The chronic ear Viêm tai giữa mạn tính (sách tiếng anh)

The chronic ear, Cuốn sách nguyên bản tiếng anh về viêm tai giữa mạn tính và điều trị, các phẫu thuật điều trị, giải phẫu tai giữa và xương chũm các bước phẫu thuật: vá nhĩ, chỉnh hình tai giữa, chỉnh hình xương con, phẫu thuật xương chũm, mở sào bào thượng nhĩ, phẫu thuật khoét chũm tiệt căn, có hình ảnh chi tiết, phân loại và định nghĩa các phẫu thuật, có hình ảnh đẹp.

The Chronic Ear Joh n L Dor n h offer, MD, FACS Professor an d Vice Ch air of Adult Ser vices Sam uel D McGill Ch air in Otolaryngology Research Director, Division of Otology an d Neurotology Director, Hearing an d Balan ce Cen ter Departm en t of Otolaryngology—Head an d Neck Surger y Un iversit y of Arkan sas for Medical Scien ces Arkan sas Ch ildren’s Hospital Little Rock, Arkan sas Mich ael B Glu t h , MD, FACS Associate Professor of Surger y Medical Director, Com preh en sive Ear an d Hearing Cen ter Research Director, Bloom Otopath ology Lab Section of Otolar yn gology—Head an d Neck Surgery Un iversit y of Ch icago Medicin e an d Biological Scien ces Ch icago, Illin ois Th iem e New York • Stuttgart • Delh i • Rio de Jan eiro Executive Editor: Tim othy Y Hiscock Man aging Editor: J Ow en Zurh ellen IV Director, Editorial Ser vices: Mar y Jo Casey Production Editor: Sean Wozn icki In tern ation al Production Director: An dreas Sch abert Vice Presiden t, Editorial an d E-Product Developm en t: Vera Spilln er In tern ation al Marketing Director: Fion a Hen derson In tern ation al Sales Director: Louisa Turrell Director of Sales, North Am erica: Mike Rosem an Sen ior Vice Presiden t an d Ch ief Operatin g Of cer: Sarah Van derbilt Presiden t: Brian D Scan lan Librar y of Con gress Cat alogin g-in -Pu blicat ion Dat a Th e ch ron ic ear / [edited by] Joh n L Dorn h offer, Mich ael B Gluth p ; cm In cludes bibliograph ical referen ces an d in dex ISBN 978-1-60406-864-1 (h ardcover) – ISBN 978-1-60406-865-8 (eISBN) I Dorn h offer, Joh n L., editor II Gluth , Mich ael B., editor [DNLM: Ear Diseases–th erapy Ch ron ic Disease Ear Diseases–diagnosis W V 200] RF291.35 617.8–dc23 2015002879 Im por t a n t n ote : Med icin e is an ever-ch an gin g scien ce u n d ergoin g tin u al d evelop m en t Research an d clin ical experien ce are tin u ally exp an d ing ou r kn ow ledge, in p ar ticu lar ou r kn ow ledge of p rop er treatm en t an d d rug th erapy In sofar as th is book m en tion s any d osage or ap p lication , read ers m ay rest assu red th at th e au th ors, ed itors, an d p u blish ers h ave m ad e ever y effor t to en su re th at su ch referen ces are in accord an ce w ith t h e st at e of k n ow le dge at t h e t im e of p r od u ct ion of t h e b ook Neverth eless, th is does n ot involve, im ply, or express any guaran tee or respon sibility on th e part of th e publish ers in respect to any dosage in struction s an d form s of application s stated in th e book Ever y u ser is requ ested to exam in e carefu lly th e m an ufacturers’ lea ets accom panying each drug an d to ch eck, if n ecessar y in consultation w ith a physician or specialist, w h eth er th e dosage sch edules m en tion ed th erein or th e contrain dication s stated by th e m an ufacturers differ from th e statem en ts m ade in th e presen t book Such exam in ation is part icularly im portan t w ith drugs th at are eith er rarely used or h ave been n ew ly released on th e 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Rüdigerstrasse 14, 70469 Stuttgar t, Germ any +49 [0]711 8931 421, custom erservice@th iem e.de Th iem e Publish ers Delh i A-12, Secon d Floor, Sector-2, Noida-201301 Uttar Pradesh , In dia +91 120 45 566 00, custom erser vice@th iem e.in Th iem e Publish ers Rio de Jan eiro, Th iem e Publicaỗừes Ltda Edifício Rodolph o de Paoli, 25 º an dar Av Nilo Peỗan h a, 50 Sala 2508 Rio de Jan eiro 20020-906 Brasil +55 21 3172-2297 / +55 21 3172-1896 Cover design : Th iem e Publish ing Group Typesettin g by DiTech Process Solution s Prin ted in Ch in a by Everbest Prin tin g Co, Ltd ISBN 978-1-60406-864-1 Also available as an e-book: eISBN 978-1-60406-865-8 54321 Th is book, in cludin g all part s th ereof, is legally protected by copyright Any use, exploitation , or com m ercialization outside th e n arrow lim its set by copyright legislation w ith out th e publish er’s sen t is illegal an d liable to prosecution Th is applies in part icular to ph otostat reproduction , copying, m im eograph ing or duplication of any kin d, tran slatin g, preparation of m icro lm s, an d elect ron ic data processin g an d storage To m y w ife, Mar y, for all h er person al an d profession al support th rough all th ese years To m y patien ts, studen ts, an d frien ds in th e eld, all over th e w orld, w h o h ave taugh t m e, in spired m e an d m ade th is career a fascin atin g journ ey of kn ow ledge an d frien dsh ip — JLD To m y paren ts, m y w ife April, an d m y son s Cam eron , Ch rist ian , an d Graem e for m agn ifyin g m y life To Marcus Atlas for teach ing m e th e n uan ces of otologic surger y To Joh n Dorn h offer for h is m en torsh ip — MBG Cont ent s Preface xi Acknow ledgm ent s xiii Cont ribut ors xv Mast er Glossary xxi Part 1 The Fundam ent als of Chronic Ear Disease Chronic Ear Disease in t he Modern Era: Evolut ion of Treat m ent , Epidem iology, and Classificat ion Adva Buzi, Michael B Gluth, and Bruce Black Eust achian Tube Dysfunct ion, Mucosal Gas Exchange, and E usion Holger H Sudho Tym panic Mem brane Wound Healing and Epit helial Migrat ion 14 Peter L Santa Maria Pat hophysiology of Cholest eat om a 20 Florian Hoppe and Michael B Gluth Microbiology of Chronic Ear Disease 26 Je rey D Sharon and Richard A Chole Hist opat hology of Chronic Ot it is Media 32 Sebahattin Cureoglu and Michael M Paparella Surgical Anat om y Relevant t o t he Chronic Ear 47 Howard W Francis and Alejandro Rivas Biom at erials in Tym panom ast oid Surgery 57 Matthew Yung Middle Ear Mechanics in Hearing Reconst ruct ion 62 Manohar Bance, John J Rosowski, and Robert B A Adamson Part 10 Clinical Evaluat ion and O ce Managem ent of Chronic Ear Disease Pearls in Audiovest ibular Assessm ent 82 John L Dornho er, Samuel R Atcherson, and Shane R Anderson 11 Radiographic Evaluat ion of Chronic Ear Disease 88 Richard K Gurgel, Richard H Wiggins, and Clough Shelton 12 Inflam m at ory Condit ions and Syst em ic Diseases A ect ing t he Middle Ear 97 Shane R Anderson 13 Myringit is 102 Alexander G Bien and Jason C Goodwin vii Contents 14 O ce Evaluat ion and Managem ent of a Canal Wall-Dow n Mast oid Cavit y 106 Michael B Gluth 15 Tubo-Tym panic Diseases: Ret ract ion, At elect asis, and Middle Ear E usion 111 Stefan Volkenstein and Stefan Dazert 16 Evaluat ion and Nonsurgical Managem ent of Chronic Suppurat ive Ot it is Media 118 James Lin and Hinrich Staecker 17 Int rat em poral and Int racranial Com plicat ions of Ot it is Media 125 Matthew L Carlson, David S Haynes, and George B Wanna Part 18 Int roduct ion t o Surgical Managem ent of Chronic Ear Disease General Principles of Surgery for Chronic Ear Disease 134 Marcus D Atlas and Paula Casserly 19 Tym panost om y Tubes 142 Shane R Anderson 20 Canalplast y and Meat oplast y 148 Heng Wai Yuen 21 Cholest eat om a Dissect ion: Problem s and Solut ions 156 Bruce Black Part 22 Roundt able on Tym panic Mem brane Reconst ruct ion Overview and Int roduct ion 166 John L Dornho er and Michael B Gluth 23 Underlay and Relat ed Techniques 170 Seilesh C Babu and Brent J Benscoter 24 Overlay Tym panoplast y Technique 176 Audrey P Calzada and Eric P Wilkinson 25 Cart ilage Tym panoplast y 182 John L Dornho er Part 26 Roundt able on Ossiculoplast y Overview and Int roduct ion 190 John L Dornho er and Michael B Gluth 27 Reconst ruct ion of t he Incudost apedial Art iculat ion 192 Jan-Christo er Lüers and Karl-Bernd Hüttenbrink 28 Aut ograft Ossicular Reconst ruct ion 197 Patrick R Axon and Venkata SPB Durvasula 29 Ossiculoplast y w it h Synt het ic PORPS and TORPS 204 John L Dornho er viii Special Topics and New Horizons in Surgery for Chronic Ear Disease Fig 47.13 Transcanal otom icroscopic view of a previously operated atretic ear showing the clear line of demarcation between the squamous epithelium of the canal skin graft (left) and the red, m oist, shiny m ucosa of the m edial canal where the skin graft has sloughed and been replaced by m ucous m em brane (right) space Th e fascia is draped on to th e polish ed can al w all 1–2 m m in all direction s Air cells are packed w ith autologous tem poralis m uscle Th e skin graft is n ext placed an d an ch ored w ith a 0.4in ch Silastic disk Th e Pope Oto-Wicks are delivered in to th e can al an d hydrated w ith a topical an tibiotic solution If th e m eatus is adequate, th e lateral skin graft is delivered th rough th e m eatus after th e auricle is sutured dow n an d sim ply packed in place w ith addition al Pope Oto-Wicks.6,9 Of n ote, n ew bon e grow th is rarely seen in post pubertal patien ts On e th eor y beh in d th e form ation of n ew bon e in th e postoperative ear is th e surge of grow th h orm on e durin g th e pubertal years If th e patien t w ith n ew bon e grow th can be tem porized un til after puberty, recurren ce of n ew bon e after revision surgery is ver y low Som e atresia surgeon s advocate w aitin g un til th e patien t is 12 years of age or older to perform th e prim ar y surgery.14 47.4.2 Ot orrhea and Tym panic Mem brane Perforat ion In a recen t report of 107 revision surgeries for CAA, 20 (19%) w ere perform ed for ch ron ic otorrh ea an d/or in fect ion , w ith 10 operation s secon dar y to slough in g of th e skin graft an d m ucosalization of th e can al ( Fig 47.13), secondar y to eardrum perforation ( Fig 47.14), for can al ch olesteatom a, an d for a com bin ation 10 Factors th ough t to cont ribute to slough in g of th e skin graft and replacem en t of th e skin w ith m ucous m em bran e in clude loss of blood supply to th e skin graft , exposure to large m astoid air cells, t rappin g of skin (secon dar y to n ew bon e grow th or m eatal sten osis) w ith resultan t in fect ion , an d eardrum perforation A sm all area of m ucosalization /gran ulation can be treated in th e o ce w ith silver