuvers.

of acute suppurative otitis media might form adhesions

Sade (1979) distinguished five grades of atelectasis

between the mucosa of the promontory and the

(Fig. 6.1): grade I is characterized by a mild retraction

retracted tympanic membrane.

of the tympanic membrane; in grade II the retracted

tympanic membrane comes in contact with the incus or

the stapes; in grade III the tympanic membrane touch

es the promontory; grade IV is adhesive otitis media;

and in grade V there is a spontaneous perforation of

the atelectatic ear drum with otorrhea and polyp for

mation.

Nakano (1993) proposed two types of adhesive oti

tis: type A in which the retracted and atrophic tym

panic membrane adheres completely to the promonto

ry, and type B in which retraction and adhesion affect

Figure

6.1 Classification (modified) of atelectasis according

Figure 6.2 Right ear. Grade I atelectasis according to Sade

to Sade (1979) (see text).

(1979). The tympanic membrane is retracted but does not

come into contact with the middle ear structures. A mild

retraction of the pars flaccida, through which the head of the

malleus is visible, is also noted. The base of the retraction

pocket is under control with no sign of cholesteatoma. It is

also possible in this case to assume that the drum is mobile

on Valsalva or Toynbee maneuvers. This patient presented

with very mild conductive hearing loss and a normal tym-

panogram (type A) (see Figs. 6.3 and 6.4).

Atelectasis, Adhesive Otitis Media

120

125

250

500

16KHz

-200

-100

+100

+200

Figure

6.3

Audiogram of the same case. Mild conductive

Figure

6.4 Tympanogram of the same case. Normal or type A.

hearing loss.

100

110

120

125

250

500

16KHz

Figure

6.5

Right ear. Grade I atelectasis with the malleus

Figure

6.6

Audiogram of the same case showing a 40-dB

slightly medialized. An epitympanic retraction pocket is also

conductive hearing loss.

seen. Middle ear effusion with yellowish color can be appre

ciated. Pure tone audiogram revealed a

40-dB conductive

hearing loss (Fig. 6.6), whereas the tympanogram was type B,

i.e., typical of middle ear effusion (Fig.

6.7). In this case, the

insertion of a ventilation tube is indicated to avoid further

retraction of the tympanic membrane, to aerate the middle

ear, and to improve hearing.

6 Atelectasis, Adhesive Otitis Media

-200

-100

+100

+200

Figure

6.7

Tympanogram type B of the same case, typical

Figure

6.8

Right ear. Grade I atelectasis. The tympanic

of middle ear effusion.

membrane is markedly thinned due to partial resorption of

the lamina propria. The incus is seen in transparency. Pure

tone audiogram is normal

(Fig.

6.9), whereas the tym

panogram has a very high compliance (Fig. 6.10). As the tym

panic membrane is mobile with the Valsalva maneuver, inser

tion of a ventilation tube is not indicated.

10 dBHL

100

110

120

125

250

500

16KHz

-200

-100

+ 100

+200

Figure

6.9

Audiogram of the same case (see text).

Figure

6.10 Tympanogram of the same case, type AD accord

ing to the classification of Liden-Jerger,

1976 (see text).

Atelectasis, Adhesive Otitis Media

Figure 6.11 Left ear. Grade II atelectasis with marked epi-

Figure 6.12 Right ear. Grade II atelectasis. A condition sim

tympanic retraction. The tympanic membrane touches the

ilar to the previous case but with the onset of thickening of

incus. The malleus is medialized. Air-fluid levels are seen in

the tympanic membrane.

the anteroinferior quadrant. The insertion of a ventilation

tube is necessary to restore normal conditions.

Figure

6.13 Right ear. Grade II atelectasis. The tympanic

Figure

6.14 Left ear. Grade III atelectasis. The tympanic

membrane is very thin due to absence of the fibrous layer. The

membrane touches the promontory and the incus. An

membrane adheres to the incudostapedial joint and the tensor

air-fluid level and a tympanosclerotic plaque can be seen in

tympani tendon. Insertion of a ventilation tube is indicated.

the anterior quadrant.

6 Atelectasis, Adhesive Otitis Media

Figure

6.15 Left ear. Grade III atelectasis. The thin and

Figure 6.16 Right ear. Adhesive otitis media or grade IV

atrophic tympanic membrane is in contact with the promon

atelectasis associated with a mild epitympanic retraction

tory. Middle ear effusion is seen. A tympanosclerotic plaque is

pocket. The thin and atrophic tympanic membrane complete

present in the anterosuperior quadrant. The head of the

ly covers the promontory. The tympanic membrane retraction

malleus is visible through an epitympanic retraction pocket.

has caused erosion of the long process of the incus with a

The insertion of a ventilation tube is indicated.

subsequent spontaneous myringostapedopexy As the patient

does not complain of hearing loss, surgery is not indicated.

Figure 6.17 Left ear. Grade IV atelectasis. The malleus is

media with chronic eustachian tube dysfunction. The fibrous

medialized and adherent to the promontory. The tympanic

and mucosal layers of the tympanic membrane were

membrane is atrophic. The epidermal layer of the membrane

resorbed, whereas the epidermal layer is completely adherent

is adherent to the incudostapedial joint, the promontory, and

to the medial wall of the middle ear. The promontory, round

the round window. A retraction pocket corresponding to the

and oval windows, as well as residues of the ossicular chain

eustachian tube orifice is also seen. Middle ear effusion is pre

are all visible. The handle of the malleus is completely medi

sent. Insertion of a ventilation tube is indicated.

alized and partially eroded. The long process of the incus is

eroded, whereas the stapes suprastructure is completely

Figure 6.18 Left ear. Adhesive otitis media. This case repre

absent. As the patient does not suffer from otorrhea, surgery

sents the long-term sequela of persistent secretory otitis

is not advised.

Atelectasis, Adhesive Otitis Media

Figure

6.19 Right ear. The thin and atrophic tympanic

mae. The tympanic membrane is thin and transparent due to

membrane adheres to the promontory, incudostapedial joint,

absence of the fibrous layer. The handle of the malleus is ampu

pyramidal process, and stapedius tendon. The long process of

tated. The long process of the incus is eroded and a natural

the incus is partially eroded. Calcifications are present in the

myringostapedopexy is noted. The promontory, round window,

anterior quadrants. As hearing is normal, surgery is not indi

head of the stapes, and oval window can be seen through the

cated.

thin tympanic membrane. Despite the attic epithelialization, a

true cholesteatoma has not yet formed. Regular follow-up of

Figure

6.20 Right ear. Atelectasis associated with marked

such cases is fundamental. Should the disease progress with

epitympanic erosion through which the head of the malleus

cholesteatoma formation, surgery in the form of an open tym

and body of the incus are seen covered with epithelial squa

panoplasty is indicated.

Figure 6.21 Left ear. Posterior retraction pocket. The tympanic

Figure 6.22 Right ear. The tympanic membrane, being adher

membrane remains adherent to the stapes' head even after

ent to the long process of the incus, caused erosion of the latter

Valsalva maneuver (myringostapedopexy). The remaining part of

with subsequent conductive hearing loss (see Fig. 6.23). The sec

the tympanic membrane is thick and shows tympanosclerosis.

ond portion of the facial nerve is seen superior to the oval win

Audiometry revealed normal hearing. Cases with myringostape

dow. The head of the stapes and the stapedius tendon are also

dopexy generally have good hearing; therefore, surgery is not

visible. Tympanoplastic surgery was performed on this patient. The

indicated except if conductive hearing loss develops and/or a pos

tympanic membrane was reinforced and the incus interposed

terior retraction pocket is associated with frequent otorrhea.

between the handle of the malleus and the stapes.

Surgery varies from simple myringoplasty (when the tympanic

membrane needs reinforcement) to tympanoplasty (in which the

ossicular chain is eroded and needs ossiculoplasty).

6 Atelectasis, Adhesive Otitis Media

100

110

120

125

250

500

16KHz

Figure

6.23 Audiogram of the same case showing conduc

Figure

6.24 Left ear. Meso- and epitympanic retraction

tive hearing loss.

pockets that adhere to the head of the malleus, the partially

eroded long process of the incus, and the incudostapedial

joint. A ventilation tube has been inserted in the anterior

quadrant to avoid further retraction that might lead to

cholesteatoma.

Figure 6.25 Right ear. Grade IV atelectasis. All of the mid

Figure

6.26 Right ear. Large mesotympanic retraction pock

dle ear structures can be seen in transparency. Starting from

et that caused erosion of the incus and stapes suprastructure.

the malleus and moving in a clockwise direction, we can dis

The second portion of the facial nerve passing superior to the

tinguish the tubal opening, the hypotympanum, the promon

oval window, the promontory, and the round window can all

tory, the round window, the stapedius tendon, and the incudo

be seen in transparency. In cases with good social hearing and

stapedial joint.

no otorrhea, surgery is not indicated.

Atelectasis, Adhesive Otitis Media

Summary

In grade I, II, and III atelectasis, a long-term ventila

tion tube is usually inserted to prevent further retrac

tion of the tympanic membrane. However, in cases

with marked conductive hearing loss that denotes

erosion of the incus or the superstructure of the

stapes, ossiculoplasty is performed after extraction

and sculpturing of the eroded incus or using a homol

ogous incus. A large disk of tragal cartilage is used to

reinforce the tympanic membrane.

Indications for surgery in adhesive otitis media

include cases with tympanic membrane perforation

(grade V according to Sade 1979), with or without

polypi, granulation or otorrhea, those cases with a

large infected retraction pocket causing frequent

otorrhea, or those with conductive hearing loss due

to ossicular chain erosion. In all these cases a tym

panoplasty is performed using a postauricular inci

sion. A disk of tragal cartilage is used with the peri

chondrium adherent to its lateral surface. If the han

Figure 6.27 Right ear. Posterior retraction pocket. The tym

dle of the malleus is present, it is incorporated into

panic membrane adheres to the promontory, the round win

the cartilaginous disk after creating a triangular

dow, the partially eroded long process of the incus, the head

defect for its accommodation. This technique has the

of the stapes, and the stapedius tendon. The processus

advantage of preventing retraction and adhesions

cochleariformis is clearly visible between the malleus and the

between the tympanic membrane and the promonto

long process of the incus. Middle ear effusion can be

observed anterior to the malleus and in the region of the oval

ry. At the same time, it enables repair of the tympan

window. In this case, ventilation tube insertion is indicated in

ic membrane perforation with the tragal perichondri

an attempt to prevent further erosion of the ossicular chain

um.

and the formation of mesotympanic cholesteatoma.

It can be concluded that there is no single treatment

for the atelectatic ear. The milder the degree of

atelectasis, the more conservative the treatment is. It

should be noted, however, that in the long term con

servative treatment (e.g., ventilation tube) was not

found to modify further evolution of atelectasis. As

atelectasis results from eustachian tube dysfunction,

the ideal solution would be correction of this defect.

At present, there is no acceptable "functional"

surgery for the eustachian tube. Individual treatment

should be administered according to the conse

quences of this dysfunction in each case. Such a strat

egy, however, requires a high mental elasticity and

versatile surgical techniques.

7 Non-Cholesteatomatous Chronic Otitis Media

The difference between acute and chronic otitis media is

around the perforation should be determined.

2) At

not the duration of the disease but rather the anatomo-

the level of the middle ear, the state of the mucosa, the

pathological characteristics. Untreated acute otitis

condition of the ossicular chain

(if possible), and the

media persisting for months is still a process that tends

presence or absence of epithelialization should be

essentially to return to normality. On the other hand, a

evaluated.

3) The otoscopic examination has to be

chronic otitis, even if the ear stops discharging, has

complemented with the pure tone audiometry to have

anatomopathological sequelae of clinical importance.

a better understanding of the ossicular chain (possible

The most commonly encountered forms are active

erosion of the incus, fixity of the chain).

chronic suppurative otitis media characterized by otor

Pars tensa perforations can be either central or

rhea and inactive chronic suppurative otitis media in

marginal. Marginal perforations lie at the periphery of

which the ear is dry. Naturally, the active form may

the tympanic membrane with absence of the fibrous

become quiescent either spontaneously or following

annulus. Marginal perforations are considered

treatment. The ear becomes dry and the condition is

"unsafe" because the skin of the external auditory

designated inactive. A dry perforation, however, may

canal, in the absence of the annulus, can easily

be infected, leading to ear discharge. In this latter case,

advance towards the middle ear, giving rise to

the mucosa may be hyperplastic and thick due to inter

cholesteatoma.

stitial edema, fibrosis, or cellular infiltration. In some

Otoscopic examination can often define the junc

cases, polypi are formed which may be large enough to

tion between the skin and mucosa at the borders of the

occupy the external auditory canal. In other cases, per

tympanic membrane perforation. At this junction the

sistence of suppuration can lead to ulceration of the

squamous epithelium has a "velvety" appearance. The

mucosa, formation of granulation tissue, and even

presence of a red de-epithelialized ring along the per

bone resorption. The anatomical sequelae of chronic

foration rim indicates the evagination of the mucosa

otitis media vary. They may be in the form of a simple

towards the external surface of the tympanic mem

central tympanic membrane perforation, erosion of

brane residue. However, invagination of the skin

the ossicular chain, or formation of tympanosclerosis.

towards the inner surface of the tympanic membrane

Both the active and inactive forms cause functional

residue is more difficult to diagnose. This inward skin

alterations such as conductive or mixed hearing loss

migration is favored by the atrophy of the mucosa

(very rarely sensorineural). The absence of squamous

which occurs as a result of the perforation. At the time

epithelium in the middle ear has led to the designation

of myringoplasty, freshening of the edge of the perfo

of this form as a "safe type" of otitis media. This is to

ration not only favors the attachment of the graft but

distinguish it from cholesteatoma, which is considered

also greatly reduces the risk of leaving entrapped skin

"unsafe" due to the potential complications that may

on the undersurface of the drum, which may lead to

arise from the presence of keratinized squamous

iatrogenic cholesteatoma.

epithelium in the middle ear.

Conductive hearing loss caused by tympanic mem

brane perforation has two main causes:

1) Reduction

of the tympanic membrane surface area on which the

acoustic pressure exerts its action. 2) Reduction of the

• General Characteristics of Tympanic

vibratory movements of the cochlear fluids because

Membrane Perforations

sound reaches both windows at nearly the same time

Tympanic membrane perforations are usually present

without the dampening and phase-changing effect of

at the pars tensa. Pars flaccida perforations are gener

the intact tympanic membrane.

ally associated with epitympanic cholesteatoma.

The site of the perforation cannot be correlated to

If a tympanic membrane perforation does not heal

a particular audiometric pattern. However, it is gener

spontaneously, the epithelial and mucosal layers creep

ally observed that hearing loss occurs more in the low

and meet along the borders of the perforation. This

frequencies and that for perforations of the same size,

pathological communication between the middle and

hearing loss occurs more in posterior perforations than

external ear can be considered a true "air fistula." In

in anterior ones.

the presence of a tympanic membrane perforation, the

The majority of posttraumatic and postotitic perfo

patient is subject to recurrent infections and ear dis

rations heal spontaneously. When large portions of the

charge.

tympanic membrane are lost or when chronic or recur

Whenever tympanic membrane perforations are

rent infections occur, the perforation may become per

diagnosed, the following three considerations must be

manent. In these cases, the tympanic membrane must

fulfilled: 1) At the level of the perforation the site, size,

be repaired

(myringoplasty) to restore the normal

and state of the remainder of the tympanic membrane

physiology of the ear.

Posterior Perforations

Figure 7.1 Left ear. The tympanic membrane is very thin

Figure

7.2 Right ear. Marginal posterosuperior perforation

due to atrophy of the fibrous layer. A posterosuperior mar

through which the intact incudostapedial joint, the stapedius

ginal perforation is seen. This perforation is risky because the

tendon, and the pyramidal process can be seen.

skin of the external auditory canal can easily advance into the

middle ear, forming a cholesteatoma. In this case, a myringo

plasty using an endomeatal approach is indicated.

Figure

7.3 Left ear. Perforation of the posterosuperior quad

plaque, it is advisable to remove it, conserving the epidermal

rant of the tympanic membrane. Visualized through the per

layer to be laid over the graft.

foration are the incudostapedial joint, the stapes, the

stapedius tendon, the pyramidal process, the promontory, and

Figure

7.4 Right ear. Large perforation of the posterior

the round window. The residue of the tympanic membrane is

quadrants. Normal middle ear mucosa. The incudostapedial

very thin due to absence of the fibrous layer. Tympanosclerosis

joint is intact. The oval window with the annular ligament sur

can be seen in the marginal part of the drum residue. From the

rounding the footplate can be seen. The pyramidal eminence,

surgical point of view, posterior perforations are the easiest to

the stapedius tendon, the round window, and Jacobson's

repair especially when partial reconstruction of the tympanic

nerve running on the promontory are also visible. The remain

membrane is all that is required. When the residue of the tym

ing anterior quadrants of the tympanic membrane are tym

panic membrane is transformed into a rigid tympanosclerotic

panosclerotic and rigid, blocking the mobility of the malleus.

7 Non-Cholesteatomatous Chronic Otitis

Figure

7.5 Right ear. Presence of chronic otitis media. Dry

Figure

7.6 Left ear. Posterior nonmarginal perforation. The

perforation of the posterior quadrants of the tympanic mem

incudostapedial joint, the promontory, and the round window

brane through which the head of the stapes and the round

are all discernible.

window are visible. The long process of the incus is necrosed.

The middle ear mucosa is normal. The tympanic membrane

residue shows tympanosclerosis with alternating areas of cal

cification and areas of thinned membrane due to atrophy of

the fibrous layer. The operation, performed through a post-

auricular incision, will also include the reconstruction of the

ossicular chain using the autologous incus.

Figure

7.7 Right ear. Presence of simple chronic otitis

Figure

7.8 Left ear. Perforation of the posterior quadrants

media; a posteroinferior drum perforation. The middle ear

of the tympanic membrane. The skin advances along the pos-

mucosa is normal. The round window and Jacobson's nerve

terosuperior border of the perforation towards the incudo

running on the promontory are seen. The incus can also be

stapedial joint. The middle ear mucosa appears hypertrophic.

appreciated posterior to a retromalleolar tympanosderotic

Mucoid discharge is also present. A tympanosderotic plaque

plaque. The tympanic membrane residue shows areas of atro

can be seen in the residue of the tympanic membrane.

phy alternating with areas of tympanosclerosis.

