Despite the many advances in diagnostic technologies and imaging modalities in recent years, otoscopy remains the first diagnostic option in the diagnosis of otologic disease. This is an easytoconsult book for residents and specialists, featuring brilliant diagnostic images from the newest generation of endoscopic otoscopes. Written by a renowned team of experts with 30 years of experience, this book helps readers obtain proficiency in otoscopy and in the interpretation of findings. Readers will learn what clinical consequences the diagnoses may have through case examples and treatment suggestions.
Color At las of Endo-Ot oscopy Exam inat ion–Diagnosis–Treat m ent Mar io San n a, MD Professor of Otolar yngology Depart m en t of Head an d Neck Surger y Un iversit y of Ch ieti Ch ieti, Italy Director Gruppo Otologico Piacen za an d Rom e, Italy Alessan d Ru sso, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy An ton io Car u so, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Abd elkad er Taibah , MD Neurosurgeon , Otologist , an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Gian lu ca Piras, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Wit h t h e collaborat ion of Fern an Man cin i, Hirosh i Sun ose, En rico Piccirillo, Loren zo Lauda, An n alisa Gian n uzzi, Sam path Ch an dra Prasad Rao 1007 illust ration s Th iem e Stuttgart • New York • Delh i • Rio de Jan eiro Librar y of Con gress Cat alogin g-in -Pu blicat ion Dat a is available from th e publish er 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th at it is in th e public dom ain © 2017 by Georg Th iem e Verlag KG Th iem e Publish ers Stuttgart Rüdigerstrasse 14, 70469 Stut tgart, Germ any +49 [0]711 8931 421, custom erservice@th iem e.de Th iem e Publish ers New York 333 Seven th Aven ue, New York, NY 10001 USA +1 800 782 3488, custom erservice@th iem e.com 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 Edifớcio Rodolph o de Paoli, 25 an dar Av Nilo Peỗan h a, 50 Sala 2508 Rio de Jan eiro 20020-906 Brasil Tel: +55 21 3172-2297 / +55 21 3172-1896 Cover design : Th iem e Publish ing Group Typesettin g by DiTech Process Solution s, In dia Prin ted in In dia by Replika Press Pvt Ltd ISBN 978-3-13-241523-2 Also available as an e-book: eISBN 978-3-13-241524-9 54321 Th is book, in cludin g all parts th ereof, is legally protected by copyrigh t Any use, exploitation , or com m ercialization outside th e n arrow lim its set by copyrigh t legislation w ith out th e publish er’s consen t is illegal an d liable to prosecution Th is applies in particular to ph otostat reproduct ion , 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 processing an d storage Cont ent s Preface vii Cont ribut ors viii Met hods of Ot oscopy The Norm al Tym panic Mem brane 2.1 Anat om y 2.2 Hist ology 11 Diseases A ect ing t he Ext ernal Audit ory Canal 13 3.1 Exost osis and Ost eom as 14 3.1.1 Surger y for Exostosis an d Osteom a: Can alplast y 21 3.2 Ext ernal Audit ory Canal Inflam m at ory Diseases 25 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 Eczem a Otitis Extern a Forun colosis Otom ycosis Myringit is an d Meatal Sten osis Surger y for Postin flam m ator y Sten osis of th e Extern al Auditory Can al 25 25 27 27 29 33 2.3 Physiology 11 3.4 Pat hologies Ext ending t o t he Ext ernal Audit ory Canal 40 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.4.6 Carcin oid Tum ors Histiocytosis X Men ingiom as Facial Nerve Tum ors Low er Cran ial Nerves Schw an n om a Oth er Path ologies 3.5 Tem poral Bone Fract ures 49 3.6 Carcinom a of t he Ext ernal Audit ory Canal 50 40 41 42 44 46 47 3.3 Cholest eat om a of t he Ext ernal Audit ory Canal 37 Ot it is Media 65 4.1 Secret ory Ot it is Media (Ot it is Media w it h E usion) 66 4.2 Secretory Otitis Media Secondary t o Neoplasm 69 Cholest erol Granulom a 75 At elect asis, Adhesive Ot it is Media 81 Noncholest eat om at ous Chronic Ot it is Media 93 7.1 General Charact erist ics of Tym panic Mem brane Perforat ions 94 7.7 Perforat ions Com plicat ed or Associat ed w it h Ot her Pat hologies 104 7.2 Post erior Perforat ions 94 7.8 Tym panosclerosis 107 7.8.1 7.8.2 Tym pan osclerosis Associated w ith Tym pan ic Mem bran e Perforation 107 Tym pan osclerosis w ith Intact Tym panic Mem brane 110 7.9 Principles of Myringoplast y 112 7.3 Ant erior Perforat ions 97 4.3 Acut e Ot it is Media 74 7.4 Inferior Perforat ions 99 7.5 Subt ot al and Tot al Perforat ions 100 7.6 Post t raum at ic Perforat ions 102 