n itrate cautery an d a topical an tibiotic pow der such as ch loram ph en icol/sulfan ilam ide/fun gizon e (CSF) Sm all areas can also be resected w ith a sm all curette to allow th e surroun din g skin to re-epith elialize Th ese sm all areas 336 Fig 47.14 Transcanal otom icroscopic view of a previously operated atretic ear showing a t ym panic membrane perforation Note the m ucosalization of the rem aining eardrum of m ucosalization (< cm ) m ay cause som e m oisture in th e can al but rarely cause sign ifican t otorrh ea Larger areas w ill also respon d to cauterization an d application of CSF pow der, but if th e area of m ucosalization is > 50% of th e surface area of th e can al, th e ear w ill retain m oisture an d m ay drain from tim e to t im e Th e patien t is coun seled th at th e drain age does n ot n ecessarily represen t in fect ion , it sim ply is th e w ron g tissue (m ucous m em bran e) in th e w ron g place (ear can al) Th e drain age can be m an aged an d trolled m edically, but if both ersom e to th e patien t, revision surgery to rem ove th e m ucosalized tissue (w h ich often in cludes th e t ym pan ic m em bran e) an d replace it w ith a fresh eardrum graft an d skin graft as described above can give th e patien t a dry, skin -lin ed can al Because th e can al skin in a surgically repaired atretic ear is sim ply a skin graft an d does n ot m igrate, t ym pan ic m em bran e perforation s in surgically repaired ears w ill n ot h eal Wh en exposed to th e m ucosa of th e m iddle ear, th e rem ain der of th e eardrum often m ucosalizes an d th e ear retain s m oisture Topical an tibiotic drops or pow der can keep th e drain age trolled, alon g w ith dr y ear precaution s A paper patch can be t ried as w ell; because th e skin does n ot m igrate, th e paper patch w ill stay in place but m ay n ot preven t m ucosalization an d drain age Tym pan oplasty surgery can also be o ered, but because th e skin does n ot m igrate in th e atret ic ear, a sim ple un derlay graft w ill fail For th e best ch an ce at h ealin g, surgery requires rem oval of th e rem ain in g eardrum an d m edial can al skin , w ith a n ew tem poralis fascia graft placed in a lateral graft tech n ique an d skin graft If h ealthy, th e lateral, m eatal skin can be saved, an d th e n ew m edial skin graft can overlap th e h ealthy lateral skin edge by 1–2 m m Steps to preven t m ucosalizat ion durin g th e prim ar y surgery in clude drillin g an d polish in g th e bon e superiorly (alon g th e tegm en ) an d an teriorly to rem ove all air cells, open in g as few m astoid air cells as possible, pluggin g any large m astoid air cells w ith autologous tem poralis m uscle, en surin g th e fascia graft covers th e aditus area an d does n ot “fall in to” th e posterior epit ym pan um or m astoid an tr um , an d h ar vestin g a skin graft m easurin g 0.006 in ch es (th icker skin grafts are m ore di cult to Chronic Otitis Media in the Set ting of Congenit al Ear Disease w ork w ith because th ey curl an d roll; th in n er grafts w ill break dow n an d slough ) Of th e 20 ears revised for reason s of drain age/m ucosalization , 12 ears h ad a m in im um clin ical follow -up of m on th s, w ith ears dr y an d epith elialized an d ears persistin g w ith otorrh ea despite revision surgery; ear un derw en t revision s, an d a persisten t m ucosalized can al rem ain s Ultim ately, if all else fails, th e can al can be closed.10 47.5 Congenit al Cholest eat om a A w h ite m ass beh in d an in tact t ym panic m em bran e is th e classic description of congen ital ch olesteatom a, w h ich accoun ts for approxim ately 2% to 4%of all ch olesteatom as; h ow ever, congen ital ch olesteatom a h as been repor ted in th e m astoid,15 th e in fratem poral fossa,16 th e Eustach ian tube,17 th e t ym pan ic m em bran e,18 an d th e facial n er ve can al.19 Th e criteria for th e diagn osis in clude th e follow in g: a w h ite m ass m edial to a n orm al t ym pan ic m em bran e; a n orm al pars flaccida an d pars ten sa; n o prior h istory of otorrh ea or perforation s; an d n o prior otologic procedures Prior bouts of otitis m edia are n ot groun ds for exclusion 20,21 Th eories beh in d th e form ation of congen ital ch olesteatom a in clude th e Invagin ation Th eory, w h ere in flam m ation in th e m iddle ear or retract ion of th e t ym pan ic m em bran e causes th e t ym pan ic m em bran e or part of th e t ym pan ic m em bran e to invagin ate to form a congen ital ch olesteatom a.22 Th e Ectoderm Migration Th eor y proposes th at ectoderm from th e prim itive extern al can al passes th rough or aroun d th e t ym pan ic rin g to en ter th e m iddle ear.23 Sade in troduced th e Metaplasia Th eor y, in w h ich otitis m edia or an oth er in flam m ator y m iddle ear process results in squam ous m etaplasia, leadin g to keratin form ation 24 Fin ally, th e m ost accepted th eor y beh in d th e form ation of congen ital ch olesteatom a w as proposed by Mich aels in 1986, th e Epiderm oid Form ation Th eor y.2 Mich aels iden tified epith elial cells (“epiderm oid form ation ”) in th e lateral w all of th e em br yon ic t ym pan ic cavit y th at n orm ally disappear by 33 w eeks of gestat ion If th e rest of th e cells n ot involute, gen ital ch olesteatom a form s.2,25 Th e diagn osis of congen ital ch olesteatom a is often m ade by an astute pediatrician w h o n otes th e w h ite retrotym pan ic m ass Ch ildren are also referred after failing a sch ool h earin g test or h earin g test in th e pediatrician’s o ce Th e h earin g loss is duct ive in n ature as th e ch olesteatom a exerts a m ass e ect on th e t ym pan ic m em bran e an d ossicles A t ypical location is th e anterior-superior quadran t of th e m esot ym panum , alth ough th ey can also develop posteriorly, even in th e m astoid cavit y.1,5, 26,27 Th ese posterior m astoid ch olesteatom as often reach a large size before th ey becom e clin ically apparen t, grow in g from th e m astoid th rough th e aditus in to th e epit ym pan um , w h ere th ey w ill again cause conduct ive h earin g loss by m ass e ect on th e in cus bon e It h as been proposed th at th ese posterior congen ital ch olesteatom as are m ore com m on in th e Asian populat ion 28 In gen eral, disease severit y depen ds on location , patien t age, ossicular in tegrit y, an d n um ber of an atom ic sites involved.29 Evaluation an d m an agem en t of congen ital ch olesteatom a depen ds on th e size an d exten t of disease Bin ocular m icroscopy sh ow s a w h ite retrot ym panic m ass ( Fig 47.15) th at does n ot m ove w ith pn eum atic otoscopy (as opposed to m yrin gosclerosis, w h ich m oves w ith th e eardrum on pn eum atic Fig 47.15 Intraoperative image of a right ear showing a white m ass behind an intact t ym panic m em brane in the anterior-superior quadrant of the m iddle ear t ypical of congenital cholesteatom a Fig 47.16 Axial high-resolution CT showing a rounded m ass in the anterior m esot ympanum consistent with congenital cholesteatom a otoscopy) Tun in g fork testin g establish es th e n ature of th e h earin g loss, if any Preoperative audiom etr y to docum en t h earin g levels, degree of h earin g loss, an d bon e duction th resh olds is m an dator y Com puted tom ography can be h elpful an d is recom m en ded, but is n ot n ecessary, for surgical plan n in g to evaluate size an d exten t of disease ( Fig 47.16) High -resolution CT can in form decision s about surgical approach (tran scan al versus postauricular), th e n eed for m astoidectom y, th e possible n eed to stage th e procedure, an d th e poten tial h earin g outcom e Soun d en ergy m ay be conducted th rough a large, erosive congen ital ch olesteatom a, givin g th e patien t relat ively good h earin g despite bulky disease Th e h earin g w ill be w orse after surger y w h en th e ch olesteatom a is rem oved Th e stapes superstruct ure m ay be eroded w ith n o n ection betw een th e footplate an d th e t ym panic m em bran e 337 Special Topics and New Horizons in Surgery for Chronic Ear Disease Fig 47.18 Intraoperative otom icroscopic im age of the exposure achieved with an extended t ym panomeatal flap dissecting the eardrum off the m anubrium and reflecting it inferiorly The cholesteatom a was incised, and the interior keratin debris was rem oved, leaving the m atrix to be dissected and excised Fig 47.17 Ear canal incisions (right ear) for an extended t ympanomeatal flap to dissect the eardrum off the m alleus and reflect it inferiorly attached to the um bo Exten t of surger y depen ds on exten t of disease Con gen ital cholesteatom as h ave classically been described as closed (cystic; isolated m ass) or open (m ore invasive) Isolated ch olesteatom a in th e m esotym pan um can be approach ed tran scan al w ith total rem oval of disease th rough a t ym pan om eatal flap Larger disease in th e an terior-superior quadran t can be accessed th rough a postauricular approach an d an exten ded t ym pan om eatal flap, w h ere th e eardrum is carefully an d sh arp ly dissected o th e m alleus an d reflected in feriorly to th e um bo ( Fig 47.17; Fig 47.18; Fig 47.19) On ce exposed, th e ch olesteatom a m atrix is in cised, th e in terior ten ts rem oved, and th e m atrix dissected an d excised Larger disease m ay require m ore exten sive surgery, in cluding m astoidectom y or a staged approach w ith ossiculoplasty, th e details of w h ich are foun d in th is book More exten sive in itial disease, ossicular erosion , an d th e n eed for ossicular rem oval are associated w ith residual disease Th e best ch an ce for com pletely rem ovin g congen ital ch olesteatom a at in it ial su rger y requ ires rem ovin g involved ossicles if t h ey are erod ed ; for exam p le, if t h e gen it al ch olest eatom a is abu t t in g or envelop in g t h e in cu s or st ap es, or if t h e gen ital ch olesteat om a is m ed ial t o t h e m alleu s or in cu s.30 Ot h er risk factors for recid ivistic d isease in clu d e old er age at d iagn osis,31 p rior att icotom y, an d stap es d estru ction Exten sion in to th e Eu stach ian tu be is a risk factor for a retraction p ocket.32 Hearin g ou t com es are excellen t w it h lim it ed d isease an d early d