Anterior Perforations

Figure

7.9 Right ear. Marked posterior marginal perforation

through which the skin penetrates into the middle ear. The

ossicular chain is not identifiable.

Anterior Perforations

Figure

7.10 Left ear. Anterior perforation of the tympanic

Figure 7.11 Right ear. Anterior perforation in a patient with

membrane through which the tubal orifice is visible. A white

anterior and posterior humps of the external auditory canal as

mass is present behind the anterosuperior margin of the per

well as exostosis of the superior canal wall. In this case,

foration. This mass can be either a cholesteatoma or a tym-

canalplasty should be performed at the same time as my

panosclerotic plaque. The consistency of the mass can be test

ringoplasty.

ed using an instrument under the microscope; the

cholesteatoma is soft and will break, whereas tympanosclero

sis is generally hard.

7 Non-Cholesteatomatous Chronic Otitis Media

Figure

7.12 Left ear. Dry anteroinferior perforation. The

Figure

7.13 Right ear. Anteroinferior perforation. The pos

middle ear mucosa is normal. The tympanic membrane

terior and anterior residues of the tympanic membrane show

residue shows tympanosclerosis, giving it a white aspect. The

tympanosclerosis. The anteroinferior residue of the drum is

tubal orifice can be seen from the anterior margin of the per

de-epithelialized. The tubal orifice is also visible.

foration.

Figure 7.14 Right ear. Anteroinferior perforation. Two tym-

panosclerotic plaques are appreciated: one anteromalleolar

and the other retromalleolar. The middle ear mucosa is nor

mal. The hypotympanic air cells are seen through the perfo

ration.

Subtotal and Total Perforations

• Subtotal and Total Perforations

Figure 7.15 Right ear. Large tympanic membrane perfora

Figure

7.16 Right ear. Perforation of the inferior quadrants

tion. The tubal orifice, the hypotympanic air cells, the

of the tympanic membrane. All the tympanic membrane

promontory, the round and oval windows, and the intact

residue shows dense tympanosclerosis. Removal of these scle

stapes can be viewed. An onset of necrosis of the incus can

rotic plaques during myringoplasty assures an adequate vas

be distinguished.

cularity to the graft, and thus a high success rate for the oper

ation.

Figure 7.17 Right ear. Similar case. The promontory and the

Figure

7.18 Left ear. Subtotal perforation. The annulus as

round window are visible. A tympanosclerotic plaque that

well as a fibrous rim are visualized along the inferior border of

engulfs the ossicular chain is seen at the level of the postero-

the perforation. The handle of the malleus is medialized. The

superior border of the perforation.

tubal orifice, the hypotympanic air cells covered with mucosa,

Jacobson's nerve on the promontory, and the long process of

the incus are visible. The residue of the tympanic membrane

is thickened. In cases in which only a small anterior residue of

the tympanic membrane is found, an overlay technique in

which the graft is put over the annulus is used, thus prevent

ing detachment of the anterior part of the graft leading to

reperf oration.

7 Non-Cholesteatomatous Chronic Otitis

Figure

7.19 Left ear. Total perforation of the tympanic

Figure

7.20 Left ear. Subtotal perforation of the tym

membrane through which evolving tympanosclerotic plaques

panic membrane. The middle ear mucosa is normal. The tym

are visible. The stapes and the stapedius tendon are visible.

panic membrane residue is de-epithelialized. The incudo-

The long process of the incus is partially eroded. The handle

stapedial joint, the medialized handle of the malleus, and the

of the malleus is medialized and adherent to the promontory.

hypotympanic air cells are visible.

The tubal orifice and the hypotympanic air cells are also

noted.

Posttraumatic Perforations

• Posttraumatic Perforations

Figure

7.21 Left ear. Posttraumatic perforation of the tym-

Figure

7.22 Left ear. Posttraumatic perforation in the pos-

panic membrane in the region of the cone of light. The blood

terosuperior quadrant. The characteristic radial tear, running

clot over the perforation has not been removed. This clot

in the same direction as the fibers of the tympanic membrane,

helps to guide spontaneous healing of the drum.

is apparent. Hemorrhagic points separating the epidermal

layer from the fibrous layer are visible. These tiny hemor

rhages are typical of posttraumatic perforations. This type of

tympanic membrane perforation has a very high incidence of

spontaneous healing.

Summary

The presence of a tympanic membrane perforation

that does not heal spontaneously as in chronic otitis

media represents an anatomical and functional

defect that needs surgical correction in the majority

of cases.

Myringoplasty is indicated in cases with and without

otorrhea, with a small or a large air-bone gap, and

with no age limit. It is contraindicated when the tym

panic membrane perforation is present in the only

hearing ear.

Myringoplasty is generally performed using a post-

auricular incision under local anesthesia-except for

children where general anesthesia is used. The tym

panic membrane is repaired by an autologous tempo

ralis fascia graft. We prefer the underlay technique in

the majority of cases because it gives better results

both anatomically and functionally. The overlay tech

nique is used in selected cases when the anterior

residue of the tympanic membrane is pathologic or

absent. When properly performed, the overlay tech

nique gives optimal results in these cases.

Canalplasty is done whenever bony humps of the

external canal are present that limit control of the

perforation borders. If reperforation occurs after

myringoplasty

(in about

5% of cases), a revision

operation is indicated after a few months. The results

of the first and second operations in terms of graft

take and reperforation are generally comparable.

7 Non-Cholesteatomatous Chronic Otitis

• Perforations Complicated or

Associated with Other Pathologies

Figure

7.23 Right ear. Total perforation. Epidermization is

In the second stage, the middle ear is checked for any resid

present in the regions of the mesotympanum and the ossicu

ual skin, and the ossicular chain is reconstructed.

lar chain. The round window, hypotympanic air cells with

thickened mucosa, Jacobson's nerve running on the promon

Figure

7.24 Left ear. Large perforation with diffuse epider

tory, and the tubal orifice are well visualized. This case is an

mization of the middle ear associated with purulent otor

example of chronic otitis media complicated by the presence

rhea. In these cases, even if the ossicular chain proves intact,

of skin in the middle ear. Tympanoplasty should be staged. In

mastoid exploration should be done. A second stage is per

the first stage, the skin is removed without traumatizing the

formed 1 year after the first operation to check for any skin

ossicular chain, and the tympanic membrane is reconstructed.

residues.

Figure

7.25 Right ear. Perforation of the inferior quadrants

Figure

7.26 Right ear. Another example of chronic otitis

of the tympanic membrane, the residues of which show tym

media complicated with diffuse epidermization of the middle

panosclerosis. Epidermization is evident over the promontory.

ear. Surgery follows the same rules as for cholesteatoma.

Since epidermization is limited in this case, a single-stage tym

panoplasty can be performed.

Perforations Complicated or Associated with Other Pathologies

Figure

7.27 Right ear. Large tympanic membrane perfora

Figure

7.28 Right ear. Granulomatous otitis media. A

tion. The anterior drum residue shows tympanosclerosis. The

roundish mass fills the middle ear. Serous otorrhea is present.

ossicular chain is difficult to identify because of the presence

of epidermization at this level. The round window is visible. A

staged tympanoplasty is also indicated in this case.

Figure

7.29 Right ear. Small perforation of the inferior

Figure

7.30 Right ear. Case similar to that in Figure 7.29.

quadrants of the tympanic membrane with eversion of the

The mucosa has replaced the epithelial layer. Ear discharge is

mucosa onto the outer layer of the membrane. Tympano

also present. During myringoplasty, curettage of the everted

sclerosis, both antero- and posteromalleolar, can be noted.

mucosa is necessary until the fibrous layer of the tympanic

membrane is reached.

7 Non-Cholesteatomatous Chronic Otitis Media

Figure

7.31 Left ear. Perforation of the anterior quadrants.

Figure

7.32 Right ear. Posterior perforation. The residues of

Skin envelopes the handle of the malleus. During myringo

the tympanic membrane appear whitish and bulging. During

plasty, curettage of the skin is necessary before reconstruc

surgery, the middle ear was occupied by granulomatous tissue

tion.

that proved to be tuberculosis (TB) on histopathological exam

ination. This patient had a past history of pulmonary TB.

Tuberculous otitis media should be suspected in cases of pul

monary TB presenting with otorrhea.

• Tympanosclerosis

Tympanosclerosis is characterized by fibroblastic inva

result of loss of blood supply can also occur. The mid

sion of the submucosal spaces of the middle ear fol

dle ear mucosa is very thin with reduced vascularity. In

lowed by thickening, hyalinization, and fusion of colla

some cases, tympanosclerotic plaques are seen extrud

gen fibers into a homogenous mass with calcium

ing from the mucosa to present as white middle ear

deposits and phosphate crystals. Though the patho

masses.

genesis is not yet clear, it seems that chronic otitis

media is a predisposing factor.

Two distinct forms are recognized:

Tympanosclerosis with Intact tympanic membrane.

This is characterized by calcareous plaques

(chalk

patches) in the fibrous layer of the tympanic mem

brane. The antero- and posteromalleolar regions are

usually involved. The periannular region of the inferi

or quadrants is also affected, forming a horseshoe pat

tern. The pars tensa is rigid, thick, and loses its elastic

ity, assuming a whitish aspect. Atrophic and thinned

areas can also occur. Infrequently, in very advanced

cases, the tympanosclerotic plaques occupy all the

middle ear spaces, attic, and aditus and completely

block the ossicular chain. The tympanic membrane in

these cases is very thick or even replaced by the

plaques.

Tympanosclerosis associated with tympanic mem

brane perforation. The perforation is frequently cen

tral or subtotal and the annulus, infiltrated by calcium

deposits, is well visualized. Frequently, submucous

nodular deposits are encountered in the middle ear.

Ossicular fixation or erosion due to devitalization as a

Tympanosclerosis Associated with Perforation

• Tympanosclerosis Associated with

Perforation

Figure

7.33 Right ear. Tympanosclerosis associated with

Figure 7.34 Right ear. Tympanosclerosis with perforation. A

perforation. The tympanic membrane residues and the middle

large tympanosclerotic plaque is noted in the anterior residue

ear (promontory and hypotympanum) show the characteristic

of the tympanic membrane. The middle ear is also involved.

plaques. The malleus is blocked by tympanosclerosis.

The promontory, oval window, stapes footplate, and round

window can be appreciated.

Figure

7.35 Right ear. Perforations of the inferior quadrants

Figure

7.36 Right ear. Tympanosclerosis with perforation.

with tympanosclerosis involving the residues of the tympanic

The tympanosclerotic process involves the anterior residues of

membrane and the middle ear.

the tympanic membrane and the mucosa of the promontory

reaching to the posterior mesotympanum. At this level, ossi

fication of the stapedius tendon is seen. The tympanic seg

ment of the fallopian canal is covered by a sclerotic plaque.

The long process of the incus is eroded.

7 Non-Cholesteatomatous Chronic Otitis Media

Tympanosclerosis with Intact Tympanic

Membrane

Figure 7.37 Left ear. Tympanosclerosis and intact drum. The

Figure

7.38 Left ear. The intact tympanic membrane shows

majority of the tympanic membrane is thinned due to atrophy

tympanosclerotic plaques lying both anterior and posterior to

of the fibrous layer. Two tympanosclerotic plaques are present

the malleus that alternate with areas of atrophy (in the inferi

near the anterior and posterior margins.

or quadrants).

Summary

Chronic otitis media associated with tympanosclero

sis represents a more complex anatomopathological

entity. In cases with intact tympanic membrane,

surgery is indicated in the presence of a significant

air-bone gap, signifying ossicular chain affection.

Should erosion or fixation of the ossicles be found,

ossiculoplasty is performed. Fixation of the stapes is

an indication for stapedotomy.

In cases associated with tympanic membrane perfo

ration, it is often possible to perform a single-stage

reconstruction in which myringoplasty is performed

with or without ossiculoplasty. A fixed stapes, how

ever, is an indication for staging where myringoplas

ty is performed first, followed by a second-stage

stapedotomy after a few months. In all suspected

cases, the patient should be informed preoperatively

of the possibility of staging surgery.

In a small percentage of cases of chronic otitis media

with tympanosclerosis, a good postoperative func

Figure

7.39 Left ear. Tympanosclerosis with intact drum. A

tional level can deteriorate with time due to refixa-

large plaque is visible in the posterior quadrants of the tym

tion of the ossicular chain with consequent air-bone

panic membrane. The anterior quadrants are thinned and

gap. In such cases, after achieving closure of the tym

atrophic, allowing visualization of the tubal orifice.

panic membrane, a hearing aid is recommended.

8 Chronic Suppurative Otitis Media with

Cholesteatoma

Cholesteatoma is an epidermal inclusion cyst localized

In rare cases, the cholesteatoma can invade the

in the middle ear, whose capsule and matrix is formed

labyrinth, cochlea, posterior and middle fossa durae,

from stratified squamous epithelium. The desquamat

the internal auditory canal, and the petrous apex,

ing debris includes pearly white lamellae of keratin

forming a petrous bone cholesteatoma

(see Chapter

that accumulate concentrically, forming the cholestea-

10).

tomatous mass.

Treatment of cholesteatoma is exclusively surgical.

The term cholesteatoma is actually a misnomer. It is

Early this century, radical mastoidectomy, a destruc

derived from the Greek "cole" or bile, "steatos" or fat,

tive procedure for the middle ear, was performed with

and "oma" or tumor. There is no relation between

the only goal being eradication of infection to save the

cholesteatoma and bile or fat. The suffix "oma"

ear.

(tumor), however, is more appropriate because

In the early

1950s, the concept of tympanoplasty

cholesteatoma can be considered an epidermal inclu

was introduced. Tympanoplasty was aimed at eradica

sion cyst.

tion of infection as well as reconstruction of the tym-

Cholesteatoma can be divided into congenital

pano-ossicular system. Today, two types of tym

(middle ear or petrous bone) and acquired (middle ear

panoplasty are employed: closed tympanoplasty in

or petrous bone). Congenital cholesteatoma is derived

which the posterior canal wall is preserved, and open

from entrapped ectodermal cellular debris during

tympanoplasty in which the posterior canal wall is

embryonic development. When it involves the middle

drilled. Both techniques, when performed appropri

ear, it appears as a whitish retrotympanic mass that

ately and with the proper indications, can produce

may be localized either anterior or posterior to the

excellent results in terms of eradication of

malleus (see Chapter 9). When it involves the petrous

cholesteatoma and restoration of hearing. In children,

part of the temporal bone, it is termed congenital

the closed technique is preferred, performed in two

petrous bone cholesteatoma and in the majority of

stages, in the majority of cases due to their highly cel

cases it is localized in the petrous apex (see Chapter

lular mastoids and in an attempt to preserve the anato

10). In this chapter we will deal exclusively with

my of the ear as much as possible. In adults, particu

cholesteatoma involving the middle ear. Petrous bone

larly in epitympanic cholesteatoma with marked ero

cholesteatoma is dealt with in a later chapter.

sion of the scutum, in cases with sclerotic mastoids, or

when middle ear atelectasis is present, an open tym

Acquired cholesteatoma of the middle ear can be

panoplasty is performed (see also Chapter 13).

caused by invasion of the skin of the external auditory

canal into the middle ear through a marginal perfora

tion. It can also originate from a epitympanic retrac

tion pocket that becomes so deep that keratin debris

can no longer be expelled, leading to their accumula

tion and subsequent cholesteatoma formation. Such

retraction pockets can remain asymptomatic until they

become infected, resulting in otorrhea and hearing

loss. In other cases, the only symptom might be pro

gressive hearing loss due to erosion of the ossicular

chain by the developing cholesteatoma.

Because it is not always easy to establish a clear

distinction between epitympanic or posterosuperior

retraction pockets and cholesteatoma, we prefer to fol

low up these patients with otomicroscopy and

endoscopy. In cases in which the retraction pocket

becomes deep, giving rise to a cholesteatoma, a tym

panoplasty is indicated. Because of the early stage of

the disease, surgery can be done in a single stage.

Fetid otorrhea and hearing loss are the main com

plaints in cholesteatoma. In addition, complicated

cases can manifest with vertigo and/or facial nerve

paralysis. Vertigo occurs as a result of labyrinthine fis

tula, which is most commonly located in the lateral

semicircular canal. Facial paralysis can be caused by

pressure of the cholesteatoma sac or neuritis.

8 Chronic Suppurative Otitis Media with Cholesteatoma

Epitympanic Retraction Pocket

Figure 8.1 Right ear. Early epitympanic retraction pocket.

Figure

8.2 Right ear. Epitympanic retraction pocket with

The tympanic membrane shows grade I atelectasis. Middle

the onset of tympanosclerosis of the pars tensa of the tym

ear effusion with characteristic yellowish coloration of the

panic membrane.

drum is seen. In the anterosuperior quadrant, the tubal orifice

is visible in transparency, whereas the long process of the

incus is evident in the posterosuperior quadrant. In the area

of the cone of light, an atrophic part of the tympanic mem

brane due to a previous myringotomy can be appreciated.

Figure 8.3 Right ear, similar case. The anterior quadrants of

transition from a simple retraction pocket to an initial attic

the pars tensa are retracted and thickened.

cholesteatoma. The distinction between the two is sometimes

difficult. In suspected cases, a high-resolution computed

Figure

8.4 Right ear. A large controllable epitympanic

tomography (CT) scan (bone window) is beneficial for better

retraction pocket with erosion of the scutum. The head of the

evaluation of the extension of the retraction pocket. In cases

malleus is seen. Middle ear effusion gives the tympanic mem

where the condition remains stable with regular follow-up and

brane the characteristic yellowish coloration. To prevent pro

where hearing is normal, no surgery is required. If the pocket

gression of the retraction pocket and the formation of adhe

extends deeper, giving rise to a frank cholesteatoma, surgery

sions, myringotomy, ventilation tube insertion, and regular fol

is indicated. If hearing is normal, an open tympanoplasty

low-up are indicated. These cases frequently represent the

(modified Bondy technique) is performed in a single stage.