Chronic Suppurat ive Ot it is Media w it h Cholest eat om a 117 8.1 Epit ym panic Ret ract ion Pocket 118 8.2 Epit ym panic Cholest eat om a 120 v Contents 8.3 Mesot ym panic Cholest eat om a 129 8.6 Surgical Treat m ent of Cholest eat om a: Individualized Technique 139 8.4 Cholest eat om a Associat ed w it h At elect asis 134 8.6.1 8.6.2 8.6.3 Can al Wall Up (Closed) Tym pan oplast y 139 Can al Wall Dow n (Closed) Tym pan oplast y 145 Modified Bon dy’s Techn ique 153 8.5 Cholest e at om a Associat ed w it h Com plicat ions 136 Congenit al Cholest eat om a of t he Middle Ear 159 10 Pet rous Bone Cholest eat om a 167 10.1 Surgical Managem ent 184 10.1.2 Problem s in Surger y 193 10.1.1 Th e Tran sotic an d Modified Tran scoch lear Approaches 184 11 Tem poral Bone Paragangliom as 195 11.1 Clinical Present at ion of Tym panic and Tym panom ast oid Paragangliom as 197 11.5.1 Surgical Man agem en t 208 Clinical Present at ion of Tym panojugular Paragangliom as 197 11.6.1 Surgical Man agem en t 218 11.2 11.3 Im aging Charact erist ics 197 11.6 11.7 Class B: Tym panom ast oid Paragangliom as 213 Class C: Tym panojugular Paragangliom as 221 11.7.1 Surgical Man agem en t 236 11.3.1 Tym pan ojugular Paragan gliom as 197 11.8 11.4 Classificat ion: The Modified Fisch Classificat ion Syst em for TJP 198 11.8.1 Surgical Techn ique 237 11.5 Class A: Tym panic Paragangliom as 205 12 Rare Ret rot ym panic Masses 241 12.1 Di erent ial Diagnosis of Ret rot ym panic Masses 242 12.2 12.3 Type A Infrat em poral Fossa Approach 237 12.5 Facial Nerve Tum ors 250 12.6 Aberrant Carot id Art ery 260 12.7 Int ernal Carot id Art ery Aneurysm 261 12.8 High Jugular Bulb 262 Meningiom a 242 Low er Cranial Nerves Neurinom a 247 12.4 Chondrosarcom a of t he Jugular Foram en 249 13 Meningoencephalic Herniat ion 267 13.1 Surgical Managem ent 276 13.1.1 Tran sm astoid Approach 276 13.1.2 Tran sm astoid Approach w ith Min icran iotom y 278 13.1.3 Subtotal Petrosectom y 279 14 Post surgical Condit ions 285 14.1 Myringot om y and Insert ion of Vent ilat ion Tube 286 14.2 St apes Surgery 290 14.3 Myringoplast y 293 14.3.1 Failures an d Com plication s 297 14.4 Tym panoplast y 301 14.4.1 Can al Wall Up (Closed) Tym pan oplast y 301 14.4.2 Can al Wall Dow n (Open ) Tym pan oplast y 316 14.4.3 Meatoplast y, Blin d-Sac Closure of th e Extern al Auditory Can al 327 14.5 Hearing Im plant s 329 References 331 Index 337 vi Preface Despite advan ces in diagn ostic tech n iques an d im aging m odalit ies, otoscopy rem ain s th e corn erston e in th e diagn osis of otologic diseases Ever y otolar yngologist, pediatrician , or even gen eral practition er dealin g w ith ear diseases sh ould h ave a good kn ow ledge of otoscopy Th is atlas is based on 30 years of experien ce in Gruppo Otologico in th e t reatm en t of otologic an d n eurotologic disorders, w ith m ore th an 32,000 surgical operation s an d 300,000 sultation s It presen ts a vast collect ion of otoscopic view s of a variety of lesion s th at can affect th e ear an d tem poral bon e Many exam ples are given for each disease so th at th e reader becom es acquain ted w ith th e variable presen tation s each path ology can h ave W h ile otoscopy alon e can establish th e diagn osis in som e cases, param eters such as h istory or audiological an d n euroradiological evaluation are required in oth ers An im portan t aspect of th is atlas is th at it ju xtaposes, w h en appropriate, th e clin ical picture, radiological diagn osis, an d in t raoperative n din gs w ith th e otoscopic n din gs of th e patien t Needless to say, ever y patien t sh ould be sidered as a w h ole, an d in som e particular cases, th e otoscopic n din gs m igh t on ly be th e “tip of th e iceberg.” Otalgia, otorrh ea, an d gran ulation s in th e extern al auditory can al are m an ifestation s of otit is extern a, but w h en th ey persist, particularly in th e elderly, th ey sh ould arouse suspicion of m align an cy Ot itis m edia w ith effu sion can be a sim ple disease w h en seen in ch ildren , w h ereas un ilateral persisten t otitis m edia w ith effusion in an adult m ay be th e on ly sign of a n asoph ar yn geal carcin om a A sm all att ic perforation in th e presen ce of facial n er ve paralysis an d sen sorin eural h earin g loss m ay be all th at is seen in a gian t petrous bon e ch olesteatom a Th e m an ifestation of an aural polyp can var y from a m ucosal polyp associated w ith ch ron ic suppurative otitis m edia to th e m uch less