iagn osis More exten sive gen ital ch olesteatom as w ill requ ire ossicu lar recon st ru ct ion ; n ever t h eless, th ese p atien ts d o n ot t yp ically h ave Eu stach ian tu be d ysfu n ction , 338 Fig 47.19 Intraoperative otom icroscopic im age of the reflected eardrum and m esot ympanum after the cholesteatom a was excised an d h earin g resu lts can be m ain t ain ed lon g-t erm w ith 60% t o 70% of p atien t s enjoyin g closu re of t h e air-bon e gap t o w it h in 10 d B.33,34 47.6 Conclusion Alth ough ch ron ic ear disease in patien ts w ith congen ital m iddle ear abn orm alities is rare, it m ay take several form s, in cluding congen ital m iddle ear ch olesteatom a, congen ital ear can al ch olesteatom a in th e settin g of congen ital extern al auditory can al sten osis, as a postoperative com plication of CAA surgery, or as congen ital m iddle ear ch olesteatom a Evaluation of th ese lesion s requires carefu l m icroscopic otoscopy, an in dex of suspicion , an d h igh -resolution CT im aging to evaluate th e presen ce an d exten t of disease Based on im aging fin din gs an d th e path ophysiology of disease, a ration al surgical approach can be un dertaken , an d th e patien t an d fam ily appropriately coun seled on expected outcom es, both sh ort- an d lon g-term , after surgery Chronic Otitis Media in the Set ting of Congenit al Ear Disease References [1] Caugh ey RJ, Jah rsdoerfer RA, Kesser BW Con gen ital ch olesteatom a in a case of congen ital aural atresia Otol Neurotol 2006;27(7):934–936 [2] Mich aels L Origin of congenital ch olesteatom a from a n orm ally occurrin g epiderm oid rest in th e developin g m iddle ear In t J Pediatr Otorh in olaryn gol 1988;15(1):51–65 [3] Li PM, Lin os E, Gurgel RK, Fisch bein NJ, Blevins NH Evaluatin g th e utilit y of n on -echo-plan ar di usion -w eigh ted im aging in th e preoperative evaluation of ch olesteatom a: A m eta-an alysis Lar yn goscope 2013;123(5):1247–1250 [4] Vercruysse JP, De Foer B, Som ers Th , Casselm an J, O eciers E Magn etic reson an ce im aging of ch olesteatom a: an update B-ENT 2009;5(4):233–240 [5] Cole RR, Jah rsdoerfer RA Th e risk of ch olesteatom a in congen ital aural sten osis Lar yn goscope 1990;100(6):576–578 [6] Kesser B, Jah rsdoerfer R Surgery for congen ital aural atresia In : A Julian n a Gulya M, Lloyd B Min or M, Den n is S Poe M, eds Surgery of th e ear 6th edition ed Sh elton , CT: People’s Medical Publish in g House-USA; 2010:413–422 [7] Mazita A, Zabri M, An eeza WH, Asm a A, Saim L Ch olesteatom a in patien ts w ith gen ital extern al auditor y can al an om alies: retrospect ive review J Lar yn gol Otol 2011;125(11):1116–1120 [8] Casale G, Nich olas BD, Kesser BW Acquired ear can al ch olesteatom a in gen ital aural atresia/sten osis Otol Neurotol 2014;35(8):1474–1479 [9] Kesser BW Repair of congenital aural atresia In : McKin n on BJ, ed Operative tech n iques in otolar yn gology-h ead an d n eck surgery Vol 21, Issue ed New York: Elsevier, In c.; 2010:278–86 [10] Oliver ER, Hugh ley BB, Sh on ka DC, Kesser BW Revision aural atresia surgery: in dication s an d outcom es Otol Neurotol 2011;32(2):252–258 [11] Lam bert PR Con gen ital aural atresia: Stability of surgical results Lar yn goscope 1998;108(12):1801–1805 [12] De la Cruz A, Teufert KB Con gen ital aural atresia surgery: Lon g-term results Otolaryn gol Head Neck Surg 2003;129(1):121–127 [13] Moon IJ, Ch o YS, Park J, Ch un g WH, Hon g SH, Ch an g SO Lon g-term sten t use can preven t postoperative can al sten osis in patien ts w ith congenital aural atresia Otolaryn gol Head Neck Surg 2012;146(4):614–620 [14] Ch an g SO, Lee JH, Ch oi BY, Song JJ Lon g term results of postoperative can al sten osis in congen ital aural atresia surgery Acta Otolaryn gol Suppl 2007;558 (558):15–21 [15] Gian n uzzi AL, Merkus P, Taibah A, Falcion i M Con gen ital m astoid ch olesteatom a: case series, defin ition , surgical key poin ts, an d literature review An n Otol Rh in ol Lar yn gol 2011;120(11):700–706 [16] Abdel-Aziz M Con gen ital ch olesteatom a of th e in fratem poral fossa w ith gen ital aural atresia an d m astoiditis: a case report BMC Ear Nose Th roat Disord 2012;12:6 [17] Sim MW , Stew ar t TA, Sn issaren ko EP, Xu HX Congen ital ch olesteatom a involving th e Eustach ian tube In t J Pediatr Otorh in olaryn gol 2011;75 (4):600–602 [18] Sh u MT, Lin HC, Yan g CC, Ch en YC Con gen ital ch olesteatom a in th e t ym pan ic m em bran e Ear Nose Th roat J 2010;89(8):E27 [19] Sin a-Kh adiv M, Alem i AS, Ziai K, Djalilian HR Con gen ital ch olesteatom a origin atin g w ith in th e facial n erve can al Otolaryn gol Head Neck Surg 2010;143 (5):708–709 [20] Leven son MJ, Mich aels L, Parisier SC, Juarbe C Con gen ital ch olesteatom as in ch ildren: An em bryologic correlation Lar yn goscope 1988;98(9):949–955 [21] Leven son MJ, Mich aels L, Parisier SC Con gen ital ch olesteatom as of th e m iddle ear in ch ildren : origin an d m an agem en t Otolaryn gol Clin North Am 1989;22 (5):941–954 [22] Tos M A n ew path ogen esis of m esotym panic (congen ital) ch olesteatom a Laryn goscope 2000;110(11):1890–1897 [23] Aim i K Role of th e tym pan ic rin g in th e path ogen esis of congenital ch olesteatom a Lar yn goscope 1983;93(9):1140–1146 [24] Sadé J, Babiacki A, Pin kus G Th e m etaplastic an d congen ital origin of ch olesteatom a Acta Otolaryn gol 1983;96(1–2):119–129 [25] Mich aels L An epiderm oid form ation in th e developing m iddle ear: possible source of ch olesteatom a J Otolaryn gol 1986;15(3):169–174 [26] In okuch i G, Okun o T, Hata Y, Baba M, Sugiyam a D Congen ital ch olesteatom a: posterior lesion s an d th e stagin g system An n Otol Rh in ol Lar yn gol 2010;119 (7):490–494 [27] Warren FM, Ben n ett ML, W iggin s RH, III, et al Congen ital ch olesteatom a of th e m astoid tem poral bon e Lar yn goscope 2007;117(8):1389–1394 [28] Hidaka H, Yam aguch i T, Miyazaki H, Nom ura K, Kobayash i T Con gen ital ch olesteatom a is predom in an tly foun d in th e posterior-superior quadran t in th e Asian population : System atic review an d m eta-analysis, in cludin g our clin ical experien ce Otol Neurotol 2013;34(4):630–638 [29] Rich ter GT, Lee KH Con tem porar y assessm en t an d m an agem en t of congenital ch olesteatom a Curr Opin Otolaryn gol Head Neck Surg 2009;17(5):339–345 [30] Stapleton AL, Eglo AM, Yellon RF Con gen ital ch olesteatom a: Predictors for residual disease an d h earin g outcom es Arch Otolar yn gol Head Neck Surg 2012;138(3):280–285 [31] Lim HW , Yoon TH, Kan g W S Con gen ital ch olesteatom a: clin ical features an d grow th pattern s Am J Otolaryn gol 2012;33(5):538–542 [32] Lazard DS, Roger G, Den oyelle F, Ch auvin P, Garabédian EN Con gen ital ch olesteatom a: Risk factors for residual disease an d retraction pockets—a report on 117 cases Lar yn goscope 2007;117(4):634–637 [33] Doyle KJ, Luxford WM Con gen ital aural ch olesteatom a: Results of surgery in 60 cases Lar yn goscope 1995;105(3 Pt 1):263–267 [34] Rizer FM, Luxford WM Th e m an agem en t of congenital ch olesteatom a: Surgical results of 42 cases Lar yn goscope 1988;98(3):254–256 339 Special Topics and New Horizons in Surgery for Chronic Ear Disease 48 Skin Graft ing in t he Managem ent of Chronic Ear Disease David H Jung and Michael J McKenna 48.1 Int roduct ion Split-th ickn ess skin graft in g h as been an im portan t tool in th e kit of otologic surgeon s for over 100 years Th ese grafts can be placed prim arily at th e tim e of t ym pan oplasty or t ym pan om astoidectom y Split-th ickn ess skin grafts m ay also be placed secon darily to address post-surgical m astoid cavit ies or t ym pan ic grafts presen tin g w ith m yrin git is Alth ough split-th ickn ess skin graft in g is n ot required for epith elialization to occur, it does appear to decrease th e tim e required for com plete h ealing 48.2 Pat ient Select ion We use prim ar y split-th ickn ess skin grafts routin ely, n ot on ly in t ym pan om astoidectom y surgery, but also in can alplast y an d aural atresia repair In cavities or grafts th at rem ain poorly h ealin g, w e also perform secondar y split-th ickn ess skin graft in g as n eeded to obtain a dr y, safe ear 48.3 Surgical Technique 48.3.1 Prim ary Graft s Our curren t tech n ique for prim ar y split-th ickn ess skin graft in g at th e Massach usetts Eye an d Ear In firm ar y h as been passed dow n from Schukn echt to gen eration s of train ees Th e basic setup is sh ow n in Fig 48.1 After gen eral an esth esia h as been in duced, th e arm is prepped an d m in eral oil is applied to th e don or site an d th e battery-pow ered derm atom e Th e graft is h ar vested from th e m edial aspect of th e ipsilateral upper arm ( Fig 48.2) Follow in g h ar vest, th e skin graft is laid flat, epith elial side dow n , on to OTOSILK graft dressin g (Boston Medical Products, In c., Westborough , Massach usetts) th at h as been ligh tly covered w ith bacitracin Th e OTOSILK allow s for easy m an ipulation of th e grafts w ith out sacrificin g pliabilit y Th e grafts are th en cut in to sm aller pieces, covered w ith m oist gauze, an d set aside for later use durin g surgery We favor th in grafts given th at th ey better form to surfaces an d appear to sur vive better over t im e As sh ow n in Fig 48.3, a cm x cm graft is su cien t for a can al w all-dow n procedure Th e don or site is th en covered w ith a sterile adh esive dressing w rapped w ith sterile gauze On ce th e t ym pan om astoid procedure is com pleted an d th e fascia an d cartilage grafts h ave been placed ( Fig 48.4), th e trim m ed skin grafts are brough t in to th e field an d placed over th e exposed bon e an d fascia w ith th e epith elial an d OTOSILK sides facin g up It is our practice to rotate an in feriorly based periosteal flap over bon e paté in to a can al w all-dow n cavit y for partial obliteration ,1 an d w e also place skin grafts over areas of th e flap th at lie exposed w ith in th e cavit y We part ially overlap th e grafts at th e edges ( Fig 48.5) To h old th e grafts in place, w e apply m ultiple OTOSILK otologic strips soaked in cort isporin solution in a starburst pat tern th at covers all th e grafts Pieces of cotton soaked in cort isporin are th en gen