Epitympanic Cholesteatoma

• Epitympanic Cholesteatoma

dBHL

100

110

120

125

250

500

16KHz

Figure 8.5 Right ear. Epitympanic erosion with cholesteato

Bondy technique was performed. This technique allows eradica

ma. The patient complained of fetid otorrhea and attacks of

tion of the cholesteatoma and also conserves hearing (for the

bloody ear discharge of several years' duration. Inflammatory tis

modified Bondy technique, see Chapter 13).

sue is seen surrounding the area of epitympanic erosion. As pre

operative hearing was nearly normal (see audiogram, Fig. 8.6),

Figure

8.6 Audiometry of the case described in Figure 8.5.

a single-stage open tympanoplasty in the form of a modified

Normal preoperative hearing.

Figure

8.7 Right ear. Epitympanic erosion with cholesteato

Figure

8.8 Right ear. Epitympanic erosion with cholesteato-

ma. The tympanic membrane is completely tympanosclerotic.

matous squamae. The patient did not complain of otorrhea.

The patient did not complain of otorrhea (dry cholesteatoma).

The pars tensa is intact. Intraoperatively, the cholesteatoma

was found to have partially eroded the head of the malleus

and the short process of the incus. The ossicular chain, how

ever, maintained its continuity. A modified Bondy technique

was performed and the normal preoperative hearing was

conserved.

8 Chronic Suppurative Otitis Media with Cholesteatoma

Figure

8.9 CT of the previous case, coronal view. The

Figure

8.10 Right ear of a

46-year-old patient suffering

cholesteatoma is located in the epitympanic area. The middle

from bilateral cholesteatoma. An epitympanic erosion with

ear is free.

cholesteatoma and middle ear effusion showing an air-fluid

level can be seen. CT scan (Fig. 8.12) demonstrates choles

teatoma extension into the mastoid. Intraoperatively, a fistula

of the lateral semicircular canal was encountered, as well as

erosion of the incus. A single-stage open tympanoplasty was

performed with autologous incus interposition between the

handle of the malleus and the head of the stapes. In patients

with bilateral cholesteatoma, an open technique is preferred.

Figure

8.11 Left ear of the same patient. Cholesteatoma

self-cleaning of the cholesteatoma debris

(see CT scan,

with marked erosion of the scutum and epidermization of the

Fig. 8.12). Because of the total destruction of the ossicular

attic and mesotympanum. The cholesteatoma debris was par

chain, a second stage was programmed for functional recon

tially cleaned. The residual pars tensa shows tympanosclero

struction.

sis. Intraoperatively, the ossicular chain was absent. The oto-

scopic view of the left ear is apparently more advanced than

Figure

8.12 CT of the previous case showing cholesteato

the right ear. This, however, was not the case intraoperative

ma extension in the mastoid in the right ear and self-cleaning

ly since the marked epitympanic erosion shown here allowed

of the cholesteatoma debris in the left ear.

Epitympanic Cholesteatoma

Figure

8.13 Left ear. Small epitympanic erosion with

Figure

8.14 Left ear. Large epitympanic erosion with

cholesteatoma. The skin surrounding the erosion is hyperemic

cholesteatoma and fetid otorrhea. The head of the malleus

and everted.

and body of the incus are eroded.

Figure

8.15 Right ear. Large epitympanic erosion with

that this technique, if properly performed, ensures complete

cholesteatoma. This 18-year-old patient did not complain of

eradication of the pathology and better long-term follow-up,

otorrhea. Ipsilateral hearing was normal, whereas the con

thus minimizing the risk of recurrence. Further surgical inter

tralateral side showed severe sensorineural hearing loss sec

ventions, with their potential risk even in the most experi

ondary to a previous surgery of radical mastoidectomy. Given

enced hands, are therefore avoided.

the intact ossicular chain, an open tympanoplasty (modified

Bondy technique) was performed. According to our strategy,

Figure

8.16 Right ear. Large epitympanic erosion with

cholesteatoma in the only hearing ear is one of the absolute

cholesteatoma and polypoid tissue that covers the head of

indications for performing an open technique. The reason is

the malleus. The pars tensa is intact.

8 Chronic Suppurative Otitis Media with

esteatoma

Figure

8.17 Left ear. Epitympanic cholesteatoma. Extensive

Figure

8.18 Left ear. Cystic retrotympanic cholesteatoma

erosion of the scutum with excessive cholesteatomatous

situated posterior to the malleus. The tympanic membrane

debris. The pars tensa shows grade I atelectasis with catarrhal

shows bulging at the level of the pars flaccida and slight

middle ear effusion.

retraction with tympanosclerosis in the posterior quadrants.

Figure 8.19 Same case as in Figure 8.18 during an acute

Figure 8.20 Left ear. Epitympanic erosion occupied by a

inflammatory episode. Note the increase in size of the

cholesteatomatous mass that protrudes into the external

cholesteatomatous cyst.

auditory canal. The mass is visible behind the posterior quad

rant of the pars tensa. It engulfs the ossicular chain and

extends towards the promontory and the hypotympanum.

Epitympanic Cholesteatoma

Figure 8.21 Left ear. A large epitympanic erosion is seen

Figure

8.22 Right ear. Epitympanic erosion with choleste

with epidermization of the attic and posterior mesotympa-

atoma. Extension of the cholesteatoma into the mesotympa-

num. The cholesteatoma, visible in transparency, causes

num is seen through the bulging posterior quadrants of the

bulging of the tympanic membrane in the posterior inferior

tympanic membrane.

quadrants. Resorption of the incus and head of the malleus is

discernible.

Figure

8.23 Left ear. Epitympanic erosion with cholestea

Figure

8.24 Left ear. Epitympanic erosion with cholesteato

toma. Extension of the cholesteatoma into the mesotympa-

ma. Epidermization of the posterior mesotympanum is seen

num (visible through the transparent pars tensa).

through a posterior perforation of the tympanic membrane.

The tympanic membrane residue has a whitish color. This can

be either due to tympanosclerosis or to epidermization of the

medial surface of the tympanic membrane. Examination

under the microscope can, in many cases, determine the

exact cause.

8 Chronic Suppurative Otitis Media with Cholesteatoma

Summary

An epitympanic retraction pocket should be regular

ly checked with otomicroscopy. The 30° rigid endo

scope allows visualization of the extent of the retrac

tion pocket that can be difficult with the microscope.

When progression of the epithelium into the epitym-

panum cannot be controlled, the presence of

cholesteatoma is considered. In such cases, surgery

should be performed. Whenever a minor epitympan

ic erosion is present, we adopt a closed technique

with reconstruction of the attic using cartilage and

bone pate. This technique is valid particularly in chil

dren where the mastoid is usually very pneumatized.

Frequently, surgery is staged in these cases.

When a marked attic erosion is present, especially in

adults, we perform an open technique to avoid

cholesteatoma recurrence that can occur due to

absorption of the material used for reconstruction of

the attic defect. When preoperative hearing is normal

in the presence of attic cholesteatoma with large bony

erosion, we perform an open tympanoplasty in the

form of a modified Bondy technique. This technique

allows single-stage eradication of the disease with

conservation of the normal preoperative hearing.

Mesotympanic Cholesteatoma

Figure

8.25 Right ear. Mesotympanic cholesteatoma. The

Figure

8.26 Right ear. Posterior mesotympanic cholesteato-

epithelial squamae can be seen through the retromalleolar

ma associated with a polyp are seen at the level of the oval

perforation. Anterior to the malleus, the cholesteatomatous

window. There is evidence of discharge,

mass causes bulging and whitish coloration of the tympanic

membrane without perforating it. The entire middle ear is

filled with cholesteatoma in this case.

Mesotympanic Cholesteatoma

Figure 8.27 Left ear. Small epitympanic erosion and a

Figure 8.28 Right ear. A child with mesotympanic retrac

mesotympanic retraction pocket with wax and cholesteato-

tion and posterosuperior perforation through which

matous squamae. Extension of the cholesteatomatous mass

cholesteatomatous debris and inflammatory tissue are visible.

into the anteromalleolar region is seen through the retracted

Purulent discharge is observed. The patient was operated on

tympanic membrane.

using a staged closed tympanoplasty.

Figure

8.29 Right ear. Posterior perforation with choleste

Figure

8.30 Right ear. Total tympanic membrane perfora

atoma in the posterior mesotympanum. The cholesteatoma

tion. The handle of the malleus is absent. The long process of

tous squamae cover the region of the oval window extending

the incus and part of the stapes are covered by

towards the attic and progress anterior to and under the han

cholesteatoma, which also involves the promontory. The

dle of the malleus. The promontory and the round window

round window, hypotympanic air cells, and tubal orifice are

are visible through the perforation.

free of pathology. In these cases, a staged closed tym

panoplasty can be performed.

8 Chronic Suppurative Otitis Media with Cholesteatoma

Summary

The presence of a posterior mesotympanic retraction

pocket is usually associated with erosion of the ossic

ular chain. Surgery is indicated in these cases. The

retraction pocket is completely removed after per

forming canalplasty of the posterior canal wall. In the

same stage, the tympanic membrane is grafted, the

posterosuperior quadrant of the tympanic membrane

is reinforced, and middle ear aeration is restored

using Silastic sheeting. One year later, if the tympan

ic membrane position remains normal

(i.e., not

retracted), the ossicular chain is reconstructed.

When an extensive erosion of the posterior wall is

present, a modified radical mastoidectomy is indicat

ed in the elderly, whereas a staged open tym

panoplasty is performed in younger patients. The

same strategy is also followed in patients presenting

with bilateral cholesteatoma.

Figure

8.31 Right ear. Total perforation of the tympanic

membrane. A cholesteatoma completely covers the handle of

the malleus and the incudostapedial joint.

• Cholesteatoma Associated with

Atelectasis

Figure 8.32 Left ear. Grade IV tympanic membrane atelec

Figure 8.33 Left ear. Epitympanic erosion through which a

tasis with posterosuperior mesotympanic retraction pocket. A

cholesteatoma is shown filling the attic and causing erosion

mixture of wax and cholesteatomatous debris is seen. The

of the head of the malleus. A grade IV atelectasis of the tym

middle ear mucosa is visible because of the absence of the

panic membrane (adhesive otitis) is seen with formation of

epithelial layer.

polypoidal granulation tissue in the middle ear. In the region

posterior to the malleus, the cholesteatoma engulfs the ossic

ular chain.

Cholesteatoma Associated with Atelectasis

Figure

8.34 Left ear. Epitympanic erosion with cholesteato

Figure

8.35 Right ear. Epitympanic cholesteatoma associat

ma associated with atelectasis of the tympanic membrane. The

ed with complete atelectasis of the tympanic membrane (see

incus is absent. A natural myringostapedopexy has been creat

CTscan, Fig. 8.36).

ed. The second portion of the facial nerve is seen superior to

the stapes; inferiorly the round window is noted. The anterior

part of the tympanic membrane is affected with tympanoscle

rosis. In these cases, as hearing loss is mild (< 30 dB), a modi

fied radical mastoidectomy is indicated to maintain the normal

preoperative hearing level obtained as a result of the sponta

neous myringostapedopexy.

Summary

In adult patients with extended epitympanic erosion

or with bilateral cholesteatoma we prefer to perform

an open technique. In all cases in which a sponta

neous tympanostapedopexy with normal preopera

tive hearing or elderly patients with normal con

tralateral hearing, we prefer to leave the atelectatic

tympanic membrane untouched after having verified

the absence of any middle ear cholesteatoma. In the

presence of mesotympanic cholesteatoma, staging is

indicated. In the first operation a closed tym

panoplasty is performed with reconstruction of the

tympanic membrane, and a Silastic sheet is posi

tioned in the middle ear. Silastic favors regeneration

of the middle ear mucosa and prevents the formation

of adhesions. In the second stage, performed 6 to 8

months later, the middle ear is checked for the pres

ence of any residual cholesteatoma. The ossicular

chain is then reconstructed using, preferably, an

autologous incus. In children we always try to per

Figure 8.36 CT scan of the previous case. An epitympanic

form a staged closed tympanoplasty. If a recurrent

cholesteatoma is found. Adhesions between the tympanic

cholesteatoma

(epitympanic retraction pocket) is

membrane and the promontory can be observed. This 45-

encountered in the second stage, we do not hesitate

year-old woman underwent a modified radical mastoidecto

to transform it into an open technique.

my with no interference in the middle ear.

8 Chronic Suppurative Otitis Media with

• Cholesteatoma Associated with

Complications

Figure

8.37 Left ear. Large epitympanic perforation with

(see Fig. 8.38). In such cases, because of the presence of

pars tensa perforation. Cholesteatomatous squamae are pre

marked epitympanic erosion and of the fistula, an open tym

sent in the attic, whereas the middle ear is completely free.

panoplasty is preferred.

The handle of the malleus is present. The promontory, round

window, and hypotympanic air cells are covered with normal

Figure

8.38 Intraoperative view of the previous case. A fis

mucosa. The tympanic annulus is intact. During surgery,

tula of the lateral semicircular canal is clearly seen.

a fistula of the lateral semicircular canal was encountered

Figure 8.39 Left ear. Large polyp obstructing the external

Figure

8.40 CT scan of the previous case. A huge

auditory canal. The patient complained of fetid otorrhea,

cholesteatoma causing a fistula of the lateral semicircular

hearing loss, and vertigo. A high resolution CT scan of the

canal and erosion of the tegmen can be seen.

temporal bone was ordered (see Fig. 8.40). A CT scan of the

temporal bone should always be ordered in patients with

chronic suppurative otitis media suffering from vertigo and/or

instability.

Cholesteatoma Associated with Complications

Figure 8.41 Right ear. Epi- and mesotympanic cholesteato

Figure 8.42 CT scan of the previous case. The interruption

ma. The cholesteatomatous debris protruded through the epi-

of the lateral semicircular canal caused by the cholesteatoma

tympanic erosion. In the posterosuperior quadrant, the cho

is apparent.

lesteatomatous sac can be seen in transparency, causing

bulging of the tympanic membrane. The skin surrounding the

attic erosion is hyperemic. The pars tensa is intact. The patient

complained of frequent episodes of vertigo. A CT scan (see

Fig. 8.42) demonstrated the presence of a fistula of the later

al semicircular canal.

Figure 8.43 Left ear. Small epitympanic retraction pocket in

the only hearing ear, the cholesteatoma matrix was left over

a patient presenting with hearing loss, tinnitus, and recurrent

the fistula, whereas the tegmental erosion was repaired using

episodes of otitis media with effusion. The contralateral ear

cartilage to avoid a meningo-encephalic herniation

(see

had been operated on elsewhere using an open tym

Chapter 12).

panoplasty that resulted in total hearing loss and facial nerve

paralysis. A CT scan of the temporal bone revealed the pres

Figure 8.44 CT scan of the previous case. Cholesteatoma

ence of an epitympanic cholesteatoma that caused a fistula of

caused a fistula of the superior semicircular canal and erosion

the superior semicircular canal and erosion of the tegmen (see

of the tegmen.

Fig. 8.44). The patient underwent open tympanoplasty. Being

8 Chronic Suppurative Otitis Media with Cholesteatoma

Figure

8.45 Left ear. This patient had already undergone

Figure

8.46 Polyp in the external auditory canal with puru

bilateral radical mastoidectomy elsewhere. He presented with

lent discharge. A cholesteatoma is frequently found behind

profound bilateral hearing loss and fetid otorrhea from his left

such a polyp. In such cases, biopsy is not indicated as a CT

ear. During revision surgery, a cholesteatoma causing a

scan is often used to differentiate cholesteatoma from other

cochlear fistula was found. This patient suffered profound

pathologies

(glomus, carcinoid, or carcinoma). A tym

hearing loss in the other ear, thus the cholesteatoma matrix

panoplasty revealed the presence of a large cholesteatoma

was left over the fistula to avoid deaf ear.

occupying the attic and mesotympanum.

Summary

At present, with the diagnostic methods at hand and

cholesteatoma and clearing the infection are sufficient

increased medical care, it is very rare to find a

for the paralysis to resolve. It is very rare to find fibro

cholesteatoma with intracranial complications

(e.g.,

sis or thinning of the nerve. In these cases, facial nerve

meningitis, brain abscess, lateral sinus throm

reconstruction varies from rerouting and end-to-end

bophlebitis, etc.). However, cases of cholesteatoma

anastomosis to nerve grafting, according to the degree

with massive bone destruction, labyrinthine fistulae,

of injury and length of the injured segment.

severe sensorineural hearing loss resulting in deaf

ear, and facial nerve paralysis are not infrequently

encountered. In general, it is not necessary to order a

CT scan to diagnose a cholesteatoma. However, in

the presence of headache, vertigo, facial nerve paral

ysis, severe sensorineural hearing loss, or sudden

deafness, a high-resolution CT scan of the temporal

bone becomes highly important. Axial and coronal

cuts without contrast are required. When intracranial

complications are suspected, contrast injection is also

needed.

A labyrinthine fistula is found in less than

10% of

cases. The lateral semicircular canal, being the most

superficial, is the most commonly involved.

Treatment of a labyrinthine fistula depends on the

type

(bony or membranous) and size of the fistula.

A tegmental erosion can be repaired using cartilage

and bone pate.

Facial nerve paralysis is either due to infection of the

exposed nerve or secondary to compression by the

cholesteatoma. In the majority of cases, removing the

9 Congenital Cholesteatoma of the Middle Ear

Congenital cholesteatoma is defined as an epidermoid

cyst that develops behind an intact tympanic mem

brane in a patient with no history of otorrhea, trauma,

or previous ear surgery. Michaels studied fetal tempo

ral bones and demonstrated the presence of an epider

moid structure between 10 and 33 weeks of gestation.