com m on but m ore dan gerous tem poral bon e paragangliom a A sm all retrot ym pan ic m ass m ay represen t an an om alous an atom y such as a h igh jugular bulb or an aberran t carotid arter y It m ay also represen t fran k path ology such as facial n er ve n eurom a, gen ital ch olesteatom a, or even en -plaque m en in giom a In each ch apter, a surgical sum m ar y th at lists th e differen t approaches for th e m an agem en t of th e path ology dealt w ith is provided Th rough out th e book, em ph asis is on h ow th e otoscopic view an d th e clin ical pict ure m ay affect th e ch oice of treatm en t an d th e surgical tech n ique At th e en d of th is atlas, a ch apter on postsurgical dition s is presen ted Th e presen ce of previous surger y poses special dif culties because of th e distorted an atom y Moreover, th e otologist sh ould be able to distin guish bet w een w h at is sidered to be n orm al postsurgical h ealin g an d com plicat ion s th at n eed furth er in ter ven t ion Our goal is to offer an easy-to-con sult book for residen ts, specialists, an d gen eral pract ition ers So, th is rst-step approach to patien ts w ith otologic diseases can open a w ider view on com plete kn ow ledge of otology, n eurotology, skull base path ology an d surger y, an d n euroradiology Drs Russo, Taibah , Caruso, an d Gian luca Piras, a n ew young colleague w h o h as been w orkin g w ith us for th e past year, h elped to accom plish th is w ork w ith th eir act ive an d en th usiastic participation A special th an k goes to th e oth er m em bers of Gruppo Otologico, for th eir tribut ion in th e realization of th is book: Drs Piccirillo, Lauda, Gian n uzzi, an d Prasad Th e auth ors w ould like to th an k Mr Steph an Kon n r y at Th iem e Publish ers for h is excellen t cooperat ion an d h elp Th an ks also go to Paolo Piazza, n euroradiologist , for h is t in uous cooperat ion an d to Fern an Man cin i for th e illustration s in cluded in th e book Ma r io Sa nna , MD vii Cont ribut ors An t on io Car u so, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Sam p at h Ch an d Prasad Rao, MS, DNB, FEB-ORLHNS ENT an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy An n alisa Gian n u zzi, MD, Ph D Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Alessan d Ru sso, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Loren zo Lau d a, MD ENT an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Mar io San n a, MD Professor of Otolaryn gology Depart m en t of Head an d Neck Surgery Un iversit y of Ch ieti Ch ieti, Italy Director Gruppo Otologico Piacen za an d Rom e, Italy Fer n an d o Man cin i, MD ENT an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy viii En r ico Piccir illo, MD ENT an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Hirosh i Su n ose Depart m en t of Otolaryn gology Medical Cen ter East Tokyo Wom en’s Medical Un iversit y Tokyo, Japan Gian lu ca Piras, MD Otologist an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Abd elkad er Taibah , MD Neurosurgeon , Otologist , an d Skull Base Surgeon Gruppo Otologico Piacen za an d Rom e, Italy Postsurgical Conditions 326 Fig 14.150 Left ear TORP in extrusion following a second- stage open t ym panoplast y In the first stage, a cholesteatoma involving the attic and mesot ympanum and causing erosion of the ossicular chain was removed In the second stage, a TORP was used for reconstruction It was placed bet ween the footplate of the stapes and the t ympanic membrane One year postoperatively, early extrusion of the prosthesis is observed To avoid this complication, a tragal cartilage has to be placed between the prosthesis and the t ympanic membrane Fig 14.151 Right ear In this case of a modified Bondy’s technique, incus erosion occurred years postoperatively due to the presence of a significant retraction pocket The middle ear shows a catarrhal effusion Fig 14.152 Right ear A modified Bondy’s technique Two cholesteatomatous pearls are present in the cavit y They are easily removed in the outpatient clinic The at tic, antrum, and mastoid were exteriorized The ossicular chain was left in situ Fig 14.153 Left ear A cholesteatom atous pearl seen in the attic following a modified Bondy’s technique Postsurgical Conditions Fig 14.154 Sam e patient after removal of the pearl in the outpatient clinic Fig 14.155 Radical mastoidectomy A mucosal cyst causes complete obstruction of the external auditory canal 14.4.3 Meat oplast y, Blind-Sac Closure of t he