tly laid on top of th e strips.2 Th e otologic strips are th en folded back over th e cotton to com plete th e “rosebud” dressin g ( Fig 48.6), an d lateral strip gauze packin g is placed 48.3.2 Secondary Graft s Our t reatm en t of secondar y skin grafts is sim ilar to th at of prim ar y grafts Th is procedure can be perform ed in th e o ce un der local an esth esia,2 but pat ien ts often prefer gen eral an esth esia Gen eral an esth esia also allow s for m ore aggressive debridem en t of gran ulation s as w ell as th e option to exen terate Fig 48.1 Basic m aterials for collecting a splitthickness skin graft OTOSILK graft dressing is lightly coated with bacitracin A battery-powered derm atom e is used to collect the graft after applying mineral oil to the skin and the derm atom e blade Following graft harvest, the site is covered with a plastic adhesive dressing and a needle is used to fenestrate the adhesive to allow egress of blood The arm is then wrapped with sterile gauze 340 Skin Graft ing in the Managem ent of Chronic Ear Disease Fig 48.2 The split-thickness skin graft is harvested from the inner aspect of the ipsilateral upper arm Fig 48.3 The harvested split-thickness skin graft is laid epithelial side down onto the OTOSILK graft dressing, spread flat, and cut into sm aller pieces A graft of this size will comfortably line a canal wall-down cavit y Fig 48.4 The t ym panomastoid cavit y im mediately prior to grafting This is a canal wall-down procedure perform ed on a left ear, and the cartilage and fascia grafts have been placed Note the inferiorly based periosteal flap that has been rotated forward to partially obliterate the cavit y Fig 48.5 Split-thickness skin grafts placed over the fascia graft, exposed bone within the cavit y, and the exposed portion of the inferiorly based periosteal flap rem ain in g m astoid air cells an d revise th e m eatoplast y as n ecessar y A split-th ickn ess skin graft is h arvested as outlin ed above All disease is rem oved usin g sh arp in strum en ts, an d th e grafts are laid dow n , follow ed by a rosebud dressin g 48.4 Post operat ive Care Fig 48.6 The rosebud dressing OTOSILK strips have been laid radially to cover the grafts, followed by cotton to hold the grafts in place The strips have been folded back over them selves to complete the dressing Postoperative care is th e sam e for eith er prim ar y or secon dary grafts At th e 1-w eek follow -up appoin tm en t , th e lateral packin g is rem oved an d th e patien t is started on n eom ycin an d polym yxin B sulfates an d hydrocort ison e otic suspen sion drops Th e patien t rem oves th e adh esive arm dressin g at h om e at approxim ately 7–10 days Tw o w eeks after th e procedure, th e rosebud dressin g is rem oved, alon g w ith th e graft backin g strips, takin g care n ot to disturb th e grafts Th e patien t is in structed to sw itch to n eom ycin an d polym yxin B sulfates an d hydrocort ison e solution drops un til follow -up in 4–6 w eeks Main ten an ce of th e resultan t ear can al or m astoid cavity th en proceeds as required 341 Special Topics and New Horizons in Surgery for Chronic Ear Disease 48.5 Com plicat ions 342 Problem s w ith th e arm don or site are rare Typically th e don or site h as dried by th e 1-w eek post-operative appoin tm en t Hypert roph ic scarrin g of th e don or site can , h ow ever, be a problem , especially in ch ildren Th e m ost com m on com plication involving split-th ickn ess skin graft in g w ith in th e ear is failure of th e grafts to take, th e m ost t ypical cause of w h ich is in fection in th e im m ediate postoperat ive period auth ors repor ted an average t im e of 3.2 w eeks to epith elialization in grafted cavities, an d n on -grafted cavities required an average of 6.6 w eeks to epith elialize, a di eren ce th at w as statistically sign ifican t Th ere w as n o sign ifican t di eren ce in com plication s betw een th e t w o groups.8 Overall, th e data suggest th at prim ar y split-th ickn ess skin graft in g prom otes h ealing after t ym pan om astoid surgery, an d th at prim ary split-th ickn ess skin graft in g can play a role in an e ective surgical strategy w h en routin ely perform ed 48.6 Out com es 48.7 Conclusion Description s of split-th ickn ess skin graft in g in otologic surgery exten d back to th e late 1800s Follow in g th e first description of skin graft in g by Th iersch , Sieben m an n espoused split-th ickn ess skin graft in g to speed epith elialization follow in g m astoid surgery.3 Older repor ts can be di cult to in terpret, as radical m astoid cavities w ere often sidered togeth er w ith fen estration cavities th at w ere previously free of in fect ion an d/or ch olesteatom a In th is regard, a report from 1954 described an average h ealin g tim e for n on -grafted fen estration cavities of 4.4 m on th s, w h ereas cavities gen erated from both fen estration an d t ym pan om astoidectom y procedures required an average of 1.7 m on th s to h eal after secon dary split-th ickn ess skin graft in g.4 A m ore recen t report foun d th at secondar y split-th ickn ess skin graft in g resulted in com plete epith elialization of 45 out of 52 cavities present in g w ith postoperative otorrh ea or sign ificant gran ulation tissue.3 Alth ough n o ran dom ized, cont rolled studies h ave been perform ed for secondar y split-th ickn ess skin graft in g, th e evidence supports th e idea th at split-th ickn ess skin graft in g is a usefu l tech n ique to address poorly h ealin g cavities an d grafts follow in g t ym panom astoid surgery Th ere is a sim ilarly lon g h istory of prim ar y split-th ickn ess skin graft in g in ch ron ic ear surgery In 1925, Mosh er reported h is m eth od of skin graft in g usin g a para n m old to h old th e grafts in place.5 A later retrospective series m easurin g tim e to epith elialization claim ed an average of 9.3 w eeks w ith splitth ickn ess skin graft in g com pared w ith 25.6 w eeks in cavities w ith out split-th ickn ess skin graft in g.6 Th e largest recen t retrospective series, in w h ich prim ar y split-th ickn ess skin grafts w ere used in all 248 cases, reported a 91% in fect ion trol rate follow in g t ym panom astoid surgery Notably, all th e cases in th is series presen ted w ith active ch ron ic otitis m edia, an d m ore th an h alf of th ese procedures w ere revision s.7 Fin ally, an im portan t recen t report described a ran dom ized, trolled study of prim ary split-th ickn ess skin graft in g in prim ar y can al w alldow n t ym panom astoidectom y perform ed in patien ts w ith active ch ron ic otitis m edia an d ch olesteatom a In th is study, th e Split-th ickn ess skin graft in g can speed h ealin g follow in g ch ron ic ear surgery; h ow ever, th e m ost im portan t factors in th e success of ch ron ic ear surgery are m eticulous eradication of all disease an d optim ization of post-surgical an atom y to m in im ize th e likelih ood of recurren t disease Split-th ickn ess skin graft in g m ay th erefore be view ed as a usefu l adjun ct , n ever a substitute, for a w ell-perform ed t ym pan om astoidectom y Alth ough cost an d logist ical cern s curren tly ren der such an approach im practical, prim ar y or secon dary graft in g of cultured epith elium gen erated from a sm all (1-cm ) skin biopsy m ay h old fut ure prom ise in reducin g th e m orbidit y of split-th ickn ess skin graft in g.9 References [1] Ram sey MJ, Merch an t SN, McKen n a MJ Postauricular periosteal-pericran ial flap for m astoid obliteration an d can al w all dow n tym panom astoidectom y Otol Neurotol 2004;25(6):873–878 [2] Nadol JB Jr, McKen n a MJ Surgery of th e ear an d tem poral bon e 2n d ed Ph iladelph ia: Lippin cott; 2005 [3] Morris MS, Mitch ell CC, Sn ell SW, Sperling N Con tem porar y skin graftin g in otologic surgery Ear Nose Th roat J 1992;71(12):652–654 [4] Guilford FR, Wrigh t W K Secon dary skin graft in g in fen estration an d m astoid cavities Lar yn goscope 1954;64(7):626–631 [5] Mosh er HP Meth od of skin graft in g for radical m astoid cavity An n Otol Rh in ol Lar yn gol 1925;34:1297–1299 [6] W ith ers BT, Dickson JC, Wattlew orth KL Prim ar y split th ickn ess skin graft in g of radical m astoid cavities An n Otol Rh in ol Lar yn gol 1953;62:656–662 [7] Merch an t SN, Wan g P, Jan g CH, et al E cacy of tym pan om astoid surgery for trol of in fect ion in act ive ch ron ic otitis m edia Lar yn goscope 1997;107 (7):872–877 [8] Wetm ore SJ, Bueller HA, Cost JL Split th ickn ess skin graft in g in can al w all dow n tym pan om astoidectom y Otol Neurotol 2014;35(1):97–100 [9] Prem achan dra DJ, Woodw ard B, Milton CM, Sergeant RJ, Fabre JW Lon g-term results of m astoid cavities grafted w ith cultured epith elium prepared from autologus epiderm al cells to preven t ch ron ic otorrh ea Lar yn goscope 1993;103(10):1121–1125 Index Note: Page n um bers set bold or ita lic in dicate h eadings or figures, respectively A abscesses – epidural 131 – in tracran ial, im aging 91, 93 – tem poral lobe 131, 131 – tem poral lobe, im aging 91, 93 act ive m iddle ear im plan ts (AMEIs) – com plication s 308 – im aging 300, 306 – over view 299 – patien t select ion 300 – surgical tech n ique 304, 304, 305 acute m astoiditis 127, 127 acute otitis m edia – bacteriology 26, 125 – classification – com plication s 125 – defin ition s 26, 26 – facial paralysis 129 – im plan table h earin g devices, see im plan table h earin g devices – m iddle ear-in n er ear in teraction 32, 34, 34 – risk factors acute otitis m edia w ith tym pan ostom y (AOMT) – ch aracterization 144 – m an agem en t 144 – MRSA tube otorrh ea 145 – otorrh ea 144 adh esive otitis m edia Ah n , J K 60 Ah n , S H 296 Aim i, K 311 Aitasalo, K 60 Al-Law ati, A 60 Alican dri- Ciufelli, M 49, 51 allergy 99, 99 am ph iregulin 17–18 An , Y H 296 an atom y – ear in n er vation 137, 138 – en doscopic ear surgery 310, 312– 313 – epitym panic spaces 51, 53, 54, 54 – facial n er ve 51, 55, 312 – in cudostapedial art iculation 192, 192, 193 – lateral in cudom alleal fold (LIMF) 53 – m iddle ear 48, 50, 206 – m iddle ear ven tilation 47 – over view 47 – petrous apex drain age path w ays 289–290 – pon ticulum 51 – protym pan ic space 54, 55 – Prussak’s space 