This structure tends to involute spontaneously until it

completely disappears. Michaels hypothesized that the

persistence of this structure could act as an anlage and

lead to congenital cholesteatoma. The fact that the

most classic location of congenital cholesteatoma,

namely in the anterosuperior part of the tympanum,

corresponds to the site of the fetal Michaels structure

supports this theory. In our cases, however, and con

trary to the few studies reported in the literature

(Derlacki and Clemis 1965, Friedberg 1994, Levenson

et al. 1989, Cohen 1987), the most common site of con

genital cholesteatoma was the posterior mesotympa-

num (see Table 9.1).

As no existing theory can truly explain the origin of

congenital cholesteatoma in the posterior location, a

strong conjecture can be made that these lesions might

Figure 9.1 Right ear. Congenital cholesteatoma seen as a

white retrotympanic mass causing bulging of the posterior

represent a different entity from those of the anterior

guadrants of the tympanic membrane. Neither drum perfora

location and may originate from epithelial cell rests

tion nor bony erosion are detected.

that are trapped in the posterior mesotympanum dur

ing the development of the temporal bone. Diagnosis

is either occasional in the asymptomatic patient, or the

patient may complain of hearing loss due to erosion of

the ossicular chain or of recurrent attacks of secretory

otitis media due to occlusion of the tubal orifice by the

cholesteatomatous mass. A high degree of suspicion

and thorough examination are essential in detecting

the presence of these lesions.

Table 9.1 Classification of congenital cholesteatoma of the

middle ear

Type

Location

Number

Percent

Type A

Mesotympanic

52.27

Type A1

Premalleolar

4.54

Type A2

Retromalleolar

46.72

Type B

Epitympanic

6.81

Type A/B

Mixed

40.90

Figure

9.2 Right ear. A small whitish retrotympanic mass is

clearly seen. The mass lies posterior to the malleus (type A2).

By definition, a cholesteatoma is considered congenital when

the tympanic membrane is intact and there is no history of

otorrhea or previous ear operations (including myringotomy

or ventilation tube insertion).

9 Congenital Cholesteatoma of the Middle Ear

Figure 9.3 Left ear. A case similar to that in Figure 9.2. The

Figure 9.4 Right ear, intraoperative view. A small premalle-

cholesteatoma caused erosion of the long process of the

olar congenital cholesteatoma (type A1) can be seen behind

incus with resultant conductive hearing loss.

the intact tympanic membrane.

Summary

Congenital cholesteatoma of the middle ear is an

infrequent pathology during infancy and childhood.

It presents behind an intact tympanic membrane,

either anterior or posterior to the handle of the

malleus.

Anterosuperior cholesteatoma can be removed

through an extended tympanotomy that permits the

preservation of the tympanic membrane and ossicu

lar chain integrity. Posterior cholesteatoma, however,

requires a staged closed tympanoplasty. The second

stage serves to check for any residual cholesteatoma.

The ossicular chain, which is generally eroded in the

posterior type, can be reconstructed at this stage.

Figure

9.5 Same case, intraoperatively, after elevation of

the tympanomeatal flap.

10 Petrous Bone Cholesteatoma

Unlike middle ear cholesteatoma, petrous bone

cholesteatoma represents an epidermoid cyst that

involves the petrous part of the temporal bone. This

type of cholesteatoma involves and/or is related to

very important structures

(namely, the facial nerve,

posterior labyrinth, cochlea, internal carotid artery,

internal auditory canal, and posterior and middle fossa

dura); therefore, the management of such lesions

should be performed in centers specialized in otoneu

rology and skull base surgery. The main presenting

symptom is fetid otorrhea, which frequently reoccurs

in an open mastoid cavity. The second most common

Figure

10.1 The supralabyrinthine type of petrous bone

symptom is progressive facial nerve palsy, that occurs

cholesteatoma is centered on the region of the geniculate

ganglion. Most frequently, it extends anteriorly towards the

in more than 50% of cases. Hearing loss can be con

basal turn of the cochlea and the internal carotid artery. Less

ductive, sensorineural, or mixed. About 50% of cases

commonly, it grows towards the retrolabyrinthine air cells.

complain of vertigo, but it is rarely the motive for the

This localization is typical of congenital cholesteatoma of the

patient's visit to the doctor. Otoscopy may be irrele

petrous bone. It may also arise due to a deep growth of an

vant or only demonstrates pars flaccida perforation or

epitympanic cholesteatoma.

an open mastoid cavity with evidence of suppurative

discharge. A computed tomography

(CT) scan and

magnetic resonance imaging (MRI) are fundamental

TS:

Transverse sinus

pc:

Posterior clinoid

to evaluate the extension of the lesion and to deter

Lv:

Labbe's vein

V2:

Trigeminal 2

SS:

Sigmoid sinus

V3:

Trigeminal 3

mine the surgical approach.

ev:

Emissary vein

C1:

First cervical vertebra

Petrous bone cholesteatoma is defined as congeni

JB:

Jugular bulb

VII:

Facial nerve

tal when it develops from epithelial cell rests

JV:

Jugular vein

IX:

Glossopharyngeal nerve

entrapped in the petrous bone during embryological

ICA:

Internal carotid artery

Vagus nerve

development. In such cases, the first symptoms are

pp:

Pterygoid processes

XI:

Spinal accessory nerve

facial nerve paralysis, vertigo, and deaf ear due to

za:

Zygomatic arc

XII:

Hypoglossal nerve

invasion of the facial nerve and labyrinth. This type

et:

Eustachian tube

represents about 3% of all cases of cholesteatoma and

is localized at the level of the petrous apex.

Petrous bone cholesteatoma is defined as acquired

when a middle ear cholesteatoma follows the cell

tracts of the temporal bone in a lateral to medial direc

tion and invades the underlying structures. The most

frequent symptoms in such cases are fetid otorrhea fol

lowed by hearing loss

(conductive, perceptive, or

mixed), facial nerve paralysis, and vertigo.

The iatrogenic form also develops in an old radical

cavity or as a late occurrence following tympanoplasty.

The most common symptoms in such cases are also

fetid otorrhea, facial nerve paralysis, hearing loss, and

Figure

10.2 The infralabyrinthine type of petrous bone

vertigo.

cholesteatoma is usually encountered in an old radical mas-

We classify petrous bone cholesteatoma into five

toid cavity. It is localized in the region of the hypotympanum

types according to its localization and extension:

and the infralabyrinthine air cells. It may extend posteriorly

supralabyrinthine, infralabyrinthine, massive labyrin

towards the posterior cranial fossa or anteriorly towards the

thine, infralabyrinthine apical, and apical.

internal carotid artery, petrous apex, and clivus.

10 Petrous Bone Cholesteatoma

ICA

CLIVUS

JVICA

JV ICA

Figure

10.3

The massive labyrinthine type of petrous bone

Figure

10.4 The infralabyrinthine apical type of petrous

cholesteatoma largely involves the posterior labyrinth and the

bone cholesteatoma originates from the infralabyrinthine or

cochlea. It may extend anteriorly towards the internal carotid

apical compartments. When it originates from the former, it

artery, medially towards the internal auditory canal, posterior

extends into the petrous apex. In some cases it may grow

ly towards the posterior fossa, or interiorly towards the infra-

towards the sphenoid sinus or the horizontal portion of the

labyrinthine compartment. Abbreviations are given in Figure

internal carotid artery.

10.1.

ICA

CLIVUS

JV ICA

Figure

10.5

The apical type of petrous bone cholesteatoma

is a rare congenital lesion. It may solely involve the apical com-

partment, causing erosion of it. It may involve the trigeminal

nerve or more posteriorly the posterior cranial fossa. It may

also engulf the horizontal portion of the internal carotid

artery.

Petrous Bone Cholesteatoma

Figure

10.6 Left acquired or iatrogenic supralabyrinthine

Figure

10.7 CT scan of the case presented in Figure 10.6,

petrous bone cholesteatoma in a radical cavity. A whitish

axial section. Involvement of the lateral semicircular canal and

retrotympanic mass is seen at the level of the second portion

the vestibule is well visualized. The cholesteatoma invades the

of the facial nerve. The patient presented with progressive

cochlea anteriorly, while medially it reaches the fundus of the

facial nerve paralysis and total hearing loss. A correct diagno

internal auditory canal. The posterior semicircular canal is not

sis depends not only on otoscopy but also on the symptoma

invaded.

tology (facial paralysis, anacusis) and a high-resolution CT

scan.

Figure

10.8 CT scan of the case presented in Figure 10.6,

Figure

10.9 Postoperative CT scan. A transcochlear

coronal section. The medial extension of the cholesteatoma

approach was performed and the operative cavity was oblit

can be appreciated.

erated with abdominal fat.

10 Petrous Bone Cholesteatoma

Figure

10.10 Right acquired supralabyrinthine petrous

Figure

10.11 CT scan of the case presented in Figure

bone cholesteatoma. A whitish mass is present in the mastoid

10.10. The cholesteatoma invades the cochlea. Total removal

cavity of an open tympanoplasty. The mass occupies the

of the pathology was accomplished using a transcochlear

whole epitympanum and extends interiorly behind the tym

approach with obliteration of the operative defect using

panic membrane. The patient presented with ipsilateral facial

abdominal fat. The external auditory canal was closed as cul-

paralysis and conductive hearing loss.

de-sac. The facial nerve was infiltrated at the level of the

geniculate ganglion and was repaired using a sural nerve

graft.

Figure

10.12 Another example of right acquired supra-

Figure

10.13 CT scan of the case presented in Figure

labyrinthine petrous bone cholesteatoma. The patient pre

10.12, coronal view. Typical location and erosion of acquired

sented with right facial nerve paralysis. Otoscopy reveals a

small supralabyrinthine petrous bone cholesteatoma.

right epitympanic erosion.

Petrous Bone Cholesteatoma

Figure

10.14 Left congenital supralabyrinthine petrous

Figure

10.15 CT scan of the case presented in Figure

bone cholesteatoma with extension towards the apex.

10.14. Coronal view showing extension of the cholesteatoma

Otoscopy is negative. The patient complained of progressive

into the internal auditory canal.

facial nerve paralysis of 5 years' duration as well as conduc

tive hearing loss.

Figure

10.16 CT scan of the case presented in Figure

Figure

10.17 Right congenital infralabyrinthine apical

10.14. Axial view showing cholesteatoma extending into the

petrous bone cholesteatoma in a 30-year-old female patient.

petrous apex.

In the posterosuperior quadrant a white retrotympanic view is

observed. The patient had complained of right anacusis since

childhood and instability of 1 year duration. The facial nerve

was normal.

10 Petrous Bone Cholesteatoma

Figure

10.18 CT scan of the case presented in Figure

Figure

10.19 CT scan of the case presented in Figure

10.17. Coronal view demonstrating the involvement of the

10.17. A more anterior coronal view at the level of the

infralabyrinthine apical compartment by the cholesteatoma.

cochlea.

Figure

10.20 Postoperative CT scan showing total removal

Figure

10.21 Polyp in the external auditory canal in a

of the cholesteatoma through the transcochlear approach

patient who had undergone a tympanoplasty (see CT scan,

and obliteration of the operative cavity using abdominal fat.

Fig. 10.22). The patient presented with otorrhea and hearing

loss.

Petrous Bone Cholesteatoma

Figure

10.22 CT scan of the case presented in Figure

Figure

10.23 Postoperative CT scan showing total removal

10.21. A large infralabyrinthine apical petrous bone

cholesteatoma extending to the cavernous sinus and to the

sphenoid sinus can be seen. Total removal was achieved using

an infratemporal fossa approach type B.

Figure

10.24 Left acquired petrous bone cholesteatoma of

Figure

10.25 CT scan of the case presented in Figure 10.24

the massive type. The patient had complained of fetid otor

demonstrating cholesteatoma invading the labyrinth.

rhea and hearing loss since early childhood. Six months

before presentation, he started to experience facial nerve

paralysis. A radical mastoidectomy was performed in another

center with partial removal of the pathology. The second and

third portions of the facial nerve can be observed in the mas

toid cavity. The patient underwent surgery using a

transcochlear approach to obliterate of the cavity with abdo

minal fat.

10 Petrous Bone Cholesteatoma

Figure

10.26 Left radical mastoid cavity. This patient was

operated on using a combined middle cranial fossa and trans-

mastoid approach for the removal of a petrous bone

cholesteatoma. The facial nerve was left as a bridge in the

middle of the cavity. On follow-up the patient complained of

recurrent episodes of facial nerve paralysis due to accumula

tion of cerumen and debris in the cavity. Therefore, the

patient underwent a second operation for obliteration of the

cavity with abdominal fat and closure of the external audito

ry canal as cul-de-sac.

Summary

When a patient presents with hearing loss

(sen

promised inner ear function. The former is utilized in

sorineural or mixed) and/or facial nerve paralysis

small supralabyrinthine cholesteatoma, while the lat

with or without a retrotympanic mass, the probabili

ter is utilized in small infralabyrinthine cholestea

ty of petrous bone cholesteatoma should be consid

toma with no involvement of the internal carotid

ered. In such cases, it is necessary to perform a high -

artery.

resolution CT scan of the temporal bone.

The ideal treatment for petrous bone cholesteatoma

is radical surgical removal, although destruction of

the labyrinth and rerouting of the facial nerve may be

required. The status of the contralateral ear must

also be considered.

The modified transcochlear approach is the most

appropriate for the removal of petrous bone

cholesteatoma. This approach offers direct lateral

access to the petrous bone and allows the removal of

all types of petrous bone cholesteatoma with their

possible extension into the clivus or sphenoid sinus.

In addition, it has the advantage of minimizing the

occurrence of cerebral spinal fluid (CSF) leak and

allows control of the different vital structures, includ

ing the internal carotid artery. Closure of the external

auditory canal as cul-de-sac and obliteration of the

operative cavity with abdominal fat avoids the risk of

infection and the need for frequent toilet of a very

deep cavity.

The middle cranial fossa approach and the radical

mastoidectomy can be used in cases with noncom-

11 Glomus Tumors (Chemodectomas)

The glomus body was first described by Guild in 1941

nal auditory canal can lead to serous or purulent otor

as a small highly vascular mass of epithelioid cells

rhea due to irritation of the skin and retention of squa

located in the region of the adventitia of the jugular

mae and epithelial debris. Hemorrhagic discharge

bulb. In

1953, Guild described glomus formations

rarely occurs.

along the tympanic branches of the glossopharyngeal

Fisch classified glomus tumors into four classes

and vagus nerves

(Jacobson's and Arnold's nerves,

based on location and extension seen on high-resolu

respectively).

tion CT scans (see Table 11.1 and Figs. 11.1-11.6).

Glomus bodies are mainly found in the tympanic

On otoscopy, a retrotympanic pulsatile mass is usu

region, jugular bulb, at the carotid bifurcation, and

ally seen in the inferior quadrants. The mass is red or

related to the vagus nerve. They are classified as para

bordeaux red. In some cases the mass may have a red

ganglia that are derived from the neural crest. While

dish-blue color due to the presence of middle ear effu

the carotid and vagal bodies function as chemorecep-

sion secondary to eustachian tube blockage. The tumor

tors stimulated by the changes in the oxygen tension,

may be seen as a polyp in the external auditory canal

tympanic and jugular bulb paraganglia do not exhibit

either due to erosion of the floor of the canal or to the

this function.

tumor breaking through the tympanic membrane.

The term glomus tympanicum is reserved for

The diagnosis can be made clinically (history and

tumors that originate from the mesotympanum while

otoscopic findings). Computed tomography (CT) with

the term glomus jugulare is attributed to those cases

contrast and magnetic resonance imaging (MRI) with

that arise from the jugular bulb or the hypotympanum

gadolinium allow exact definition of the tumor exten

with secondary invasion of the bulb. These tumors are

sion. Radiology also helps to differentiate between

highly vascular and they derive the blood supply main

glomus tumors and other lesions such as aberrant

ly from the ascending pharyngeal artery. It is claimed

carotid artery, high jugular bulb, cholesterol granulo

that they have a hereditary transmission as autosomal

ma, or meningioma extending into the middle ear.

dominant traits with penetrance that increases with

Carotid and vertebral angiography allows identifica

age.

tion of the arteries supplying the tumor; and they

In the majority of cases, the initial symptoms are

should be embolized before surgery to avoid excessive

hearing loss (conductive, sensorineural, or mixed) and

intraoperative bleeding.

pulsatile tinnitus synchronous with pulse. The tumor

In cases in which the horizontal carotid artery is

can extend into the labyrinth, causing vertigo of

engulfed by the tumor, the balloon occlusion test is

peripheral origin; towards the jugular foramen, lead

indispensable for studying the perfusion by the con

ing to deficits of one or more of the lower cranial

tralateral carotid artery as well as for the safety of the

nerves (IX-XI); or towards the occipital condyle, lead

closure of the involved carotid.

ing to hypoglossal nerve paralysis. Patients suffering

from preoperative affection of the lower cranial nerves

run a better postoperative course as compensation of

Table

11.1 Classification of glomus tumors according to

the contralateral side would have already started. The

Fisch (1978)

contralateral vocal cord compensates by crossing the

Class A: Glomus tympanicum

midline to meet the paralyzed cord, thereby markedly

Class B: Tympanomastoid

reducing the risk of aspiration pneumonia. On the

Class C: Glomus jugulare

other hand, patients with preoperative intact lower

CI: Carotid foramen

cranial nerves in whom the nerves are sacrificed dur

C2: Vertical ICA until genu

ing the operation suffer from deglutition problems in

C3: Horizontal ICA

the postoperative course. Nasogastric feeding is used

C4: ICA + FL

in such cases and oral feeding is resumed only when

Class D: Intracranial extension

compensation from the contralateral side occurs. A

De (1-2): Intracranial extradural

useful alternative is vocal cord medialization either by

Di (1-2): Intracranial intradural

Teflon injection or by medialization thyroplasty using

cartilage or silicon.

ICA = internal carotid artery; FL

= anterior foramen

The tumor can also extend into the petrous apex,

lacerum

leading to paralysis of the abducent nerve and trigem

inal neuralgia, or invade the mastoid, resulting in facial

nerve paralysis. Further extension can also occur in the

external auditory canal. Tumors occupying the exter

11 Glomus Tumors (Chemodectomas)

JVICA

Figure

11.1

The class A tumor originates from glomus for

Figure

11.2 The class B tumor originates at the level of the

mations along the course of Jacobson's nerve. They are local

promontory and invades the hypotympanum without affect

ized to the middle ear. Abbreviations are given in Figure 10.1.

ing the jugular bulb. The tumor also can extend into the mas

toid and the retrofacial air cells.

JVICA

Figure

11.3 The class C tumor originates in the dome of

Figure

11.4 The class C2 tumor erodes the vertical carotid

the jugular bulb and destroys the infralabyrinthine compart

canal up to the carotid genu.

ment. The tumor may spread in the following directions: inte

riorly, along the internal jugular vein and cranial nerves IX—XII;

superiorly, towards the otic capsule and the internal auditory

canal; posteriorly, into the sigmoid sinus; anteriorly, to the

internal carotid artery; more medially, to the petrous apex and

the cavernous sinus; or laterally, to the hypotympanum and

middle ear. Class C tumors are further subdivided according

to the degree of erosion of the carotid canal. The C1 tumor

erodes the carotid foramen without involvement of the

carotid artery.

JV ICA

Figure

11.5 The class C3 tumor involves the horizontal seg

Figure

11.6

The class C4 tumor grows to the anterior fora

ment of the carotid.

men lacerum and extends to the cavernous sinus. Class D

indicates intracranial extension of the tumor. This might be

extradural (De) or intradural (Di).

Glomus Tumors (Chemodectomas)

Figure

11.7 Left ear. Glomus tympanicum or class A tumor.

Figure

11.8 CT scan of the case presented in Figure 11.7.

The small red mass behind the anteroinferior quadrant is

The lesion is limited to the region of the promontory. There

localized on the promontory and does not extend towards the

are no visible signs of bone erosion.

hypotympanum (see Fig. 11.7).

Figure

11.9 Left ear. Class A glomus tumor. The tumor is

Figure 11.10 CT scan of the case described in Figure 11.9.

again limited to the promontory (see Figs. 11.10 and 11.11).

11 Glomus Tumors (Chemodectomas)

Figure

11.11 The tumor was removed using a transcanal

Figure

11.12 Left ear. Another example of a small class A

approach after having bipolarly coagulated the tympanic

glomus tumor.

arteries that supply the tumor.

Figure

11.13 Left ear. This small glomus tympanicum tumor

Figure

11.14 Left ear. Class B glomus tumor or hypotym-

is situated in the anteroinferior quadrant of the middle ear

panic tumor. The reddish mass is visible through the inferior

near the tubal orifice. Further growth of the tumor can block

quadrants of the tympanic membrane.

the tubal orifice, leading to middle ear effusion.

Glomus Tumors (Chemodectomas)

Figure

11.15 CT of the case presented in Figure

11.14.

Figure 11.16 Right ear. Class B glomus tumor. The highly

Tumor extension towards the hypotympanum is observed.

vascular red tumor mass pushes the tympanic membrane lat

There is no erosion of the bony plate covering the jugular

erally. A middle ear effusion is present.

bulb.

Figure 11.17 Right ear. Class B glomus tumor. An air-fluid

Figure

11.18 Left ear. Type B glomus tumor. The tumor

level due to middle ear effusion is seen together with the

causes bulging of the posterior quadrants of the tympanic

tumor. A tympanoplasty removed all of the tumor while con

membrane (see CT scan, Fig. 11.19).

serving the excellent preoperative hearing.

11 Glomus Tumors (Chemodectomas)

Figure

11.19 CT scan of the case in Figure 11.18. An axial

Figure

11.20 CT scan of the case in Figure

11.18. The

section demonstrates the presence of effusion in the mastoid

tumor extends to the hypotympanum but does not erode the

due to retention.

bone overlying the dome of the jugular bulb.

Figure

11.21 Right ear. Reddish mass protruding from the

Figure

11.22 CT scan of the previous case. Axial view

inferior wall of the external auditory canal.

demonstrating the erosion caused by the tumor of the bone

overlying the jugular bulb. This tumor can be considered an

intermediate class between B and C. The tumor is localized in

the hypotympanum and extends to the jugular bulb but does

not invade it.

Glomus Tumors (Chemodectomas)

Figure

11.23 Coronal section giving a better view of the

Figure

11.24 Angiography of the same case. The blood

tumor extension towards the jugular bulb. Intraoperatively, no

supply of the tumor (arrow) is derived from the ascending

invasion of the bulb was noted and the integrity of the bulb

pharyngeal artery that is a branch of the external carotid

was thus conserved.

artery.

Figure

11.25 Left ear. Class C1 glomus tumor. The only

Figure

11.26 CT scan, coronal view showing enlargement

complaint of the patient was ipsilateral pulsatile tinnitus of 4

of the jugular foramen with extension of the tumor into the

years' duration (see following figures).

middle ear.

11 Glomus Tumors (Chemodectomas)

Figure

11.27 CT scan, axial view. The jugular foramen is

Figure

11.28 Axial view demonstrates that the horizontal

enlarged. Irregular erosion of the borders of the jugular fora

segment of the internal carotid artery is free of tumor.

men can be observed (differential diagnosis with lower cranial

nerves' schwannoma).

Figure

11.29 Angiography demonstrating that the blood

Figure

11.30 MRI with gadolinium. The tumor is enhancing

supply of the tumor comes from the ascending pharyngeal,

except for some flow-void zones corresponding to large vas

the occipital, and the posterior auricular arteries.

cular spaces. This picture is pathognomonic of glomus

tumors.

Glomus Tumors (Chemodectomas)

Figure

11.31 Class C2 De2 glomus jugulare tumor of the

Figure

11.32 CT scan of the case presented in Figure

left ear. The patient complained of pulsatile tinnitus, hearing

11.31. The marked erosion of the jugular foramen and the

loss, and 2 months before presentation started to suffer from

vertical portion of the carotid canal can be appreciated.

dysphonia, dysphagia, and hypoglossal paresis. The affection

of the lower cranial nerves was progressive in nature. It result

ed from compression by the slowly growing tumor.

Figure

11.33 MRI demonstrating tumor in contact with the

Figure

11.34 Postoperative CT scan demonstrating tumor

medial aspect of the horizontal carotid artery and the poste

removal using an infratemporal fossa approach type A.

rior fossa dura without infiltrating it.

11 Glomus Tumors (Chemodectomas)

Figure

11.35 Right ear. Class C3 Di2 glomus jugulare

Figure

11.36 MRI, sagittal view demonstrating intradural

tumor. The patient complained of pulsatile tinnitus and mixed

extension of the tumor.

hearing loss of 12 months' duration.

Figure

11.37 MRI, coronal view after first-stage removal of

Figure

11.38 Postoperative CT scan after the second-stage

the extradural component of the tumor using an infratempo

removal of the tumor through a petro-occipital trans-sigmoid

ral fossa approach type A. The fat (F) obliterating the opera

approach (POTS).

tive cavity can be seen. The intradural tumor residue (T) is also

observed. Staging is necessary in such cases to avoid commu

nication between the subarachnoid space and the wide open

neck spaces.

Glomus Tumors (Chemodectomas)

Figure 11.39 MR I demonstrating obliteration of the opera

Figure

11.40 Right ear. Class C3 Di2 glomus jugulare

tive cavity with abdominal fat.

tumor. The patient complained of ipsilateral total hearing loss,

diplopia, grade IV facial paralysis, and dysphonia (see follow

ing figures).

Figure

11.41 CT scan axial section demonstrating the

Figure

11.42 CT scan, coronal section. The tumor involves

involvement of the jugular foramen and the horizontal seg

the internal auditory canal.

ment of the internal carotid artery. The artery was closed pre

operative^ with a balloon.

11 Glomus Tumors (Chemodectomas)

Figure

11.43 MRI, axial view giving a global idea of the

Figure

11.44 MRI, sagittal view,

extra- and intradural extension of the tumor.

Figure

11.45 Angiography before embolization.

Figure

11.46 Angiography showing marked reduction of

the tumor vascularity following embolization.

Glomus Tumors (Chemodectomas)

Figure

11.47 CT scan performed after first-stage removal

Figure

11.48 Left ear. Class C2 Di2 glomus jugulare tumor.

of the extradural part of the tumor using an infratemporal

The patient complained of hearing loss and pulsatile tinnitus

fossa approach type A. Staging is necessary to avoid commu

of 2 years' duration. He also complained of dysphonia, dys

nication between the subarachnoid spaces and the neck

phagia, paralysis of the left half of the tongue, and paresis of

spaces. The balloon used for the closure of the internal

the lower face.

carotid artery can be seen (arrow).

Figure

11.49 MRI, sagittal view demonstrating the

Figure

11.50 Preoperative CT scan. The jugular foramen is

intradural extension of the tumor as well as the inferior exten

enlarged, with involvement of the foramen magnum.

sion towards C1 and C2.

11 Glomus Tumors (Chemodectomas)

Figure

11.51 MRI with gadolinium after removal of the

Figure

11.52 CT scan following the second-stage removal

extradural part using an infratemporal fossa approach type A.

of the intradural portion of the tumor using an extreme later

Fat is seen obliterating the operative cavity (F). The intradural

al approach. The balloon used to close the vertebral artery is

tumor residue at the level of the foramen magnum is noted

visible.

(T).

Figure

11.53 CT scan following the second-stage removal

Figure

11.54 Another example of a large class C3 Di2 glo

of the intradural portion of the tumor. The removal of a large

mus tumor.

part of the left occipital condyle is also shown.

Glomus Tumors (Chemodectomas)

• Invasion of the petrous apex and clivus

• Details regarding the relationship between the tumor

and surrounding soft tissues, e.g.:

- degree of neck extension

- infratemporal fossa involvement

- intracranial and intradural extension

Radiology also helps to determine the superior and

inferior extension of the tumor, the possibility of

other associated lesions (e.g., contralateral glomus or

carotid body tumor), as well as the patency of the

contralateral sigmoid sinus and internal jugular vein.

In class C and D tumors, selective digital subtraction

angiography is essential. Arteriography is performed

for both ipsilateral and contralateral internal and

external carotids and for the vertebrobasilar system.

A study of the venous phase is also of great impor

tance.

Arteriography of the external carotid artery defines

the exact feeding vessels for further embolization. In

all tumors of class C and D, embolization is funda

mental.

Figure

11.55

MRI of the case in Figure 11.54 (T= tumor).

Arteriography of the internal carotid artery shows

vascularization from the caroticotympanic artery and

from the cavernous branches of the artery as well as

the exact status of arterial invasion by the tumor.

Study of the vertebrobasilar system demonstrates the

vascularization of intracranial extension of the tumor

from muscular, meningeal, and parenchymal (PICA,

AICA) branches. Arterial supply from these latter

branches indicates a definite intradural extension of

the tumor. This study also provides indications for

Summary

the possibility of embolizing muscular or meningeal

branches.

Because of

the complex anatomy of the temporal

When arteriography shows clear involvement of the

bone and the structures at the base of the skull, as

internal carotid artery in its horizontal segment (C3

well as the invasiveness, rich vascularity, and aggres

and C4 tumors), a balloon occlusion test to evaluate

sive behavior of glomus tumors, surgery for these dif

the collateral circulation and the possibility of sacri

ficult lesions is problematic.

ficing the artery is necessary. In some selected cases,

Glomus tumors generally present with hearing loss

when the temporary balloon occlusion test is nega

and pulsatile tinnitus. When the lower cranial nerves

tive, it might be necessary to perform a permanent

are invaded, a jugular foramen syndrome becomes

closure of the artery 30 to 40 days before operation.

manifest.

In 1978, Fisch classified these lesions into four types:

Otoscopy usually reveals a reddish retrotympanic

A, B, C, and D. He introduced the type A infratem

mass. A definitive diagnosis is obtained after neuro-

poral fossa approach for the management of tumors

radiological studies are performed. These include a

localized in the jugular foramen that were considered

high-resolution CT scan with bony window, MRI

inoperable at that time due to the presence of the

with and without gadolinium, and digital subtraction

facial nerve in the middle of the operative field and

angiography. Radiological studies are essential not

the inaccessibility of the internal carotid artery and

only to confirm the diagnosis and define the exact

petrous apex. To overcome these obstacles, Fisch

tumor class, but also to properly evaluate these

proposed anterior rerouting of the facial nerve, giv

tumors. The neuroradiologist should be able to

ing direct access to the whole intratemporal course of

inform the surgeon about the following:

the internal carotid artery as well as an excellent con

• Details of the osseous lesion

trol of the large venous sinuses. Hearing loss is the

• Involvement of the jugular bulb and foramen

only permanent postoperative deficit in this

• Exact involvement of the temporal bone

approach and is the result of obliteration of the mid

• The presence of inner ear invasion

dle ear.

• The relationship between the fallopian canal and the

The type A infratemporal fossa approach is general

tumor

ly used for the removal of class C and D glomus

• Carotid canal erosion and exact involvement of the

tumors of the temporal bone according to the Fisch

internal carotid artery

classification. In cases with intradural extension

11 Glomus Tumors (Chemodectomas)

• Differential Diagnosis with Other

exceeding 2 cm in diameter, staging is indicated

Retrotympanic Masses

where the intradural part is removed in a second

stage 6 to 8 months after the first operation. This sur

A variety of diseases can present as a mass behind an

gical strategy avoids the high risk of having postoper

intact tympanic membrane. A detailed history of the

ative CSF leak should a single-stage removal be

patient, audiological assessment, and proper radiologi

attempted. The reason for such a risk is the need to

cal evaluation are essential to reach a proper diagnosis.

resect a wide area of the dura infiltrated by the

Table 11.2 summarizes the most common conditions

tumor, and hence the subarachnoid space becomes

causing a retrotympanic mass. For details of each con

widely connected to the open neck spaces. Using the

dition, the reader is referred to the relevant chapters.

staging strategy, we never experienced any CSF leak

in our cases.

To sum up, the infratemporal fossa approach offers a

Table

112 Conditions that may present as a retrotympanic

wide access to the lateral skull base. The adequate

mass

exposure and systematic management of the impor

tant arteries and venous sinuses greatly reduces the

Anomalous anatomy

intraoperative hemorrhage. An accurate preopera

High jugular bulb

tive study of the tumor extension, the preoperative

Aberrant carotid artery

tumor embolization, and the eventual closure of an

Tumors and tumor-like conditions

invaded internal carotid artery (when feasible) by the

Congenital cholesteatoma

neuroradiologist are prerequisites for successful

Iatrogenic cholesteatoma

surgery. Therefore, the collaboration between the

Glomus tumor

neuroradiologist and the skull-base surgeon is of

Facial nerve tumor (neuroma, hemangioma)

paramount importance. Lesions of the skull base are

Carcinoid tumor

rare and very difficult to treat. Management of such

Adenoma, adenocarcinoma

cases should be restricted to specialized centers to

Meningioma (Primary or secondary to temporal

avoid any serious problems.

bone invasion)

Rhabdomyosarcoma of the tensor tympani

Miscellaneous

Meningoencephalic herniation

• Meningioma

Figure

11.56 Left ear. This patient presented with dyspha

Figure

11.57 MRI of the case presented in Figure 11.56.

gia as her only symptom. A nonpulsating retrotympanic mass

Large posterior fossa meningioma located along the posterior

was noticed. The mass was whitish rather than the reddish

surface of the petrous bone.

color characteristic of glomus tumor. CT scan and MRI

demonstrated an en-plaque meningioma invading the poste

rior surface of the temporal bone.

Glomus Tumors (Differential Diagnosis)

• Facial Nerve Neurinoma

Figure

11.58 Postoperative CT scan of the case described in

Figure

11.59 Left ear. Otoscopic view similar to the previ

Figure

11.56. The tumor was removed using a modified

ous case. A whitish retrotympanic mass is seen causing

transcochlear approach. The surgical cavity was obliterated

bulging of the posterior quadrants of the tympanic mem

using abdominal fat.

brane. A small reddish mass is visible in the posterior inferior

regions of the external auditory canal (i.e., lateral to the annu-

lus). The patient complained of left hearing loss and non-

pulsating tinnitus of 2 years' duration. In the last 3 months

before presentation, left facial nerve paresis started to appear

(see following figures).

Figure

11.60 CT scan, axial view, of the case presented in

Figure

11.61 CT scan, coronal view. The mass eroded the

Figure 11.59. The tumor is centered on the left iuqular fora

bony plate over the jugular bulb extending into the hypotym-

men.

panum.

100

11 Glomus Tumors (Chemodectomas)

Figure 11.62 MRI, axial view, shows a mass centered on the

Figure

11.63 MRI, sagittal view, of the case in Figure 11.59.

jugular foramen (T= tumor).

Figure

11.64 Angiography did not show the characteristic

Figure

11.65 Left ear. The patient complained of left facial

tumor blush of glomus tumors. During surgery, the tumor

twitches of 8 months' duration, sensation of ear fullness asso

proved to be a facial nerve neurinoma, as confirmed later by

ciated with pulsating tinnitus of 6 months' duration, and pro

histopathological examination. The tumor was arising from

gressive conductive hearing loss of 3 months' duration.

the mastoid segment of the nerve and extended to the jugu

lar bulb.

Glomus Tumors (Differential Diagnosis)

101

Figure

11.66 CT scan, axial view, showing the presence of

Figure

11.67 CT scan, coronal view. The bony plate over

a tumor involving the mastoid, middle ear, and hypotympa-

the jugular bulb is not eroded.

num without extension to the carotid canal.

Figure

11.68 MRI with gadolinium of the previous case.

Figure

11.69 Left ear. Mass protruding into the posterior

The tumor shows nonhomogeneous enhancement with con

auditory canal. The patient complained of left mild hearing

trast. Histopathological examination following tumor removal

loss and left facial nerve palsy H.B. grade III of 6 months'

revealed a facial nerve neurinoma (T= tumor).

duration (H.B.: House-Brackmann [see references]).

102

11 Glomus Tumors (Chemodectomas)

Figure

11.70 CT scan demonstrated the presence of tumor

Figure

11.71 CT scan showed also erosion of the posterior

involving the vertical portion of the facial nerve.

wall of the external canal.

Figure

11.72 CT scan. The tumor extended to the genicu

Figure

11.73 MRI showed a mass extending to the parotid

late ganglion.

gland area.