54, 54, 311 – radiography 89, 90 – retrotym pan um 49, 51, 52 – sin us tym pan i 49, 51, 51–52 – subpyram idal space 52, 52 – tem poral bon e osteology 47, 48–50 – tem poral bon e pn eum atization 49, 54 – ten sor fold 54, 55 – tym panic m em bran e 48, 50 – ven tilation system 53, 53, 53 an esthesia – gen eral 136 – gen eral prin ciples 136 – local 137 – toxicity 137 an tibiotic pow der 121, 121 an tibiotic resistan ce 29 an tibiotics, topical vs system ic 29 Arriaga, M 145 Asai, M 77 atelectasis, see t ym pan ic m em bran e atelectasis Atlas, M D 296 Aubr y, K 296 audiom etr y, pure tone, see pure-tone audiom etr y audiovestibular assessm en t – ch ecklist 86 – over view 82, 87 – pure-tone audiom etr y, see pure-tone audiom etr y – radiography, see radiography – speech recogn ition th resh old 86 – tym panom etr y 85 – w ord recogn ition testin g 86 Austin , D F autograft ossiculoplasty, see ossiculoplasty (autograft) autoim m un e vasculitis 97 Axon , P R 296 Ayach e, S 318 B Badr-El-Din e, M 318 Ban ce, M 73–74, 76–77 Bassioun i, M 33 Baum gar tn er, W D 308 Bellucci, R J Berco, E 106 Bin gh am , B J 144 biofilm s – biom aterials 59 – ch olesteatom a 29 – otitis m edia (ch ron ic suppurative) 29 – otitis m edia (ch ron ic) 42, 42 bioglass 58, 60 biom aterials, see specific m aterials – application s 57, 58 – biofilm s 59 – calcium ph osph ates 57 – ceram ics 57, 58, 60, 275 – gold piston s 59 – hydroxyapatite 57, 58, 60, 275 – hypersen sitivity reaction s 57 – ion om eric cem en t 275 – m astoid obliteration 59, 60 – m etals 57, 57, 276 – ossiculoplast y 58, 59 – over view 57, 60 – polym ers 57, 57, 275 – types 57 Black, B bladder can cer h istopath ology 38 BLADE DW I 95 Bobbin tym panostom y tube 143 Böh eim , K 308 Bon Alive 58 Bon din g, P 145 Bon dy m odified radical m astoidectom y 246, 247 bon e duction h earin g aids 299, 308 bon e-an chored system s surgical techn ique 304, 306 BONEBRIDGE h earin g aid 299, 305– 306, 306, 308 Borgstein , J 116 Bottrill, I 60 Brackm an n , D 145 breast can cer h istopath ology 38, 40 Briggs, R J 308 Brors, D 60 Brow n , M 106 Brow n in g, G G 64 Bruce, I 116 C calcium ph osph ates 57 can al w all recon struct ion , see m astoid obliteration – com plication s 269 – outcom es 269 – over view 266 – patien t select ion 266 – postoperative care 267 – soft w all, see soft w all can al recon struction – surgical tech n ique –– bon e paté in cision , collection 266 –– can al w all cuts 266, 267 –– disease eradication 266 –– ear can al packin g, closure 267 –– epitym panum blockage 267, 268 –– m astoid obliteration 267 –– m astoidectom y 266 –– patien t preparation 266 –– posterior w all replacem en t 267, 268 –– tym panoplasty 267, 268 – titan ium cage –– hydroxyapatite 57, 58, 60, 275 –– ion om eric cem en t 275 –– outcom es 277 –– over view 275 –– patien t select ion 276 –– postoperative care 277 –– surgical tech n ique 276, 276, 277 can alplasty – bony exposure prin ciples 140 – com plication s 154 – fibrotic plug rem oval 151 – in dication s 148, 148 – outcom es 155 – over view 148 – patien t select ion 148 – postoperative care 154 – skin graftin g 151, 155 – soft tissue sten osis 151, 153 – surgical tech n ique –– an esthesia inject ion 149 –– bon e drillin g 150, 151, 151–152 –– circum feren tial sten osis preven tion 150 –– en daural in cision 149, 150 –– lateral tym pan oplasty 177, 178 –– m astoid air cell open in g 151 –– m edial skin elevation 150, 150 –– postauricular in cision 149, 150 –– prin ciples 149, 152 –– skin redraping 151 –– soft tissue exposure 149, 149 Carh art’s n otch 83, 83, 85 cart ilage tym pan oplasty – com plication s (in traoperative) 186 – com plication s (postoperative) 187 – m osaic tech n ique 184, 185–186 – outcom es 188 – over view 182 – patien t select ion 182 – pediatric 182 – perich on drium /cart ilage islan d flap tech n ique 183, 183, 184 – postoperative care 185 – revision surgery 188 – surgical tech n ique –– gen eral sideration s 182 –– m osaic 184, 185–186 –– perich on drium /cart ilage islan d flap 183, 183, 184 – T-tube placem en t, in traoperative 187, 187 – tech n ique selection 182 Caversaccio, M 296 Cayé-Th om asen , P 145 cem en t, ion om eric 275 ceram ics 57, 58, 60, 275 Ceravital prosth eses 59 cerebritis 131, 131 cerebrospin al fistula 129, 129 ch ildren, see pediatrics ch olesteatom a, see can al w all recon struction , titan ium cage, m astoidectom y (can al w all dow n ), retrograde tech n ique, ch olesteatom a, see also can al w all recon struct ion , soft w all can al recon stru ction – α -lam in in 21, 22 – acquired 6, 20, 37, 233, 247, 260, 290 – an terior epit ym pan ic 24 – attic 24, 24, 272 – bacteriology 27–28, 28 – biofilm s 29 – bon e destruction 23, 23, 37, 39, 125–126, 126 – classification 5, – clin ical evaluation 119 – collagen IV 21 – congen ital 20, 290, 337, 337, 338 – dissection , see ch olesteatom a dissection – ear can al sten osis 332, 332, 333–334 – EGFR 21, 21 – epith elial invasion (im m igration ) th eor y 37, 38–39 – epitym panic 119, 247 – epitym panic, im aging 88, 88–89 – etiologies 20, 174 – exposure, t ym pan om astoidectom y 229, 229 – exteriorization , t ym pan om astoidectom y 230 – facial n erve im agin g 89, 90 – h istology 20, 21 – h istory – iatrogen ic, im plan tation 20 343 Index – im aging 121, 138, 260 – im m igration th eor y 20 – im plan table h earin g devices 301, 307 – in congenital aural atresia 331, 331, 332 – in flam m ation 22, 22 – in terleukin s 22 – invagin ation th eor y 37, 38 – inverted V loss 85, 85 – Ki67 21, 21 – m astoidectom y (CWD) 246 –– See a lso m astoidectom y (can al w all dow n ) – m esotym panic (pars ten sa) 24 – m etaplasia th eor y 20 – m iddle ear cleft path ological ch anges 37, 37, 38 – MMPs 22 – outcom es 254 – pars flaccida, im aging 88, 89 – path ogen esis 37, 38–39 – path ophysiology 20 – pediatric 23, 253 – petrous apex –– classification 290 –– exten t, classification 291 –– h earin g preservation in 296 – prevalen ce – proliferation 20 – proliferation th eor y 20 – recurren t 49, 51, 85, 163, 163, 254, 264 – recurren t disease in ciden ce 273 – residual, post-obliteration 284 – retraction pocket th eor y 20, 24 – retrograde tech n ique, see retrograde tech n ique, ch olesteatom a – surgical decision -m akin g 122 – tem poral bon e, spread in 23, 24 – α -lam in in 21 ch olesteatom a dissection – attic disease 159, 162, 162 – attic invagin ation 161 – attic-m astoid pen etration 163, 163 – case evaluation 157, 157 – ch olesteatom a exposure 157, 158– 159 – CW U surgery 158, 161 – disease assessm en t 157 – dural exposure 162, 162–163 – en doscopic 315, 317 – Eustach ian orifice invagin ation 157, 162 – fistula 162 – in strum en tation 156, 156, 157 – m alleus h an dle reten tion 157, 163 – m astoid disease 161, 162 – m atrix rem oval 157, 158, 159 – over view 156 – posterior m esotym panum 159, 160 – preparation 156 – residual 163, 163 – sac ch aracterist ics 157, 158, 159 – surgical sch em e 157 – tech n ique selection 160 ch olesterol gran ulom a h istopath ology 40, 42 Ch om aitree, T 27 ch ron ic ear disease – classification – epidem iology – h istory 344 – prevalen ce – risk factors ch ron ic otitis m edia – biofilm s 42, 42 – bon e involvem en t 32, 33 – ch olesterol gran ulom a h istopath ology 40, 42 – clin ical presen tation 288 – com plication s 44 – com plication s, diagn ostic im agin g 90 – congen ital aural atresia, see congen ital aural atresia – CSF fistula 292, 295 – defin ition s 32 – di eren tial diagn osis 288, 288 – di usion -w eigh ted MRI 297 – etiologies 47 – facial n er ve im agin g 89, 90 – facial n er ve outcom es 296 – facial n er ve paralysis 294–295 – facial paralysis 129 – gran ulation tissue ch anges 35, 37 – h istopath ology 32, 32 – im aging 300 – im plan table h earin g devices, see im plan table h earin g devices – in tracran ial abscesses, im aging 91, 93 – m astoiditis, im agin g 92, 94 – m en in gitis 296 – m iddle ear cleft path ological ch anges 35, 37 – m iddle ear-in n er ear in teraction 32, 34, 34 – otic capsule erosion im agin g 92, 94 – otorrh ea, persisten t 95, 95 – pars ten sa path ology 41 – petrous apex drain age path w ays 288, 289–290 – sen sorin eural h earin g loss 295 – sigm oid sin us th rom bosis im agin g 90, 92 – skull base approach es to –– com plication s 292, 295 –– in fracoch lear 289, 291 –– outcom es 296, 296 –– patien t select ion 288 –– postoperative care 295 –– selection of 292 –– tran sm astoid in fralabyrin th in e 289 –– tran stem poral 289, 291 – skull base tech n iques –– com bined petrosal 293 –– in tratem poral fossa 294 –– lateral-to-m edial m iddle fossa 293 –– m edial-to-lateral m iddle fossa 293 –– m iddle fossa 292, 293 –– subtotal petrosectom y 294 –– tran scochlear 292, 292 –– tran scrusal 292, 292 –– tran slabyrin th in e 291 –– tran sotic 292 – surgical approach generally 300 – tym panic m em bran e perforation s 33, 34 – vascular injur y 296 ch ron ic otom astoiditis 228 ch ron ic silen t otitis m edia 32, 33–34 ch ron ic sten osin g otitis extern a 151, 153 ch ron ic suppurative otitis m edia – an tibiotic pow der in gredien ts 121, 121 – an tibiotics, topical vs system ic 29 – bacteriology 27, 27, 28 – biofilm s 29 – classification 4, 4, – clin ical evaluation 118, 119, 119– 120 – duct ive h earin g loss 122 – defin ition s 26, 27, 118 – fun gi 28, 28 – m edical m an agem en t, refractory cases 122 – m edical m an agem en t, routin e cases 121 – patien t ch aracterist ics 123 – pediatric 123 – radiologic im aging 120, 121 – risk factors 3, 118 – surgical decision -m akin g 120, 122, 123 Ch urg-Strauss syn drom e 98, 98, 99 Cin am on , U 11 Clark, M P 60 cleft palate bacteriology 27 coch lear im plan ts 299, 306 Colletti, V 308 com bined petrosal approach tech n ique 293 com plication s, otitis m edia – acute m astoiditis 127, 127 – cerebritis 131, 131 – cerebrospin al fistula 129, 129 – epidural abscess 131 – facial paralysis 128 – gen eral sideration s 125 – labyrin th in e fistula, see labyrin th in e fistula – labyrin th itis, see labyrin th itis – m en in gitis, see m en in gitis – m en in goen ceph alocele 129, 129 – otitic hydroceph alus 130 – over view 125 – petrous apicitis 127 – physical exam in ation 126 – sigm