Glomus Tumors (Differential Diagnosis)

103

Ectopic Internal Carotid Artery

Figure 11.74 Another MR I of the same case. A combined

Figure

11.75 Left ear. A small pulsating reddish area in the

middle fossa-transmastoid approach with parotid extension

anteroinferior quadrant of the tympanic membrane. This pic

was performed. During surgery the tumor (T) proved to be a

ture may be confused with a glomus tympanicum tumor.

facial nerve neurinoma extended from the parotid to the

intralabyrinthine segment of the facial nerve. The nerve was

reconstructed with sural graft.

High Jugular Bulb

Figure

11.76 A high-resolution CT scan established the

Figure

11.77 Left ear. Tympanosclerosis involving the whole

diagnosis of an ectopic internal carotid artery.

tympanic membrane. An epitympanic erosion with choleste

atoma is also visible. At the level of the posteroinferior quad

rant, a bluish mass is observed. A CT scan (see Fig. 11.78)

proved this mass to be a high jugular bulb.

104

11 Glomus Tumors (Chemodectomas)

Figure

11.78 CT scan of the previous case. The uncovered

Figure

11.79 Right ear. Another example of a high jugular

jugular bulb is seen protruding into the middle ear.

bulb covered by a thin bony shell in a young male patient with

a skull-base malformation (see following figures).

Figure

11.80 CT scan, axial view. The jugular bulb pro

Figure 11.81 CT scan, coronal view. The high jugular bulb

trudes into the middle ear.

can be observed.

Glomus Tumors (Differential Diagnosis)

105

Figure

11.82 Left ear. A high and uncovered jugular bulb

Figure

11.83 CT scan of the case in Figure 11.82.

reaching up to the level of the round window is visible

through a posterior tympanic membrane perforation.

• Polypoidal Pulsating Mass

Figure

11.84 Left ear. A polypoidal pulsating red mass is

Figure

11.85 CT scan, in this case, demonstrated the pres

seen in the external auditory canal. This example has been

ence of a glomus tumor eroding the surrounding bone in an

included to emphasize the fact that biopsy of external audi

irregular way giving a moth-eaten appearance.

tory canal polypi should never be taken without radiological

investigations.

106

11 Glomus Tumors (Chemodectomas)

• Internal Carotid Artery Aneurysm

Figure

11.86 MRI demonstrates the presence of fluid voids

Figure

11.87 Guglielmi coils used to occlude an intrape-

typical of large intratumoral vessels.

trous internal carotid artery aneurysm.

Figure

11.88 CT scan of the case presented in Figure 11.87

demonstrating occlusion of the aneurysm with the coils.

Glomus Tumors (Differential Diagnosis)

107

Summary—Meningioma

Posterior fossa meningiomas are the second most

• Tumor-brain stem interface

common tumor of the cerebellopontine angle. These

• Invasion of the dura and bone

tumors are characterized by a higher morbidity and

• Relationship between the tumor and the vertebrobasi

mortality than acoustic neurinoma.

lar and carotid systems

Surgical removal of these lesions poses many prob

• Necessity of eventual embolization

lems because of the deep location, the involvement

The main blood supply of these tumors comes from

of vital neurovascular structures, and the large sizes

large dural arteries. However, significant contribu

these tumors usually attain before diagnosis.

tions may also come from pial arteries or from dural

Moreover, they have an aggressive behavior with fre

branches of the internal carotid and vertebral arter

quent involvement of the dura and bone. Total

ies. The angiographic data helps the neuroradiolo

removal is fundamental to avoid recurrence and is

gist and the skull-base surgeon to determine the

better achieved in the first operation. Total removal

need for embolization. When indicated, it should be

with minimal morbidity can be obtained utilizing an

performed a few days before surgery. It not only

array of approaches that must be adapted to each

decreases the intraoperative bleeding, but also pro

individual case.

duces a certain amount of tumor necrosis, rendering

In general, an ideal approach is that which allows

some cases easier to remove.

total removal with minimal or no brain retraction.

Close cooperation between the neuroradiologist and

The site of the tumor is the most important factor for

the skull-base surgeon offers optimal chances for

the choice of the surgical approach. The size of the

successful management of these challenging tumors.

tumor, the patient's age and general medical condi

tion, and the preoperative status of the cranial nerves

are other factors to consider.

Tumors localized posterior to the internal auditory

canal in young patients with good preoperative hear

ing can be removed using a retrosigmoid approach.

In the elderly, however, a translabyrinthine approach

is preferred to avoid cerebellar retraction. In cases of

involvement of the jugular foramen, a POTS

approach is adopted.

In small tumors lying anterior to the internal audito

ry canal, the middle fossa transpetrous approach is

utilized. In large petroclival lesions, which pose more

difficulties due to their deep location, the intimate

relation with the brain stem, and the involvement of

vital neurovascular structures, the modified

transcochlear approach should be used, irrespective

of the preoperative hearing. This approach permits a

wide and direct exposure, and a flat angle of vision

with no cerebellar or brain stem retraction.

Moreover, it allows the removal of any infiltrated

dura or bone.

Though total removal can be obtained in the majori

ty of petroclival meningiomas, it is not always neces

sary or even safe. Subtotal removal is decided on in

the absence of an arachnoid plane of cleavage

between the tumor and the brain stem or when the

perforating arteries are at risk of interruption during

total tumor removal.

Neuroradiologic evaluation is fundamental to plan

surgery. A CT scan with contrast to evaluate the

bone, MRI with gadolinium, and in some cases, digi

tal subtraction angiography are of paramount impor

tance in each case.

The neuroradiologist should provide the surgeon

with information on the following:

• Anatomical relations of the tumor

• Tumor consistency

• Vascularity

• Peritumoral edema

108

11 Meningioma—Facial Nerve Neurinoma

Summary—Facial Nerve Neurinoma

Tumor involvement of the facial nerve has been esti

Differential diagnosis of these lesions includes

mated to be the cause of facial palsy in 5% of cases.

acoustic neuroma, congenital cholesteatoma,

Though uncommon, facial neuromas should be con

chemodectoma, facial nerve hemangioma, and

sidered in the differential diagnosis of facial nerve

parotid tumors. Introdural facial nerve neuromas

dysfunction. Unfortunately, the rarity of facial neuro

pose a major diagnostic difficulty, usually being mis

mas and the diversity of their clinical picture, togeth

taken for acoustic neuromas. Apart from the few

er with the fact that their presentation may mimic

cases in which tumor extension to the geniculate gan

other more common pathologies, renders the diagno

glion could establish the diagnosis, most of these

sis of these tumors difficult.

cases were actually diagnosed intraoperatively.

Facial nerve dysfunction is the most common symp

Congenital cholesteatomas of the petrous bone are

tom. It can vary from the classic progressive palsy to

uncommon lesions that usually present with hearing

sudden or recurrent facial palsy or hemifacial spasm.

loss and facial weakness or paralysis and, therefore,

In limited cases the function of the nerve is normal.

can be mistaken for facial neuromas. Moreover, these

Therefore, all patients with progressive facial palsy

lesions appear on CT as smoothly marginated expan

must be considered to have a tumor until proved

sile lesions, and on MRI as hypo/isointense on Tl

otherwise. Moreover, all patients with Bell's palsy

and hyperintense on T2 images. Unlike facial neuro

persisting for more than 4 weeks and with recurrent

mas, however, cholesteatomas do not show enhance

facial paralysis should be investigated for the pres

ment following contrast administration, a fact that

ence of a tumor.

helps to differentiate between the two lesions.

The second most common complaint is hearing loss.

Treatment generally aims at total removal of the

Conductive hearing loss is usually associated with

tumor, restoration or preservation of facial nerve

tumor involvement of the middle ear with subse

function, and conservation of hearing. The surgical

quent interference with the ossicular chain.

approach depends on the extent of the lesion and the

Sensorineural hearing loss is attributable to inner ear

preoperative hearing level. There is general agree

erosion or extension of the tumor into the internal

ment that surgical removal is the treatment of

auditory canal.

choice. There is some controversy, however, regard

Most diagnosed tumors are of large size. One reason

ing facial neuromas and absence of or mild preoper

is that the facial nerve can accommodate tumor

ative facial nerve paresis. Some surgeons prefer to

expansion to some extent before significant pressure,

delay surgery because the patient is faced with the

with subsequent dysfunction, can occur. Another rea

inevitable postoperative paralysis followed by some

son is the relatively long duration of symptoms

degree of recovery that will never be better than

before diagnosis is made. Because of the absence of

H.B. grade III. Patient counseling is important in

classic symptomatology in such cases, a higher index

these cases.

of suspicion is needed for early diagnosis. Diagnostic

The age at presentation is another factor to be con

work-up includes audiometric testing, vestibular test

sidered. If the patient is young, early surgical resec

ing, and auditory brain-stem evoked response.

tion should be done because these tumors grow inex

Electrophysiologic testing of facial nerve function in

orably with subsequent intracranial or extra temporal

such cases is of little or no benefit. The usefulness of

extension, making the approach more difficult and

these tests in the diagnosis of facial neuromas has

postoperative complications more likely. Moreover,

been challenged by other authors

(Dort and Fish

tumor growth causes progressive degeneration and

1991, Neely and Alford 1974).

regeneration of facial nerve fibers, leading to collag-

Advances in radiologic techniques have aided great

enization of the distal part of the nerve with conse

ly in the diagnosis of these lesions. The characteristic

quent poor recovery of facial function following

appearance on CT is that of an enhancing soft tissue

reconstruction. Another reason is that these tumors

mass, usually in the perigeniculate region, with sharp

are potentially invasive: otic capsule erosion may be

bony erosion and enlargement of the fallopian canal.

present in about

20% of the cases. On the other

High resolution CT scan is the best method to assess

hand, in an elderly patient with an absence of or mild

middle and inner ear involvement by tumor.

facial nerve paresis, facial nerve decompression may

However, MRI with gadolinium is the best available

suffice if surgery is to be performed.

method for the preoperative assessment of tumor

When total tumor removal involves resection of a

extension, especially of those involving the internal

long segment of the nerve, a cable graft is usually

auditory canal, cerebellopontine angle, and/or the

needed for reconstruction of the facial nerve. The

parotid region. Both methods are believed to be

length of the graft and whether it is from the sural or

complementary for the preoperative assessment and

great auricular nerve has no effect on the eventual

the choice of the most suitable surgical approach for

recovery of facial function.

removal of these tumors. However, because these

In summary, facial nerve neuromas are uncommon

tumors show intraneural spread, it is still doubtful

tumors requiring a high degree of suspicion for their

whether MRI with gadolinium can show the full

diagnosis. Recent advances in radiological tech

extent of the lesion. Therefore, the surgeon should be

niques are the cornerstone for the diagnosis and pre

prepared to expose the whole length of the facial

operative assessment of these cases, and early surgi

nerve.

cal resection gives the best prognosis.

109

12 Meningoencephalic Herniation

Meningoencephalic herniation is the herniation of

meningeal and/or encephalic tissue in the middle ear

or mastoid. It occurs in connection with infection, pre

vious surgery, head trauma, or congenital tegmental

defects. A patient with meningoencephalic herniation

has a high risk of developing meningitis and epilepsy

due to epileptogenic focus in the herniating tissues.

The patient may present with a pulsatile retrotympan-

ic mass, cerebrospinal fluid (CSF) leakage, and apha

sia. However, the most common manifestation is that

of a conductive or mixed hearing loss with a draining

ear or serous otitis media.

Figure

12.1 Left meningoencephalic herniation in a patient

who had previously undergone open tympanoplasty. The her

nia protrudes into the attic through a small tegmental defect

and appears otoscopically as a pulsatile retrotympanic mass.

Figure

12.2 CT scan of the case described in Figure 12.1,

Figure

12.3 MRI of the previous case. The protrusion of the

coronal view. The osseous defect with the herniating tissue

cerebral tissue into the middle ear is visible.

can be clearly visualized.

110

12 Meningoencephalic Herniation

Figure

12.4 Postoperative CT scan. The hernia was man

Figure

12.5 Left meningoencephalic hernia. The superior

aged using a middle fossa approach. The bony defect was

wall of the external auditory canal is dehiscent. A soft,

repaired using cartilage. The temporal craniotomy (arrow) and

reducible, nonpulsating mass is observed. The patient had a

the cartilage (arrowhead) are clearly visible.

history of head trauma with transverse fracture of the tem

poral bone that occurred 3 years before presentation. He

complained of left hearing loss and the sensation of ear full

ness.

Figure

12.6 Preoperative CT scan of the case in Figure 12.5

Figure

12.7 CT scan of the previous case 1 year postopera

demonstrating the herniation of cerebral tissue into the mid

tively. The hernia was managed using a middle fossa ap

dle ear.

proach, placing a cartilaginous plate to reconstruct the bony

defect after having sectioned the neck of the herniating tis

sue. The cerebral tissue, which is left in the ear during the

operation, is resorbed with time as seen in the CT scan

Merfingoencephalic Herniation

111

Figure

12.8 Left meningoencephalic herniation in a patient

Figure

12.9 CT scan of the case presented in Figure 12.8.

who had previously undergone multiple ear surgeries. The

only manifestation was conductive hearing loss.

Figure

12.10 Another example of a right meningoence

Figure

12.11 CT scan of the case presented in Figure

phalic herniation in a patient who had undergone open tym

12.10, coronal view. The tegmen antri is absent and the her

panoplasty. Otoscopically, a large pulsatile mass is visible in

niation of the temporal lobe in the mastoid cavity and exter

the attic.

nal auditory canal is demonstrated.

112

12 Meningoencephalic Herniation

Figure

12.12 A patient with a history of left open tym

Figure

12.13 CT scan, coronal view, soft-tissue window of

panoplasty presenting with conductive hearing loss. Otoscopy

the case presented in Figure 12.12 demonstrating the herni

demonstrates a badly performed cavity with high facial ridge,

ating cerebral tissue into the cavity.

secretions, granulations in the posterior wall of the cavity and

an attic defect through which a soft-tissue mass protrudes

into the middle ear. A CT scan was performed that confirmed

the presence of a meningoencephalic hernia (see following

figures).

Figure

12.14 CT scan, axial view. Arrows show the herniat

Figure

12.15 CT scan, coronal view, bone window.

ing cerebral tissue.

Meningoencephalic Herniation

113

Figure

12.16 CT scan of a patient with a congenital

Figure

12.17 Right ear. Meningoencephalic herniation in a

tegmental defect. This patient has a higher risk of meningitis

plurioperated patient. The otoscopy shows a new tympanic

following an episode of otitis.

membrane lateralized by a retrotympanic whitish mass. The

patient complained of right ear anacusis and H.B. grade III

facial nerve palsy of 1 year duration.

Figure

12.18 CT scan revealed the presence of a mass

Figure

12.19 MRI also demonstrated the presence of

occupying the surgical cavity with erosion of the cochlea and

meningoencephalic herniation (arrows). During surgery, the

absence of the tegmen.

cholesteatoma was confirmed together with a large

encephalic herniation.

114

12 Meningoencephalic Herniation

Summary

Herniation of the meningeal and/or encephalic tissue

into the middle ear space is a rare condition occurring

most frequently postsurgically, spontaneously due to

congenital defects, post infection, and post trauma.

For herniation to occur, a bony defect should be pre

sent. Through this dehiscence, a meningocele, an

encephalocele, or both can occur. The most appropri

ate term seems to be meningoencephalic herniation.

The condition can lead to serious sequelae such as

CSF leak, meningitis, epilepsy, and aphasia. There

fore, once diagnosed, surgical correction should be

performed. The herniated tissue is usually resected

and the defect is reconstructed. The surgical

approach is determined by the size of the defect.

Small defects are managed using a transmastoid

approach. In hernias with middle-sized defects, the

transmastoid approach is combined with a minicran-

iotomy, which allows the placement of a larger piece

of septal cartilage for reconstruction of the defect. In

large defects, however, a middle cranial fossa

approach is adopted. In this approach, the dura of the

temporal lobe is carefully elevated until the neck of

the hernia is identified and bipolarly coagulated. The

herniated part is left inside the middle ear or mastoid

where it acts as a barrier against infection of the

intracranial spaces. The defect is reconstructed by

placing a piece of temporalis fascia between the cere

bral tissue and the dura; another piece of fascia is

placed extradurally. Next, a piece of cartilage is

placed between the bony defect and the dura to rein

force the sealing. In other cases, a piece of muscle can

also be placed between the bony defect and the car

tilage for further reinforcement.

115

13 Postsurgical Conditions

As seen in the previous chapters, some otoscopic views

may be difficult to interpret. This difficulty increases in

cases involving previous surgery because of the distor

tion of the normal anatomy. The examiner should be

competent and experienced enough to distinguish

between cases with normal postoperative healing and

those with recurring pathology and/or immediate and

late postoperative complications.

In this chapter, postoperative otoscopic views with

and without complications and/or recurrence are pre

sented.

• Myringotomy and Insertion of a

Ventilation Tube

The indications of myringotomy and ventilation tube

insertion have been discussed previously. Myringo

tomy is usually performed in the anteroinferior quad

rant of the tympanic membrane in the region of the

cone of light. The incision is made in a radial direction

using a myringotomy knife. In cases with a hump of

Figure

13.1 Left ear. The Sultan ventilation tube. This type

the anterior wall of the external auditory canal,

has two small wings: an outer one with which the tube can be

myringotomy can be performed immediately inferior

held using the ear forceps and an inner one, viewed through the

tympanic membrane, which facilitates tube insertion and pre

to the umbo in the posteroinferior quadrant. The inci

vents rapid extrusion. If properly inserted, the Sultan ventilation

sion should never be made in the posterosuperior

tube can remain for about 6 to 18 months before extrusion.

quadrant to avoid injury to the ossicular chain. The

operation is performed under general anesthesia in

children. In adults, however, local anesthesia is suffi

cient. After making a radial incision of the tympanic

membrane, the middle ear effusion is aspirated and

the ventilation tube is inserted. In the majority of

cases, hearing improves immediately.

The patient is instructed to avoid water entering

the ear by blocking it with cotton anointed with petro

latum when taking a shower or with rubber earplugs

when swimming. Infection could occur if water were to

enter the middle ear through the ventilation tube.

Should this occur, ear lavage with a disinfectant solu

tion consisting of 2% boric acid in 70% alcohol is indi

cated. When the tube is obstructed by cerumen or

crusts, the administration of hydrogen peroxide drops

is usually sufficient to restore its patency.

There are many types of commercially available

ventilation tubes, but they can be generally grouped

into short- and long-term tubes. Tubes with a larger

inner flange usually remain in place longer. Once

extruded, the myringotomy site closes spontaneously

in about 98% of cases.

Figure

13.2 Left ear. In this case, the tube has been placed

inferior to the umbo due to the presence of an anterior hump

in the anterior canal wall.

116

13 Postsurgical Conditions

Figure

13.3 Right ear. The consequences of a misplaced

Figure

13.4 Left ear. A long-term ventilation tube inserted

ventilation tube is shown. A healed myringotomy is seen in

6 months after tympanoplasty because of an observed ten

the posterosuperior quadrant (at 9 o'clock). Two months later

dency for graft retraction. The graft is seen in an optimal con

the tube was extruded. During tube insertion, however, dislo

dition with no evidence of retraction, indicating patency of

cation of the incus occurred. The dislocated incus fell to the

the ventilation tube. This tube has been in situ for more than

hypotympanum where its body and short process can be

10 years.

clearly seen. In the anteroinferior quadrant, immediately

under the umbo, another healed myringotomy site (this time

correctly placed) is visible. In the latter, tube extrusion

occurred 1 year later.

Figure

13.5 Left ear. Long-term ventilation tube. A large

Figure

13.6 Left ear. Example of a long-term "T" tube

tympanosclerotic plaque that formed

1 year after the tube

inserted in the anteroinferior quadrant of the tympanic mem

insertion can be clearly seen. Such plaques result from hem

brane. After its insertion the two wings of the tube open by

orrhagic infiltrate between the epidermal and fibrous layers of

virtue of their retained "memory," thereby preventing tube

the tympanic membrane secondary to the myringotomy and

extrusion.

are asymptomatic.

Myringoplasty

117

quadrant where the graft is detached from the anteri

or residues of the tympanic membrane and falls into

the middle ear. When an overlay technique is utilized,

blunting of the anterior angle can occur with resultant

conductive hearing loss. Lateralization, in which the

graft is detached from the handle of the malleus, is

another possible complication that leads to conductive

hearing loss. It occurs mostly when the graft is placed

lateral rather than medial to the handle of the malleus.

Stenosis of the external auditory canal, due either to

inflammatory reaction or as a result of bad reposition

ing of the meatal flaps, can also occur.

Figure

13.7 Left ear. A ventilation tube in the process of

extrusion. It is preferable not to take out the tube but rather

wait for self-extrusion to occur. Closure of the myringotomy

site occurs in about 98% of cases.

• Myringoplasty

The aim of reconstructing a tympanic membrane

perforation is twofold: first, to allow the patient to

have a normal social life with no restrictions, even

regarding water entry into the ear, and second, to cor

rect the hearing loss resulting from the perforation.

There are essentially two techniques for myringo

plasty. The underlay technique is utilized in the pres

ence of an anterior residue (at least the annulus) of the

tympanic membrane, under which the graft can be

placed. In the absence of any anterior residue of the

membrane, the overlay technique is used. In such

cases, the graft is positioned against the anterior wall

of the external auditory canal.

Normally, the tympanic membrane forms an acute

angle with the anterior wall of the external auditory

canal. While performing myringoplasty, it is generally

possible to respect this angulation when the annulus is

present anteriorly.

The myringoplasty operation is considered a suc

cess when the reconstructed tympanic membrane is

Figure

13.8 Left ear. Normal aspect of the reconstructed

intact, well epithelialized, and has normal angulation

tympanic membrane. The posterior quadrant is slightly ele

with the external auditory canal. These characteristics

vated. In this case, a posterior perforation was grafted with

temporalis fascia using an underlay technique.

allow the patient to have a normal social life (hearing

improvement and possibility of water entry into the

ear). Reperforation is a frequent complication of

myringoplasty that occurs in about 5 to 10% of cases in

the best series. Reperforation occurs more commonly

in the underlay technique, particularly in the anterior

118

13 Postsurgical Conditions

Figure

13.9 Right ear. Myringoplasty with an underlay tech

Figure

13.10 Left ear. Another example of a tympanic

nique. The reconstructed tympanic membrane is thicker than

membrane perforation that was repaired using an underlay

normal. The anterior angle is maintained. The handle of the

technique with preservation of the anterior residue. The pos

malleus is clearly visible except for the umbo, which is

terior quadrants are slightly lateralized, making it difficult to

detached from the membrane. Tympanosclerotic plaques are

see the handle of the malleus.

also visible.

Figure

13.11 Left ear. Similar case. The repaired tympanic

Figure

13.12 Right ear. Underlay myringoplasty. The

membrane is well attached to the malleus except for the area

malleus is slightly medialized. The repaired tympanic mem

of the umbo due to lateralization of the posteroinferior quad

brane is whitish in its anterior quadrants and vascularized in

rant.

the posterior ones. The anterior angle is normal.

Myringoplasty

119

Figure

13.13 Left ear. The repaired tympanic membrane

Figure

13.14 Right ear. The repaired tympanic membrane

retains a normal anterior angle and is well vascularized,

has normal thickness. The short process of the malleus can be

though thicker than normal. A small cholesteatomatous pearl

observed, although the handle is not visible due to lateraliza

is observed. This pearl can be easily removed in the outpatient

tion.

clinic under the microscope.

Figure

13.15 Left ear. Another example of a graft that is

Figure

13.16 A lateralized reconstructed tympanic mem

detached from the handle of the malleus using an underlay

brane with blunting of the anterior angle following an over

technique.

lay technique. Both complications lead to altered mobility of

the tympanic membrane with consequent conductive hearing

loss.

120

13 Postsurgical Conditions

Figure

13.17 The external auditory canal is wide but the

Figure

13.18 Similar case. The reconstructed tympanic

repaired tympanic membrane is lateralized and shows blunt

membrane is lateralized with marked blunting of the anterior

ing.

angle.

Figure

13.19 Postoperative myringitis. The tympanic mem

Figure

13.20 A patient who has undergone quadruple

brane is hyperemic, thickened, and lateralized following a

myringoplasty. In these cases, myringitis and canal stenosis

tympanoplasty. The epidermal layer is substituted by granula

are frequent; therefore, it is necessary to remove the patho

tion tissue. Myringitis is a rare complication that usually

logical tissues, perform canalplasty, and use free skin flaps.

resolves with local steroid applications. In very rare cases, re

operation is necessary. The pathological tympanic membrane

is removed followed by grafting.

Myringoplasty

121

Figure

13.21 Left ear. Reperforation of the tympanic mem

Figure

13.22 Reperforation of the tympanic membrane.

brane with granulations near the perforation. In such cases,

Myringitis with otorrhea can be appreciated. Lavage and

curettage of the granulation and freshening of the edges

freshening of the perforation edges as well as insertion of

under the microscope may lead to spontaneous closure of the

Gelfoam (in the middle ear) can favor spontaneous closure of

perforation.

the perforation.

Figure

13.23 Left ear. Stenosis of the external auditory

Figure

13.24 Right ear. Partial stenosis of the external

canal following myringoplasty.

auditory canal following myringoplasty. For the management

of this complication, it is usually sufficient to incise the skin of

the canal and insert a plastic sheet for about 20 days, while

using local medication of steroid lotion.

122

13 Postsurgical Conditions

• Tympanoplasty

Tympanoplasty operations can be classified into those

without mastoidectomy, performed with chronic otitis

media in which the tympanic membrane perforation is

associated with necrosis of the ossicular chain, and

those with mastoidectomy, performed in chronic sup

purative otitis media with cholesteatoma. As men

tioned previously, tympanoplasty with mastoidectomy

can be either closed or open.

In closed tympanoplasty, the posterior wall of the

external auditory canal is kept intact. This technique is

employed in children and in patients with very pneu-

matized mastoids to avoid having a large cavity.

Regular otoscopic follow-up is essential to identify the

formation of a retraction pocket or a recurrent

cholesteatoma. Should these occur, there should be no

hesitation in switching to an open technique.

In open tympanoplasty, the posterior wall of the

external auditory canal is removed. The indications of

this technique in the treatment of cholesteatoma

Figure

13.25 Retrotympanic cholesteatoma following

include: a wide erosion of the posterosuperior wall,

myringoplasty. This iatrogenic cholesteatoma can be

cholesteatoma in the only hearing ear, bilateral

explained by the entrapment of epidermal residues in the

cholesteatoma, cholesteatoma in patients with Down's

middle ear or malpositioning of the meatal flap at the level of

syndrome, the presence of a contracted mastoid, a

the anterior angle. It can be managed by incision of the

large labyrinthine fistula, and recurrent cholesteatoma

cholesteatoma sac, aspiration of its contents, and insertion of

following a closed tympanoplasty. Because the posteri

a plastic sheet in the external auditory canal for about 20 days

or canal wall is removed, the mastoid cavity is exteri

to favor healing.

orized and on otoscopy the external auditory canal and

the mastoid appear as one communicating cavity. If

properly performed, the cavity appears rounded in

shape, dry, and well epithelialized. On the other hand,

a badly performed cavity may appear wet, irregular,

and be lined with granulation tissue in addition to

accumulated debris. There may also be the possibility

of a residual cholesteatoma.

In cases of tympanoplasty, it is usually possible to

see the reconstructed ossicular chain through the tym

panic membrane. We generally prefer to utilize an

autologous or homologous incus for reconstruction. In

our experience (more than 1000 tympanoplasties) we

never encountered any case of extrusion when the

incus was used. In contrast, variable rates of extrusion

were noticed when biological materials

(e.g., plasti-

pore, ceramics, hydroxyapatite) were utilized.

Although the use of homologous ossicles has

never been proven to transmit slow viruses

(e.g.,

Creutzfeldt-Jakob disease), the theoretical risk makes

it more prudent to use predominantly autologous tis

sue or biomaterial of better characteristics that might

appear in the future.

Later on in this chapter, some otoscopic views of

cases managed by the modified Bondy technique are

shown. This is an open technique indicated in epitym-

panic cholesteatoma with a good preoperative hearing

in which the tympanic membrane and the ossicular

chain are intact. Some cases of radical mastoidectomy

are also shown. This technique is used mainly in elderly

patients with sensorineural hearing loss in which the

only goal of surgery is to have a dry and safe ear.

Tympanoplasty

123

Figure

13.26 Left ear. The sculptured incus is visible under

Figure

13.27 Right ear. Staged closed tympanoplasty. The

the handle of the malleus. The reconstructed tympanic mem-

tympanic membrane has a normal angle and is well attached

brane appears very thin but intact. The anterior angle is per-

to the handle of the malleus. The cartilage used for recon-

fect. A piece of cartilage placed over the incus is clearly visible.

structing the attic is visible. In this region, a small self-cleaning

retraction pocket can be seen.

Figure

13.28 Right ear. Staged closed tympanoplasty per

Figure

13.29 Right ear with a previous tympanoplasty. The

formed

10 years previously for the management of a

tympanic membrane is thin with mild blunting. The sculp

cholesteatoma. The tympanic membrane is whitish, slightly

tured incus is visible.

thicker than normal, but retains a good anterior angle. The

annulus is well seen anteriorly. The handle of the malleus is in

a good position. There are no signs of resorption of the pos

terior canal wall.

124

13 Postsurgical Conditions

Figure

13.30 Right ear. Otoscopic view after a second-

Figure

13.31 Left ear. Perfect reconstructed tympanic

stage tympanoplasty in which the incus was used for ossicu

membrane with optimal thickness and no blunting. The sculp

loplasty. The tympanic membrane and the handle of the

tured incus is in contact with the handle of the malleus: It is

malleus are excellently positioned.

slightly elevated with respect to the level of the tympanic

membrane.

Figure

13.32 Left ear. Another example of the incus posi

Figure

13.33 Left ear. Ossiculoplasty. The tympanic mem

tioned under the handle of the malleus.

brane is retracted and the malleus is medialized. The sculp

tured incus is displaced posteriorly and is adherent to the pos

terior mesotympanum. Two tympanosclerotic plaques are

noted anteriorly and interiorly.

Tympanoplasty

125

Figure

13.34 Left ear. Posteriorly displaced incus that was

Figure

13.35 Right ear. Slightly retracted reconstructed

used for ossiculoplasty. The trough created on the incus to fit

tympanic membrane. A T-shaped collumela from homologous

the handle of the malleus is clearly seen. Revision surgery is

cartilage is visible. The collumela has been placed between

necessary to reposition the displaced incus and improve the

the tympanic membrane and the footplate of the stapes.

patient's hearing.

Figure

13.36 Left ear. Ossiculoplasty. A piece of cartilage

Figure

13.37 Right ear. Closed tympanoplasty. Sculptured

that was interposed between the reconstructed ossicular

incus in a perfect position under the reconstructed tympanic

chain and the tympanic membrane can be visualized. It

membrane. The cartilage used to reconstruct the postero-

appears as a whitish thick mass that causes elevation of the

superior wall of the external auditory canal is also visible.

posterior quadrants of the tympanic membrane.

126

13 Postsurgical Conditions

Figure

13.38 Right ear. Post tympanoplasty. Good position

Figure

13.39 Left ear. In the posterosuperior quadrant a

of the tympanic membrane. In this case, it is difficult to iden

TORP (total ossicular replacement prosthesis) with its circular

tify the type of ossicular chain reconstruction due to the thick

head is noted. The overlying cartilage is partially resorbed.

ness of the tympanic membrane, particularly noted at its pos

There are no signs of extrusion.

terior quadrants.

Figure

13.40 Right ear. Another example of a TORP that is

Figure

13.41 Left ear. Posterosuperior perforation of the

visible through the tympanic membrane. The overlying carti

reconstructed tympanic membrane with extrusion of the

lage, which is whitish in color, has been displaced into the

TORP. The shaft of the prosthesis has caused an erosion of the

posteroinferior quadrant. There are no signs of extrusion.

footplate of the stapes (which appears through the perfora

tion as a rounded dark area).

Tympanoplasty

127

Figure

13.42 Left ear. Anteroinferior reperforation due to

Figure

13.43 Right ear. An example of TORP extrusion that

an acute otitis media, occurring 3 years after a staged closed

occurred 1 year after a second-stage tympanoplasty. The head

tympanoplasty. A rectangular cartilage used for ossiculoplasty

of the prosthesis can be seen despite the surrounding wax.

is visible. The cartilage is well integrated in the tympanic

The tympanic membrane residue is atelectatic.

membrane residue.

Figure

13.44 Left ear. Gold prosthesis in the process of ex

Figure

13.45 Right ear. Post tympanoplasty. Large reperfor

trusion in a staged closed tympanoplasty.

ation. In the posterosuperior quadrant a Teflon prosthesis is

interposed between the medialized malleus and the footplate

of the stapes. The round window is visible in the postero-

inferior quadrant. The anterior residue of the tympanic mem

brane is tympanosclerotic.

128

13 Postsurgical Conditions

Figure

13.46 Right ear. Post stapedectomy. The atticotomy

Figure

13.47 Left ear. A rare case of extrusion of a stapes

is seen in the posterosuperior quadrant. The preserved chor

prosthesis. The metallic ring is seen extruding through a

da tympani is well appreciated.

microperforation covered with epidermal squames. The Teflon

shaft of the prosthesis can be visualized through the tympanic

membrane.

Figure

13.48 Right ear. A cholesteatomatous pearl in the

Figure

13.49 Incision of the skin over the cyst.

external auditory canal in a patient who had previously under

gone a stapedectomy. The tympanomeatal flap was not cor

rectly repositioned. This skin was thus folded in on itself and

the entrapped epithelium gave rise to this pearl. This compli

cation was easily resolved in the outpatient clinic by incising

the skin (see Fig. 13.49) and removing the cholesteatomatous

cyst (see Fig. 13.50).

Tympanoplasty

129

Figure

13.50 Removal of the cholesteatomatous cyst.

Figure

13.51 Left ear. Silastic sheet in extrusion through a

posterosuperior perforation. The handle of the malleus is

clearly visible anteriorly. In general, Silastic is inserted in first-

stage tympanoplasty. This material is usually placed in the

middle ear to favor the restoration of the normal mucosal lin

ing of the middle ear and to avoid the formation of adhesions

in the meantime. It is removed during the second-stage tym

panoplasty, except in cases showing a tendency towards

atelectasis.

Figure

13.52 Right ear. Post tympanoplasty. A white

Figure

13.53 Left ear. Good anterior angle of the recon

retrotympanic mass (cholesteatoma of the anterior angle) is

structed tympanic membrane. An anteromalleolar choleste

noted causing bulging of the tympanic membrane. The

atomatous cyst is seen. An epitympanic retraction pocket that

cholesteatoma is probably the result of inadequate removal of

is adherent to the head of the malleus and body of the incus

the epithelium in an overlay technique. The entrapped skin

is also observed.

led to the formation of the cholesteatoma.

130

13 Postsurgical Conditions

Figure

13.54 Left ear. In the posterosuperior quadrant, the

Figure

13.55 Left ear. Another example of retraction of the

sculptured incus with the short process pointing anteriorly is

tympanic membrane leading to inclination of the sculptured

seen through the retracted tympanic membrane. In cases with

incus. The dislocated incus becomes fixed to the posterior

hearing loss, repeat surgery is indicated to reinforce the tym

mesotympanum, resulting in hearing loss.

panic membrane and improve the hearing. Surgery entails

dissection of the retraction pocket from the incus, and the

placement of cartilage between the sculptured incus and the

tympanic membrane. This cartilage prevents (or delays) the

reformation of a retraction pocket and corrects the hearing

deficit.