oid sin us th rom bosis, see sigm oid sin us th rom bosis – tem poral lobe abscess 131, 131 – treatm en t paradigm 126 congen ital aural atresia – ch olesteatom a in 331, 331, 332 –– See a lso ch olesteatom a – com plication s, postoperative –– bony sten osis 335 –– ear can al sten osis 334, 335 –– m eatal sten osis 335 –– otorrh ea 336, 336 –– tym panic m em bran e perforation 336, 336 – ear can al sten osis, ch olesteatom a an d 332, 332, 333–334 – Eustach ian tube dysfun ction in 331 – over view 331, 338 – tym panoplasty 336 Cottle, R D 77 Cureoglu, S 32 D DACS system s 304 Dai, C 74 Day, G A 64 Dazert, S 60 De Den ato, G 296 De Vos, C 211 Deveze, A 60 di usion w eigh ted im aging (DW I) 94, 95 di usion -w eigh ted MRI 297 Direct Acoustic Coch lear Stim ulator (DACS) 225 Dorn h o er, J L 62, 109, 287 Drozdziew ic, D 145 drum collapse 4, 5, – See a lso t ym pan ic m em bran e Duckert, L G 145 D’Am ico, R 60 E ear can al sten osis – ch olesteatom a an d 332, 332, 333– 334 – in congenital aural atresia 334, 335 ear in n er vation 137, 138 East , D M 202 ech o plan ar im aging (EPI) 95 Edfeldt, L 60 El Garem , H 296 El-Seifi, A 103 Elbron d, O 75 Elpern , B S 75 Em m et, J R 202 en dolym ph atic hydrops 32, 34 en doscopic ear surgery – an atom y 310, 312–313 – ch olesteatom a dissection 315, 317 – com plication s 317 – dissectors, curved 314 – en doscopes 311, 313 – h istory 310 – im aging 311 – in strum en ts, specialized 313, 314 – m orbidity 318 – otologic drills 313 – outcom es 318 – patien t select ion 310, 311 – pitfalls 317 – postoperative care 316 – prin ciples 310 – suct ion can n ulas 313, 314 – tran scan al 310, 314 – tym panoplasty 314, 315–316 eosin oph ilic otitis m edia 97, 97 epiderm al grow th factors 16, 17–18 epidural abscess 131 epitym panectom y – an atom y 239 – com plication s 245 – epitym panic spaces an atom y 51, 53, 54, 54 – over view 239 – patien t select ion 239 – pearls, pitfalls 244 – postoperative care 244 – preoperative w orkup 239 – surgical tech n ique –– approach es 239, 239 –– bon e rem oval 242, 243 –– can al w all defect recon struction 244, 244 –– en daural in cision , m eatoplasty 240, 240, 241–242 –– extern al can al skin treatm en t 241, 243 –– ossicular ch ain m an agem en t 244 Index –– stepw ise 240, 240 epitym panotom y (lateral) 234, 234, 235 Eustach ian tube dysfun ction , see m iddle ear – an atom y 9, 55 – assessm en t – autograft ossicular recon struction 202 – classification – e usion subtypes n ature 12 – etiologies 8, 113, 319 – in congenital aural atresia 331 – m ech anism of fun ct ion – m iddle ear ven tilation pattern s 12 – m iddle ear-m astoid gas exch ange 10, 10 – m iddle ear-m astoid pressure regulation 11 – n egative pressure, e usion path ophysiology 12 – pediatric 8, 85 – physiology 8, – prevalen ce – selective epitym panic dysven tilation 12 – surgical in terven tion s – treatm en t 115 – treatm en t decision -m akin g 115 – tubom an om etry (TMM) 10, 10 – tym panom etr y 85 Eustach ian tuboplast y – balloon dilation outcom es 323 – balloon dilation tech n ique 322, 323 – com plication s 322 – im aging 320 – laser-assisted outcom es 323 – laser-assisted tech n ique 321, 321 – m ech anism s of act ion 324 – m icrodebrider outcom es 323 – m icrodebrider tech n ique 322 – outcom es 322 – over view 319, 324 – patien t select ion 320 – pediatric 320 – postoperative care 322 – preoperative exam in ation 320, 320 Evan s, R A 64 F 5-fluorouracil (5-FU), for m yrin gitis 104 facial n erve – an atom y 51, 55, 312 – can alplasty com plication s 155 – im aging 89, 90 – m astoidectom y injur y to 235 – m on itorin g, in traoperative 138 – outcom es in ch ron ic otitis m edia 296 – paralysis 128 – paralysis h istopath ology 45, 46 – paralysis, post-COM skull base surgery 294–295 Feen stra, L 73, 77, 116, 211 Fergie, N 296 fibroblast grow th factor in w oun d h ealin g 16, 17–18 Fisch Titan ium Total Prosth esis (FTTP) 224, 224 Fisch , U 153, 223, 293 Forin o, M 60 Fouad, B 103 Free, R H 308 Fun n ell, W R 73 G Gan , R Z 74 Gardn er, E 62 Gérard, J M 211 Gerritsm a, T 116 Gersdor , M 211 Gim en ez, E 60 Gladston e, H B 293 Gluth , M B 109 Goetz, W 60 Golden berg, R A 202 Goode, R L 66, 73–77 Goravalin gappa, R 60 Goycoolea, M V 23, 33 gran ulom atosis w ith polyan gitis 98, 98 Grayeli, A B 296 Grén m an , R 60 Grote, J J 60 Groth , A 144 Gu, T W 60 Gutteridge, I H Haeusler, R 296 Halevy, A 106 Han , C S 60 Hardy, D G 296 HASTE 95 Hayash ida, M 60 Heaton , J M 144 Hellström , S 144 Helm s, J 145 h eparin -bin din g EGF-like grow th factor 16, 17–18 Hess-Erga, J 59 Hildm an n , H 60 Huber, A M 77 Hugh es stapes m obilizer 156, 157 Hutten brin k, K-B 75 hyaluron ic acid 16, 17–18 hybrid tech n iques 258 – See a lso specific tech n iques hydroxyapatite 57, 58, 60, 275 Hyodo, J 90 hypoten sive an esthesia 137 I Iin o, Y 97 im aging, see radiography im m un osuppression 99 im plan table h earin g devices – act ive m iddle ear im plan ts (AMEIs) 299–300, 300, 306, 308 – acute otitis m edia 307 – an tibiotics 307 – bon e duction h earin g aids 299, 308 – ch olesteatom a 301, 307 – coch lear im plan ts 299, 306 – com plication s 307 – com plication s in ciden ce 308 – im aging, post-operative 306 – in fect ion 300, 307 – open m astoid cavit y 301, 302 – outcom es 308 – over view 299, 308 – patien t select ion 299 – pediatric 300–301, 307 – postoperative care 306 – prin ciples 299 – surgical tech n ique –– AMEI 304, 304, 305 –– blin d sac closure 302, 302 –– bon e-an chored system s 304, 306 –– CI in sert ion 303, 303 –– DACS system 304 –– m astoid obliteration 302, 303 –– prin ciples 302 – tym panic m em bran e atelectasis 301, 307, 308 – tym panic m em bran e perforation 300, 301 – tym panic m em bran e retraction 301, 307, 307 in cudostapedial art iculation recon struction – an atom y 192, 192, 193 – autologous m aterials 193 – bridging tech n ique 193, 193, 194, 194 – com plication s 195 – in cus body 193 – in terposition tech n ique 193, 194, 194, 195 – outcom es 196 – over view 196 – physiology 192 – postoperative care 195 – surgical tech n ique 192 – syn th etic prosth eses 194 in fect ion – im plan table h earin g devices 300, 307 – m astoid obliteration 286 In gelstedt, S 12 in n er ear fistula, see labyrin th in e fistula in terleukin s 16, 17 in tratem poral fossa approach tech n ique 294 ion om eric cem en t 275 J Jackler, R K 293 Jan zen , V D 202 Jon es, S 296 Jörgen sen, F 144 Jørgen sen, G 145 Just, T 60 K Kan g, M K 60 Kan ia, R 296 Kartush , J M keratin ocyte grow th factor 16, 17–18 Kiefte, M 73 Killion , M 75 Kim , H H 60 Kin n efors, A 60 Kley kn ife 156, 157 Kn utsson , J 327 Kom ori, M 90 Koutroupas, S 33 Kujaw ski, O B 324 Kurokaw a, H 66 Kveton , J F 60 L labyrin th in e fistula 44, 45, 128 labyrin th itis – bon e involvem en t 35, 36 – ch ron ic 35, 36 – circum scribed (localized) 34 – h istopath ology 32, 34 – m an agem en t 128 – serous (toxic) 34, 34 – suppurative 35, 35, 36 Lafon t, B 60 lateral tym pan oplasty – advan tages, disadvan tages 170 – an terior sulcus blun tin g 180 – can alplasty 177, 178 –– See a lso can alplasty – com plication s 180 – epith elial cysts 180 – graft lateralization 180 – outcom es 180 – over view 176 – patien t select ion 170, 176 – pearls, pitfalls 181 – prin ciples 168 – sen sorin eural h earin g loss 180 – surgical tech n ique –– can al skin rem oval 176, 178 –– can al skin replacem en t 179, 179 –– can alplasty 177, 178 –– fascia placem en t 177, 179 –– postauricular exposure, fascia rem oval 176, 177 –– postoperative care 179 –– preparation 176 –– tran sm eatal in cision s 176, 177 –– tym panic m em bran e de-epith elialization 177, 178 –– vascular strip replacem en t 179 Lavieille, J P 60 leukem ia, h istopath ology 35–36, 42, 44 Leun g, R 308 Lin der, T 153, 223 Lyn ch , T J III 67 M Magliulo, G 60 Magn an, J 60 Mah en dran , S 60 Makielski, K H 145 m alleostapedotom y 223, 223 March ion i, D 49, 51, 311 m ass tilt 82, 82 m astoid cavit y in stability – an tim icrobial th erapy 108 – cavit y irregularities 107, 108 – ch aracterization 106, 109 – etern al auditory m eatus 107, 108 – exam in ation , assessm en t of 107, 107 – h igh facial ridge 107, 107 – im plan table h earin g devices 301, 302 – kidn ey sh ape 107, 108 – m astoid tip 107, 107 – m icrobiology 108 – n on -saucerized cavity 107, 108 – open Eustach ian tube 107, 108 – pediatric 229 – revision surgery 109 – sym ptom s 106 – treatm en t 108 345 Index m astoid obliteration , see can al w all recon struct ion – biom aterials 59, 60 – bon e paté 281, 281, 281, 282 – cart ilage ch ips 281, 281, 281, 282 – ch olesteatom a, residual 284 – com plication s 284 – fascia 282, 282, 284 – fillers, issues w ith 286 – Hon g Kon g flap 284 – in fect ion 286 – in ferior m usculoperiosteal flap 282, 284–285 – m iddle tem poral artery flap 282, 283–285 – outcom es 286, 286 – over view 280, 287 – Palva flap 282, 283–284 – patien t select ion 280 – perich on drium 282, 282 – PORPs, TORPs in 284, 286 – postoperative care 284 – pressed m uscle 282, 282 – skin grafts 283, 285 – soft tissue flaps 282, 283–284 – soft w all can al recon struct ion tech n ique 270, 271 – surgical tech n ique –– application 283, 286 –– im plan table h earin g devices 302, 303 –– m aterials 280 –– sch em es 280 – syn th etic m aterials 281, 282 – tem poralis m uscle (m usculoperiosteum ) flap 284 m astoidectom y, see tym pan om astoidectom y – bony exposure prin ciples 139 – can al w all dow n 230 – can al w all recon struct ion 266 – ch ron ic otom astoiditis 228 – decision -m akin g sch em e 229 – pediatric 229 – tech n ique selection 229 – tubo-t ym pan ic diseases 116 m astoidectom y (can al w all dow n ) – advan tages 248, 249 – Bon dy m odified radical 246, 247 – com plication s 253 – m odified radical 246, 251 – outcom es 237, 254, 254 – over view 246, 246 – patien t select ion 246 – pediatric 253 – PORP use in 252 – postoperative care 253, 254 – radical 246 – recidivism rates 237 – subtyp es 246 – surgical tech n ique –– cavit y irregularities, elim in ation of 250 –– ch olesteatom a exposure 247 –– facial ridge low erin g 248, 249 –– m alleus preser vation 248 –– m astoid tip am putation 250, 251– 252 –– m astoidectom y, epitym pan ic dissect ion 247 –– m eatoplasty 253 –– prin ciples 247, 248 –– saucerization 250, 250, 252 346 –– sclerotic tem poral bon e 251, 253 –– tem poral bon e pn eum atization 250 –– tym panic bon e tourin g 249, 250, 253 –– tym pano-ossicular m ech an ism recon struct ion 251 – TORP use in 252 – vs CW U tech n iques 258 m astoidectom y (can al w all up) – can al defects 234, 234, 236 – can al defects recon stru ction 235 – com plication s 235 – train dication s 232 – disadvan tages 248, 249 – facial n er ve injur y 235 – goals 232 – h earin g loss 236 – in dication s 232 – outcom es 236, 237 – over view 231 – patien t select ion 231 – pediatric 229 – postoperative care 234 – preoperative evaluation 232 – recidivism rates 237 – silicon e sh eetin g placem ent 236, 237 – surgical tech n ique –– an trum exposure 233 –– can al in cision s 232 –– closure 234, 235–236 –– com plete m astoidectom y 233, 233 –– exten ded facial recess 233 –– facial recess (posterior tym pan otom y) 233, 234 –– lateral epitym pan otom y 234, 234, 235 –– postauricular in cision 232, 232 – vs CW D tech n iques 258 m astoiditis, im agin g 92, 94 Masuda, M 60 m atrix m etalloprotein ases (MMPs) 17 Matsubara, A 97 Mattioli, F 49, 51 May, J 223 May, J S 153 McDon ald, M H m eatoplasty – com plication s 154 – Fisch tech n ique 154 – M-m eatoplasty tech n ique 153, 155, 271 – outcom es 155 – over view 148 – patien t select ion 148 – postoperative care 154 – surgical tech n ique –– cart ilage m an agem en t 153, 154 –– ch al cart ilage resect ion 153 –– CW D m astoidectom y 253 –– en daural in cision 152, 153 –– Fisch 153 –– prin ciples 152 –– skin flap elevation 153 – w ith epit ym pan ectom y 240, 240, 241–242 Meh ta, R P 76 Meister, H 74 m en in gitis – h istopath ology 33, 33–34, 38–39, 46 – m an agem en t 129 – post-COM skull base surgery 296 m en in goen ceph alocele 129, 129 Merch an t, S N 67, 76–77, 202 m etals 57, 57 m eth icillin-resistant S aureus (MRSA) 29 Metrailer, A M 109 Micken h agen , A 74 m iddle ear – acoustic coupling 67 – air spaces 66 – an atom y 48, 50, 206 – ch a acoustics 63, 64 – ear can al resonan ce 63, 63, 64, 65 – extern al auditor y can al 62, 63 – fun ct ion , n orm al 64, 65 – h ead sh adow 62 – h earin g recon struction 68 –– See a lso t ym pan oplast y – h earin g recon struction surgery classification 68, 68 – im perfect reflect ion 64 – in n er ear in teract ion 32, 34, 34 – m astoid gas exch ange 10, 10 – m astoid pressure regulation 11 – m ech anical prin ciples 62 – n egative pressure coun teraction 228 – ossicular ch ain 66 – ossicular coupling 67 – path ological ch anges 35, 37 – pin n a acoustics 63, 63 – pin n a n otch 63 – pressure gain 66, 67 – prosth etic recon struct ion 71, 72 – roun d w in dow protect ion 67 – soun d pressure 62, 63, 64, 64–65 – tym panic m em bran e 65, 65, 66 – ven tilation 12, 47 Middle Ear Risk In dex 4, m iddle fossa approach tech n ique 292, 293 Min oda, R 60 Mirck, P G B 153, 271 Miuch i, S 90 Miura, M 11 m odified radical m astoidectom y 246, 251 Mo at, D A 296 Mo at-Sm ith system 291 Moore, P C 109 Morris, D P 73–74, 76 Mosh er, H P 342 Mosn ier, I 296 MRSA tube otorrh ea 145 Murugasu, E 76 m yrin gitis – ch aracterization 102 – classification system 103, 103 – clin ical presen tation 102, 102 – com plication s 104 – im aging 102 – m edical treatm en t 104 – path ophysiology 102 – physical exam in ation 103, 103 – surgical treatm en t 104 – treatm en t 104 N Nadol, J B Jr 202 Nakagaw a, T 97 Nakam ura, K 75 Nakm ali, D 74 Nan oBon e 60 Nassif, N 60 Nilssen , E L 106 Nish ih ara, S 74–75 Nitin ol 57, 57, 59 Non aka, M 97 n on ech o plan ar im aging (n on -EPI) 95 O Om ran , A 296 Osborn e, J 144 ossicular status classification ossiculoplast y – Austin -Kartush classification 211 – Austin -Kartush Group A outcom es 217 – Austin -Kartush Group C outcom es 217, 218 – Austin -Kartush Group D outcom es 219, 220 – biom aterials 58, 59 – com plication s, diagn osis 90, 92 – h istory – m alleus h an dle reten tion 157, 163 – m alleus m issing outcom es 219 – m alleus role in 211 – m alleus, stapes in tact, m obile 211 – m iddle ear environ m en t 190 –– See a lso m iddle ear – outcom es 62, 217, 218 – outcom es, judgin g 190 – outcom es, predict in g 90 – over view 190 – prim ar y 235 – prim ar y vs staged 190 – surgical tech n ique –– Austin -Kartush Group A 211, 217 –– Austin -Kartush Group B 213, 214 –– Austin -Kartush Group C 214, 217, 218 –– Austin -Kartush Group D 215, 215, 216–217 –– m alleus relocation 211, 212–213 –– silastic ban din g 212, 213–214 – via facial recess 237, 237 ossiculoplast y (autograft) – can al w all-dow n 197 – outcom es 202 – over view 197 – patien t select ion 197 – pearls 201 – pitfalls 201 – post-can al w all-dow n 201 – postoperative care 201 – surgical tech n ique –– post-can al w all up procedure 198 –– prin ciples 198 –– stapes superstructure absen t 199, 200 –– stapes superstructure presen t 198, 198, 198, 199, 199, 200, 200 ossiculoplast y (TORPs, PORPs) – an atom y 206 – Austin -Kartush Group A outcom es 217 – Austin -Kartush Group C outcom es 217, 218 – Austin -Kartush Group D outcom es 219, 220 – com plication s 210 – outcom es 209, 209, 210, 217, 218 – over view 204 – patien t select ion 204 – postoperative care 209 Index – prosth eses design 204 – prosth eses m aterials 204 –– See a lso biom aterials – prosth eses qualities 204 – stapedotom y 224 – stapedotom y w ith 224, 224 – surgical tech n ique –– Austin -Kartush Group A 211 –– Austin -Kartush Group B 214 –– Austin -Kartush Group C 214 –– Austin -Kartush Group D 215 –– fixed ossicular ch ain 209 –– gen eral prin ciples 205 –– in cus erosion 205, 207 –– in cus, stapes absen t 207, 208 –– prosth esis extrusion 206, 207 –– prosth esis to m alleus h an dle tour 206, 207 –– stapes fixation , fixed footplate on ly 223 Ossiculoplast y Outcom es Param eter Staging (OOPS) in dex 209–210 otic capsule erosion im agin g 92, 94 otitic hydroceph alus 130 otitis m edia – acute vs ch ron ic – classification – defin ition s 26, 32 – h istory – prevalen ce – radiation -in duced 100 otitis m edia w ith e usion (OME) – age 115 – allergy correlation to 99 – ch aracterization 111 – classification – clin ical presen tation 111, 111, 112 – duct ive h earin g loss 114 – defin ition s 26, 26, 32 – diagn ostic tests 113 – di eren tial diagn osis 99 – Eustach ian tube dysfun ction 115 – localization 115 – m astoidectom y 116 – m edication s 115 – m icroscopic exam in ation 114, 114 – otorrh ea 114 – outcom es 116 – path ogen esis 111 – tem poral bon e pn eum atization 114 – tim e course 115 – treatm en t decision -m akin g 114, 114 – treatm en t option s 115, 115 – tym panom etric profiles 85 – tym panostom y tubes 116 otogen ic m en in gitis, see m en in gitis otom astoiditis, ch ron ic 228 otom ycosis 28, 28, 120 otorrh ea, persisten t 95, 95, 144 OTOSILK grafts 340, 340–341 over-un der t ym pan oplast y – advan tages, disadvan tages 170 – com plication s 174 – surgical tech n ique 172, 173–174 overlay t ym pan oplast y, see lateral t ym pan oplasty P Palva, T 53 Pan osetti, E 296 Paparella tym panostom y tube 143 Paparella, M M 32–33, 40 partial ossicular replacem en t prosth esis (PORP), see PORPs Pau, H W 60 Peake, W T 67 pediatrics – cart ilage tym pan oplasty 182 – ch olesteatom a 23, 253 – ch ron ic suppurative otitis m edia 123 – Eustach ian tube dysfun ction 8, 85 – Eustach ian tuboplast y 320 – im plan table h earin g devices 300– 301, 307 – m astoid cavit y in stability 229 – m astoidectom y 229 – m astoidectom y (CW D) 253 – m astoidectom y (CW U) 229 – pure-tone audiom etr y 85 – tym panic m em bran e atelectasis 113 – tym panom astoidectom y 229 – tym panoplasty 123 Pen n ington , C L 202 petrosectom y 225, 225 petrous apex drain age path w ays 288, 289–290 petrous apicitis 127 Piccirillo, E 296 Plastipore 57, 59 Politzer, A 12 Polycel 57 polym ers 57, 57, 275 PORPs – design 205 – e cacy 58, 62 – h istory – im aging 90, 91–92 – in CW D m astoidectom y 252 – in m astoid obliteration 284, 286 – in retrograde tech n ique, ch olesteatom a 262 – ossiculoplast y w ith , see ossiculoplasty (TORPs, PORPs) – tech n ique classification s 68 – titan ium 58 Poulsen , G 39 Presutti, L 51 prim ar y T-Tube cart ilage tym pan oplasty 145, 145 PROPELLER DWI 95 prosth etic recon struct ion , see PORPs, TORPs – an gulation of prosth esis 71, 72, 75 – cart ilage overlay e ects 75 – coupling in terfaces 75 – FOM-type 72, 76–77 – footplate sh oe 77 – FOT-type 74, 76–77 – global factors a ect in g 71 – m alleus in terfaces 75 – m alleus site of tact 75 – m ass of prosth esis 74, 74 – m iddle ear fluid 77 – m iddle ear pressure 77 – prosth esis h ead size 76 – prosth esis to footplate in terface 76 – prosth esis to stapes superstructure in terface 76 – pseudom an ubrium 75 – rotation of prosth esis 72, 72 – scarrin g 77 – SHOM-type 73, 75–76 – SHOT-type 73, 74–77 – soun d distort ion 73 – – – – – soun d tran sm ission factors 71, 72 stapedius-associated factors 77 sti n ess of prosth esis 74 ten sion s 73, 73 ten sor tym pani-associated factors 77 – TM-prosth esis in terfaces 75 Prussak’s space an atom y 54, 54, 311 Pseudom on as aerugin osa 29 Puch ol, M S 60 Pulkkin en , J 60 Pun ke, C 60 pure-tone audiom etr y – audiology 82 – bon e duction th resh olds 83, 83 – Carh art’s n otch 83, 83, 85 – degree of h earin g loss 84, 84 – inverted V loss 85, 85 – issues in 83, 85 – m askin g dilem m a 84 – m ass tilt 82, 82 – otology 84 – pediatric 85 – sh adow cur ves 83, 83 – sti n ess tilt 82, 82 – surgical com plication s assessm en t 84 – surgical outcom e assessm ent 84 – test accuracy 84, 84 Puria, S 76 Pyle, G M 296 R radical m astoidectom y 246 radiography – an atom y 89, 90 – ch ron ic ear disease ch aracteristics 88 – com plication s, diagn osis 90, 92 – disease sur veillance 94 – exten t of disease 88, 88, 89 – facial n er ve 89, 90 – in tracran ial abscesses 91, 93 – m astoiditis 92, 94 – ossicular prosth eses 90, 91 – otic capsule erosion 92, 94 – otorrh ea, persisten t 95, 95 – over view 88, 96 – pn eum atization degree 88, 88, 89 – postoperative features 90, 91 – preoperative, ben efits of 88 – residual, recurren t disease 94, 95 – sigm oid sin us th rom bosis 90, 92 – surgery, preoperative im agin g 138 Ram bo, J H 106 