Figure

13.56 Right ear. Sculptured incus seen through the

Figure

13.57 Right ear. Recurrent epitympanic cholestea

tympanic membrane in a case of closed tympanoplasty. An

toma following closed tympanoplasty. The reconstructed tym

epitympanic retraction pocket is seen. This pocket should be

panic membrane (pars tensa) shows an optimal anterior angle

followed up regularly to guard against the formation of a

and is perfectly attached to the handle of the malleus. In this

recurrent cholesteatoma. Should this occur, the closed tech

case, transformation to an open technique is indicated while

nique must be transformed into an open one to avoid further

conserving the tympanic membrane and ossicular chain if

recurrence of the cholesteatoma.

there is no hearing loss.

Tympanoplasty

131

Figure

13.58 Left ear. Another example of a staged closed

Figure

13.59 Left ear. A small epitympanic retraction pock

tympanoplasty 6 years after the second stage. A large resorp

et is observed. Though smail and shallow, this pocket should

tion of the posterosuperior wall of the external auditory canal

be followed up regularly as it may become deeper with time,

associated with recurrent cholesteatoma is observed. In the

leading to the formation of a recurrent cholesteatoma.

posterosuperior quadrant, the cartilage used for ossiculoplas

ty is seen. Revision surgery was performed with transforma

tion into an open technique.

Figure

13.60 Right ear. Partial resorption of the posterior

Figure

13.61 Left ear. Total resorption of the posterior wall

wall of the external auditory canal about 7 to 8 mm from the

of the external auditory canal 3 years after a closed tym

annulus following a closed tympanoplasty. The atrophic area

panoplasty. The otoscopic view is similar to that observed

appears bluish due to lack of underlying bone. No cutaneous

after an open tympanoplasty. Repeat surgery was necessary.

retraction is seen. However, due to the lack of bone, the skin

The facial ridge was lowered and all bony irregularities were

can invaginate into the mastoid cavity giving rise to recurrent

smoothed to avoid the retention of squamous debris with

cholesteatoma. In such cases, regular long-term follow-up is

subsequent otorrhea. An adequate meatoplasty was also per

indicated.

formed.

132

13 Postsurgical Conditions

Figure

13.62 Right ear. An example of a successful closed

Figure

13.63 Left ear. Another example of a closed tym

tympanoplasty 11 years postoperatively. The tympanic mem

panoplasty 2 years postoperatively. The attic was reconstruct

brane is in perfect position and angulation. The posterior

ed using cartilage and bone pate and shows no signs of ero

canal wall is intact and there is no evidence of recurrent

sion. A small cholesteatomatous pearl is seen in the postero-

cholesteatoma (see previous cases in Figs. 13.60 and 13.61).

superior quadrant. It can be easily removed in the outpatient

clinic under microscopic control.

Figure

13.64 Right ear. A well performed open tym

Figure

13.65 Left ear. Open tympanoplasty. Attic oblitera

panoplasty. The cavity is epithelialized and the facial ridge is

tion with autologous bone.

adequately lowered. In the attic region, the material used for

obliteration can be noted.

Tympanoplasty

133

Figure

13.66 Right ear. Open tympanoplasty. Partial obliter

Figure

13.67 Right ear. A patient with bilateral

ation of the attic with bone pate.

cholesteatoma. An open tympanoplasty with obliteration was

performed. The material used for obliteration of the attic (car

tilage and bone pate) has nearly totally resorbed. The cavity is

humid, granulating, and wet. Hearing is poorer than that of

the other side in which an open technique without oblitera

tion was performed (see next figure).

Figure

13.68 Same patient, left ear. The cavity is dry,

Figure

13.69 Right ear. A badly performed open tym

smooth, well epithelialized, and the facial ridge is low.

panoplasty. The cavity is irregular, with undermined borders,

and a very high facial ridge. Purulent secretion is present in

the middle ear and the rest of the cavity.

134

13 Postsurgical Conditions

Figure

13.70 Right ear. Another example of a badly per

Figure

13.71 Left ear. Open tympanoplasty. A large perfo

formed open tympanoplasty. Purulent secretions and a high

ration of the reconstructed tympanic membrane is seen.

facial ridge are observed.

Cholesteatomatous pearls are observed in the attic.'

Figure

13.72 Right ear. Open tympanoplasty. The facial

Figure

13.73 Left ear. TORP in extrusion following a sec

ridge has not been sufficiently lowered in this case. This leads

ond-stage open tympanoplasty. In the first stage, a

to accumulation of cerumen and cellular debris in the cavity

cholesteatoma involving the attic and mesotympanum and

with subsequent infection, secretion, and maceration of the

causing erosion of the ossicular chain was removed. In the

skin lining the cavity.

second stage, a TORP was used for reconstruction. It was

placed between the footplate of the stapes and the tympan

ic membrane. One year postoperatively, early extrusion of the

prosthesis is observed. To avoid this complication, a tragal car

tilage has to be placed between the prosthesis and the tym

panic membrane.

Tympanoplasty

135

Figure

13.74 Left ear. An example of a correctly performed

Figure

13.75 Left ear. Open tympanoplasty with a well

open tympanoplasty. The cavity shows perfect epithelializa-

epithelialized cavity. The tympanic membrane shows a tym-

tion. The facial ridge is low. The tympanic membrane is well

panosclerotic plaque anteriorly; posteriorly, the ossicular chain

positioned with excellent contact with the handle of the

reconstruction is observed.

malleus.

Figure

13.76 Right ear. Open tympanoplasty. The cartilage

Figure

13.77 Right ear. Open tympanoplasty. The tympanic

used for obliteration of the attic is seen in the superior part.

bone was drilled in this case because it was involved with the

cholesteatoma. The inferior annulus is visible. Superiorly, the

chorda tympani is observed close to the incus used for recon

struction of the ossicular chain.

136

13 Postsurgical Conditions

Figure

13.78 Left ear. Example of a modified Bondy tech

Figure

13.79 Same case, intraoperative view. Exterioriza

nique. In this case, the preoperative pure tone average was 20

tion of the attic and the mastoid, lowering the facial ridge

dB. The patient conserved his preoperative hearing. The mod

until the level of the annulus.

ified Bondy technique is indicated in epitympanic cholestea

toma with an intact tympanic membrane and ossicular chain.

It is an open technique in which the attic and the mastoid are

exteriorized (Fig. 13.79) and the facial ridge is lowered until

the level of the annulus. The ossicular chain and the tympan

ic membrane are left in situ (Fig. 13.80). If necessary, the attic

is obliterated with a piece of cartilage; this procedure helps to

reduce the risk of retractions around the ossicles (Fig. 13.81).

Fascia is then inserted with two anterior tongues; one is posi

tioned under the incus body, the other between the handle of

the malleus and the long process of the incus (Figs. 13.82,

13.83). A meatoplasty according to the size of the cavity is

performed at the end of the procedure.

Figure

13.80 The ossicular chain and the tympanic mem

brane are left in situ.

Tympanoplasty

137

Figure

13.81 The attic is obliterated with a piece of carti

Figure

13.82 Fascia is inserted with two anterior tongues:

lage.

one is positioned under the incus body, another between the

handle of the malleus and the long process of the incus.

Figure

13.83 At the end of the procedure the skin flaps are

repositioned over the fascia.

138

13 Postsurgical Conditions

Figure

13.84 Left ear. Another case of the modified Bondy

Figure

13.85 Right ear. The modified Bondy technique. A

technique. Note the intact ossicular chain.

ventilation tube was inserted because of the presence of mid

dle ear effusion that did not respond to medical treatment.

Figure

13.86 Left ear. The modified Bondy technique.

Figure

13.87 Right ear. The modified Bondy technique. The

Although an attic retraction is noted recurrent cholesteatoma

attic is obliterated with cartilage.

is uncommon with this technique. The tympanic membrane is

retracted and middle ear effusion is noted. In this case, the

insertion of a ventilation tube is indicated.

Tympanoplasty

139

Figure

13.88 Left ear. Open tympanoplasty. The ossicular

Figure

13.89 Left ear. Another case of the modified Bondy

chain was reconstructed using an autologous cartilage that

technique. As the incus was slightly eroded, a piece of carti

was not extruded despite the presence of atelectasis of the

lage was placed between it and the malleus. The attic was

tympanic membrane.

obliterated with cartilage.

Figure

13.90 Right ear. The modified Bondy technique. The

Figure

13.91 Right ear. In this case of a modified Bondy

tympanic membrane is normal and the cavity is dry and per

technique, incus erosion occurred 3 years postoperatively due

fectly epithelialized.

to the presence of a significant retraction pocket. The middle

ear shows a catarrhal effusion.

140

13 Postsurgical Conditions

Figure

13.92 Right ear. A modified Bondy technique. Two

Figure

13.93 Left ear. A cholesteatomatous pearl seen in

cholesteatomatous pearls are present in the cavity. They are

the attic following a modified Bondy technique.

easily removed in the outpatient clinic. The attic, antrum, and

mastoid were exteriorized. The ossicular chain was left in situ.

Figure

13.94 Same patient after removal of the pearl in the

Figure

13.95 Radical mastoidectomy. A mucosal cyst caus

outpatient clinic.

es complete obstruction of the external auditory canal.

Tympanoplasty

141

Figure

13.96 Right ear. Radical mastoidectomy. The second

Figure

13.97 Example of a well performed meatoplasty in

portion of the facial nerve is uncovered. Scars around the

an open tympanoplasty. The performance of an adequate

nerve produced an H.B. grade III palsy.

meatoplasty that suits the dimension of the cavity is funda

mental to assure proper aeration and prevent accumulation of

epithelial debris and cerumen in the cavity.

Figure

13.98 Another example of a meatoplasty performed

Figure

13.99 Example of a meatoplasty that shows mild

in a 10-year-old boy who underwent surgery for bilateral epi-

stenosis.

tympanic cholesteatoma using a modified Bondy technique.

142

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Index

glomus tumors 83

carotid canal 84

abducent nerve paralysis 83

cavernous sinus 84

adenoid cystic carcinoma 33

cerebral tissue herniation

109, 110,112

adenoidectomy 26

cerebrospinal fluid see CSF

adenomatous tumors of middle ear 18

chemodectoma see glomus tumors

air fistula 46

cholesteatoma

anacusis, petrous bone cholesteatoma 77, 79

acquired 59

aneurysm, internal carotid artery

106

anterior angle

129

angiofibroma

36-7

atelectasis association

68-9

nasopharyngeal 30

attic 60, 66

aphasia

109

bilateral

133

Arnold's nerve 83

cochlear fistula 72

Aspergillus

complications 70-2

atelectasis

38-45

congenital 59

cholesteatoma association 68-9

epitympanic cholesteatoma 64

middle ear 73-4

epitympanic erosion 43, 69

petrous bone 59, 79, 108

grades 38

CT scan 72

post-tympanoplasty 127

cystic rctrotympanic 64

attic

debris 67

cholesteatomatous pearl

134,140

diagnosis 49

exteriorization

136

dry 61

modified Bondy technique 136

epitympanic 46, 61-6, 64, 71, 122, 136

obliteration 132, 133, 135-9

modified Bondy technique 141

reconstruction

132

extension

atticotomy 128

into anteromalleolar region 67

aural speculi 1

into mastoid 62

auricular artery 5, 90

into mesotympanum 65

external auditory canal

15-17

polyp 72

facial nerve paralysis 72

basal cell carcinoma of external auditory canal 22

hearing loss 59

Billeau ear loop 1

iatrogenic 15, 17, 46, 122

Bondy technique, modified 60, 61, 63, 66, 122, 136-41

keratin debris 59

cholesteatomatous pearls

140

lateral semicircular canal interruption 71

epitympanic cholesteatoma

141

mastoid 20

fascia insertion 136,

137

meningocephalic herniation

113

indications

136

mesotympanic 45, 66-8, 71

tympanoplasty 136

mesotympanum epidermization 65

ventilation tube

138

modified Bondy technique 61, 63, 66

bone erosion

open tympanoplasty 122

carcinoma of external auditory canal 24

ossicular chain 68

cholesteatoma

16-17

erosion 59, 68

glomus tumor 34, 105

otorrhea 59

bullae, myringitis 11

overlay technique of tympanoplasty 129

petrous bone 75-82

acquired 75, 77. 78, 81

canalplasty

11, 12,49,53

apical 75, 76

canal stenosis 120

congenital 59, 79, 108

Candida

iatrogenic 75, 77

carcinoid tumors

17-18

infralabyrinthine 75. 76, 79-80, 81, 82

carcinoma

massive labyrinthine 75, 76

external auditory canal 22-5

supralabyrinthine 75, 78, 82

imaging 25

surgical treatment 82

infratemporal fossa 24

recurrent 69, 122, 131

mastoid 23

epitympanic 130

middle ear 23

retrotympanic 122

nasopharynx 24, 25

self-cleaning of debris 62

therapy 25

semicircular canal fistula 72

carotid artery

superimposed fungal infection

ectopic 103

symptoms 72

146

Index

cholesteatomatous cyst 64,128,129

neurinoma 100-3,108

anteromalleolar 129

reconstruction 108

cholesteatomatous pearl 119, 128-9, 132

facial nerve paralysis

attic 134, 140

cholesteatoma 59. 72

modified Bondy technique 140

facial nerve neurinoma 101

cholesteatomatous squamae 67, 70

glomus tumors 83, 95

cholesterol granuloma 34-7

meningioma 99

chorda tympani 128, 135

petrous bone cholesteatoma 77, 79, 81. 82

cochlea

facial ridge

fistula 72

high 133, 134

petrous bone cholesteatoma 78

low 133. 135

collumela 125

lowering 131,132, 133,136

conchoplasty 131, 136, 141

fallopian canal 57

cone of light 5. 6

foramen lacerum, anterior 84

CSF leak 109

foramen magnum 95

glomus tumors 98

furunculosis 10

middle ear 32

cyst

cholesteatomatous 64, 128, 129

Gelfoam 121

external auditory canal obstruction 140

geniculate ganglion 102

glomus jugulare 83

tumor 21-2, 91-2

diabetes, otomycosis 14

glomus tumors 83-108

Down's syndrome 122

angiography 94

bone erosion 105

classification 83, 84

CSF leak 98

eczema 15

diagnosis 83

embolization of glomus tumors 94, 98

differential diagnosis 98-108

encephalocele 114

embolization 94, 98

endoscope 2, 3

intradural portion removal 96

epidermoid cyst

MRI with gadolinium 90, 96

congenital cholesteatoma of middle ear 73

signs/symptoms 83

petrous bone cholesteatoma 75

staging 95, 98

epitympanic erosion 66

surgery 97-8

epitympanic erosion with cholesteatoma 61-6

glomus tympanicum 83, 85, 86

atelectasis association 69

glossopharyngeal nerve 5

ossicular chain destruction 62

granulation tissue, polypoid 68

eustachian tube

granuloma see cholesterol granuloma

dysfunction 26, 42, 45

Gugliemi coils 106

extrinsic pressure 26

exostosis

external auditory canal 7, 9

obstructing 9

Hand-Schuller-Christian disease 19

surgical removal 7, 8, 9

Hartman auricular forceps 1

external auditory canal

hearing loss

carcinoma 22-5

carcinoid tumor 17, 18

cartilage reconstruction 125

cholesteatoma 59

cholesteatomatous mass 64

petrous bone 75, 82

cholesteatomatous pearl 128-9

conductive 26

cleaning 1

atelectasis 38, 39-42, 45

closure as cul-de-sac 82

cholesterol granuloma 34, 36

diseases 7-25

congenital cholesteatoma of middle ear 74

facial nerve neurinoma 102

incus erosion 43, 44

meningocephalic herniation 111

myringoplasty 119

middle ear pathology 17

tympanic membrane perforation 46

mucosal cyst obstruction 140

exostosis 7, 9

occlusion 9

facial nerve neurinoma 100,108

plastic sheet insertion 121, 122

glomus tumors 91, 92. 93, 95, 97

polyp 70, 72. 80-1,105

incus dislocation 130

stenosis 11, 12-14, 117, 120, 121

meningioma 99

tympanoplasty 122

meningocephalic herniation 110, 111, 112

wall resorption 131

polyp in external auditory canal 70

external carotid artery, glomus tumors 97

sensorineural 122

hemosiderin, blue tympanum 34

histiocytosis X 19

hypotympanic air cells 32, 50, 51,52

facial nerve

hypotympanum 44

carcinoma of external auditory canal 22

facial nerve neurinoma 101

dysfunction 108

glomus tumors 86-7, 88

graft 108

meningioma 99

Index

147

meningitis 113

meningocele 114

incudostapedial joint 41, 44

mcningocephalic herniation 109-14

incus

surgery 114

autologous 122

metastases, external auditory canal 22

dislocated 125, 130

middle ear

erosion 43, 44

carcinoma 23

modified Bondy technique 139

CSF 32

homologous 122

effusion

necrosis 38

atelectasis 42

sculpted 123, 124, 125, 130

modified Bondy technique 138, 139

infratemporal fossa, carcinoma 24

ventilation tube 138, 139

internal auditory canal

epidermization 54, 55

glomus tumors 93

Gelfoam insertion 121

petrous bone cholesteatoma 79

glue 27. 31, 32

internal carotid artery

mcningocephalic herniation 109

glomus jugulare tumor 22

Silastic sheet 69

glomus tumors 93, 97

submucous nodular deposits 56

intrapetrous aneurysm 106

myringitis 10

acute 10

bullous 10, 11

granulomatous 10, 11

Jacobson's nerve 5

postoperative 120

glomus tumors 83, 84

reperforation of tympanic membrane 121

jugular bulb

myringoplasty 43, 49, 53, 55

glomus tumors 84, 88

high 103-4, 105

endomeatal approach 47

external auditory canal stenosis 120, 121

meningioma 99

lateralization 117,120

jugular foramen

overlay technique 117,119

facial nerve neurinoma 100

perforation edge 46

glomus tumors 89-90, 93, 95, 97

postsurgical conditions 117-22

syndrome 97

quadruple 120

reperforation 117, 121

retrotympanic cholesteatoma 122

keratosis obturans 15

skin curettage 56

techniques 117

tympanic membrane perforation with otitis media 58

underlay technique 117, 118, 119

labyrinthine fistula 122

myringostapedopexy

lamina propria 5

natural 38, 43

Letterer-Siwe disease 19

spontaneous 69