Ram eh , C 60 Rask-An dersen , H 60 Ravicz, M E 76–77 retrograde tech n ique, ch olesteatom a – ch olesteatom a rem oval 260, 261– 262 – com plication s 264, 264 – outcom es 264 – over view 260 – patien t select ion 260 – postoperative care 263 – recon struct ion 262, 263 – recurren ce 264 – TORP, PORP use in 262 retrotym pan um an atom y 49, 51, 52 Roberson , J B., Jr 76 Rosow ski, J J 67, 76–77 Ruah, C B 40 S Sadé, J 11, 106 Saeed, S R, 296 sarcoidosis 99 Sarin , J 60 Sauvaget, E 296 Sch ach ern , P A 32, 40 Sen n , P 296 Seren oCem 58, 60 sh adow cur ves 83, 83 Sh aw, E A 63 Sh ea, M C Jr 221 Sh elton , C 145 Sh im izu, Y 75–76 Sh in ohara, T 59 Siddiq, M A 202 sigm oid sin us th rom bosis 90, 92, 130, 130 Silvola, J T 60, 323 sin us tym pan i an atom y 49, 51, 51–52 skin graftin g – can alplasty 151, 155 – m astoid obliteration 283, 285 – m aterials 340 – outcom es 342 – over view 340, 342 – patien t select ion 340 – postoperative care 341 – prim ar y, tech n ique 340, 340, 341 – secon dar y, tech n ique 340 Sm ith , W 296 sm okin g 264 Sm yth , G D L 59 soft w all can al recon struct ion – advan tages 270 – case study 273, 273 – com plication s 271 – train dication s 270 – m astoid m ucosa 272, 273 – outcom es 272, 272, 273 – over view 270, 270 – patien t select ion 270 – postoperative care 271 – recurren t disease in ciden ce 273 – surgical tech n ique –– gen eral approach 270 –– n on -in flam ed ears 271 –– secon d-stage surgery 270 –– silicon e sh eetin g 270, 271 –– w ith m astoid obliteration 270, 271 Son g, J J 296 Soph on o Alph a MPO 299 speech recogn ition th resh old assessm en t 86 staged n eo-m alleus plus n eo-m alleostapedotom y 223, 223 Stan gerup, S 145 stapedotom y 224, 224 stapedotom y w ith TORP ossiculoplasty 224, 224 stapes fixation surgical m an agem en t – altern atives 222, 225, 225 – an ticipation 221 – causes 221 – com plication s 225 – fixed footplate rem oval 224 – in terposition graft, typ e 224, 224 – m iddle ear audible range, status 222 – outcom es 225 – over view 221 347 Index – – – – – – patien t select ion 221 petrosectom y 225, 225 prin ciples 221 recon struct ion stabilization 224, 224 stapedotom y 224, 224 stapedotom y w ith TORP ossiculoplasty 224, 224 – tech n ique –– fixed footplate on ly 223 –– m alleostapedotom y 223, 223 –– ossicular ch ain fixed, in tact 222 –– prin ciples 222 –– staged n eo-m alleus plus n eo-m alleostapedotom y 223, 223 Sten n ert, E 74 sti n ess tilt 82, 82 Ström bäck, K 60 subtotal petrosectom y approach tech n ique 294 Sudh o , H 60 surgery gen eral prin ciples, see specific procedures – an esthesia 136 – an esthesia toxicity 137 – an tibiotic th erapy, postoperative 140 – bony exposure 139 – en daural in cision 139, 139 – facial n er ve m on itorin g 138 – field trol 140 – gen eral an esthesia 136 – local an esth esia 137 – operating room layout 134, 135 – operative site preparation , drapin g 136, 137 – over view 134 – patien t position in g 134, 136 – postauricular skin in cision 139 – preoperative im aging 138 – preoperative safety protocol 135 – soft tissue exposure 139 – surgeon position 135 – ven ous th rom boem bolism prophylaxis 140 surgical an atom y, see an atom y T T-Tube (Grace Medical) 143, 143 Takah ash i, S 60 Taper Ven t tym pan ostom y tube 143 Teflon 57 tem poral bon e 47, 49–50, 54 – ch olesteatom a, spread in 24 – osteology 48 – pn eum atization 114, 250 tem poral lobe abscesses 131, 131 tem poral lobe abscesses, im aging 91, 93 Teran ish i, R 63 tissue regen eration , see tym pan ic m em bran e regen eration titan ium 57, 57, 58, 276 – See a lso can al w all recon struct ion , titan ium cage Tom ioka-Matsutan i, S 97 Ton n dorf, J 77 TORPs – design 205 – e cacy 62 – h istory – im aging 90, 91 – in CW D m astoidectom y 252 348 – in m astoid obliteration 284, 286 – in retrograde tech n ique, ch olesteatom a 262 – m osaic recon struction 185, 186 – ossiculoplast y w ith , see ossiculoplasty (TORPs, PORPs) – tech n ique classification s 68 – titan ium 58 Tos, M 39, 145 total in traven ous an esthesia (TIVA) 137 total ossicular replacem en t prosth esis (TORP), see TORPs tran scochlear approach techn ique 292, 292 tran scrusal approach techn ique 292, 292 tran sform in g grow th factor-β in w oun d h ealing 16, 17–18 tran slabyrin th in e approach tech n ique 291 tran sotic approach techn ique 292 Triun e Tube 143 tuberculous otitis bacteriology 28 tubo-t ym pan ic diseases, see otitis m edia w ith e usion (OME), tym pan ic m em bran e atelectasis – m astoidectom y 116 – tym panoplasty 116 – tym panostom y tubes 116 tym panic m em bran e – an atom y 48, 50 – dim eric m em bran e 43, 43, 44 – epiderm ization 44, 44 – epith elial m igration 14, 14 – m ech anical propert ies 65, 65, 66 –– See a lso m iddle ear – m ucocutan eous jun ction 43, 43 – roun d w in dow protect ion 67 – structu re 14 tym panic m em bran e atelectasis – age 115 – autograft ossicular recon struction 202 – Black classification 113 – ch aracterization 111 – classification 4, 111, 113 – clin ical presen tation 111, 112 – duct ive h earin g loss 114 – diagn ostic tests 113 – Erasm us classification 113 – Eustach ian tube dysfun ction 115 – h istopath ology 39, 39, 40 – im plan table h earin g devices 301, 307, 308 – localization 115 – m astoidectom y 116 – m edication s 115 – m icroscopic exam in ation 114, 114 – otorrh ea 114 – outcom es 116 – pars flaccida retraction 39, 39, 40, 42, 113 – pars ten sa path ology 39–40, 40–42 – pars ten sa retraction 113, 119 – path ogen esis 111 – pediatric 113 – protein ase cen tration s 40 – retraction pockets 111, 112 – Sade classification 113 – tem poral bon e pn eum atization 114 – tim e course 115 – Tos classification 113 – treatm en t decision -m akin g 114, 114 – treatm en t option s 115, 115 – tym panosclerosis 112 – tym panostom y tubes 116 tym panic m em bran e perforation s – bacteriology 28 – ch ron ic 17 – classification 4, – congen ital aural atresia 336, 336 – etiology 15 – h istopath ology 43, 43 – iatrogen ic 154 – im plan table h earin g devices 300, 301 – otitis m edia (ch ron ic) 33, 34 – pars flaccida h ealing 16 – regen erative treatm en ts 18 –– See a lso t ym pan ic m em bran e regen eration – spon tan eous h ealin g rate 170 – w oun d h ealing –– factors a ect in g 17 –– grow th factors 16, 16, 18 –– in flam m atory stage 15, 15, 17 –– over view 15, 15 –– proliferative stage 15, 16 –– rem odelin g stage 15, 16 tym panic m em bran e regen eration – bFGF 325–326 – com plication s 326, 327 – gelatin spon ge 326, 326 – h earin g im provem en t 327, 328–329 – m aterials 326, 326 – outcom es 326, 327–329 – over view 325, 329 – patien t select ion 325 – postoperative care 326 – procedure, duration of 329 – rate of closure 326, 328 – strategy 325 – surgical tech n ique 326, 327 – tin n it us, aural fulln ess 329 tym panom astoidectom y, see m astoidectom y – biom aterials in , see biom aterials – ch olesteatom a exposure 229, 229 – ch olesteatom a exterior ization 230 – ch ron ic otom astoiditis 228 – decision -m akin g sch em e 229 – n egative pressure coun teraction 228 – over view 228 – pediatric 229 – tech n ique selection 229 tym panom etry 85, 113 tym panoplasty – an esthesia 166 – auricular cart ilage grafts 167 – can al w all recon struct ion 267, 268 – cart ilage, see cart ilage tym pan oplasty – classification 191 – com plication s 174 – congen ital aural atresia 336 – en daural approach 166 – en doscopic 314, 315–316 – graft m aterial 167 – h istory – lateral, see lateral tym panoplasty – m ajor colum ella subtype 191 – m in or colum ella subtype 191 – m yrin gitis 104 – over-un der, see over-un der tym pan oplasty – overlay (lateral), see lateral tym panoplasty – over view 166 – pediatric 123 – PGOW -type 68, 68, 70, 78 – postauricular approach 166 – revision 168 – RoWPOWA-t ype 68, 68, 70, 70, 78 – stapes colum ella subtyp e 191 – surgical approach 166 – tech n ique selection 168 – tem poralis fascia grafts 167 – tran s-speculum approach 166 – tubo-t ym pan ic diseases 116 – type I 191 – type II 191 – type III 191 – type IV, V 191 – un derlay graft in g, see un derlay tym pan oplasty – Wullstein classification s 69 tym panosclerosis 44, 44, 45, 222 tym panostom y tubes – ben efits, lim itation s 319 – biofilm s 59 – collar, flan ge design 143 – com plication s 144 – sequen ces, lon g-term 145–146 – design 142 – early extrusion , reten tion 144, 146 – features for specific purposes 143, 143 – fluoroplastics 142 – lon g-term tubes 143, 143 – m aterials 142 – over view 142 – perforation 144 – polyethylene 142 – prim ar y T-Tube cart ilage tym pan oplasty 145, 145 – rem oval 144 – silicon e 142 – special application s 145 – stain less steel 142 – titan ium 142 – tubo-t ym pan ic diseases 116 – w ash er tube tech n ique 146, 146 U un derlay t ym pan oplasty – advan tages, disadvan tages 170 – com plication s 174 – outcom es 174 – patien t select ion 170, 171 – postoperative care 174 – prin ciples 167, 170 – surgical tech n ique 171, 172 V van W ijh e, R G 73–74, 76 Vartiain en, E 59 ven ous th rom boem bolism prophylaxis 140 Vibran t Soun dbridge AMEI 299–300, 300, 304, 308 Vlam in g, M S 73, 77, 211 von Wedel, H 74 Voss, S E 67 Vow ler, S L 202 Index W Walger, M 74 Wan g, X 74 w ash er tube tech n ique 146, 146 Wegen er’s gran ulom atosis, see gran ulom atosis w ith polyan gitis Wein berg, J 106 Wiet, R J 296 Wilson , D F 60 Wood, M W 74 w ord recogn ition testin g 86 Worm ald, P J 106 Y Yan agih ara, N 90 Yan ez, C 321 Youngs, R 106 Yum oto, E 60 Yun g, M 202 Yun g, M W 60 Z Zah n ert, T B M 75 Zan etti, D 60 Zelterm an , D 40 Zh an g, Z 104 Zölln er, F 221 Yam ada, H 73, 76 349 ... of Chronic Ear Disease 26 Histopathology of Chronic Otitis Media 32 Surgical Anatom y Relevant to the Chronic Ear 47 Biom aterials in Tym panom astoid Surgery 57 Middle Ear Mechanics in Hearing... esis ven ous th rom boem bolism World Health Organ izat ion Part The Fundam ent als of Chronic Ear Disease Chronic Ear Disease in the Modern Era: Evolution of Treatm ent, Epidem iology, and Classificat... possible poor h earin g outcom e (e.g., Stage III*) The Fundam entals of Chronic Ear Disease Fig 1.4 Black classification of the collapsed pars tensa Stage I is collapse without hearing loss, treated