Ext ernal Audit ory Canal Exam ples of m eatoplast y h ave been sh ow n in Fig 14.156, Fig 14.157, Fig 14.158, Fig 14.159, Fig 14.160 See extern al auditor y can al closure in Fig 14.161, Fig 14.162, Fig 14.163 Fig 14.156 The performance of an adequate meatoplast y that suits the dimension of the cavit y is fundamental to assure proper aeration and prevent accumulation of epithelial debris and cerumen in the cavit y 327 Postsurgical Conditions Fig 14.158 A well-performed large meatoplast y in an open t ympanoplasty, providing perfect aeration of the cavit y Fig 14.157 Another example of meatoplast y performed in an open t ym panoplast y Fig 14.159 Another example of a meatoplast y performed in a 10year-old boy who underwent surgery for bilateral epit ym panic cholesteatoma using a m odified Bondy’s technique 328 Fig 14.160 Example of a meatoplast y that shows stenosis Postsurgical Conditions Fig 14.161 Surgical picture of a blind-sac closure of the external auditory canal The skin is everted and sutured with absorbable stitches After some months, the closed wound tends to retract inside the external auditory canal with no aesthetic issues (see Fig 14.162) Fig 14.162 Image of the same patient months after surgery The wound is com pletely closed and the skin infolded inside the external auditory canal Fig 14.163 CT scan, axial view, of the surgical cavit y (obliterated with abdominal fat) The external auditory canal is blind-sac closed (arrow) 14.5 Hearing Im plant s Hearin g im plan tology is a set of surgical tech n iques aided by devices aim ed at th e fun ction al reh abilitation of a patien t a ected by total or partial deafn ess Hearin g im plan ts are n ot a replacem en t for an ear, but th ey can h elp m any people w h o w ere e ectively declared deaf By st im ulating th e auditory n er ve, sign als are tran sm it ted to th e brain , w h ich turn s in to “h earin g.” Im plants are key for m any ch ildren or in fan ts born w ith severe h earin g loss w h o receive th e devices so th at th ey can grow up w ith auditor y skills an d h ave st ron ger lan guage skills A cochlear im plant (CI) is a surgically im planted electronic device that provides a sense of sound to a person w ho is profoundly deaf or severely hard of hearing CI m ay help provide hearing in patients w ho are deaf because of dam age to sensory hair cells in their cochleas In those patients, the im plants often can enable su cient hearing for better understanding of speech Newer devices and processing strategies allow recipients to hear better in noise, enjoy m usic, and even use their im plant processors w hile sw im m ing An auditory brainstem im plant (ABI) is a surgically im planted electronic device that provides a sen se of sound to a person w h o is profoundly deaf due to sen sorin eural h earing im pairm en t (due to illn ess or injury dam aging the coch lea or auditory nerve, and so precluding the use of a CI) The ABI uses sim ilar tech nology as the CI, but in stead of electrical stim ulation being used to stim ulate the coch lea, it is used to stim ulate the brain stem of the recipien t Active m iddle ear im plants (Esteem Im plantable Hearing System , Vibrant Soundbridge Middle Ear Im plant System , Carina Implantable Hearing System ) are surgically im planted hearing aids, w hich are placed w ithin the m iddle ear, and are suggested as a therapy for certain patients w ith conductive, sensorineural, or m ixed hearing loss for w hom alternative treatm ents (e.g., conventional hearing aids, bone anchored hearing aids) are unsuitable Active m iddle ear im plants can be fully im plantable or sem i-im plantable and work via electrom agnetic or piezoelectric transducers A bon e-anch ored h earing im plant (BAHI) is a type of h earing aid based on bon e conduction It is prim arily suited to people w h o h ave conductive hearing losses, unilateral h earing loss, and m ixed h earing losses w h o can not otherw ise wear “in the ear” or “beh in d the ear” hearing aids A patien t w ithout extern al/m iddle 329 Postsurgical Conditions ear function is one exam ple w here a BAHI could be useful w here a conventional h earing aid w ith a m old in the ear canal open ing is n ot possible to use As the inn er ear is n orm al, sound conducted via th e skull bon e could give n orm al/n ear-norm al hearing 330 Exam ples of h earin g im plan tology h ave been sh ow n in Fig 14.164, Fig 14.165, Fig 14.166, Fig 14.167 Fig 14.164 Left ear Extrusion of a Vibrant Soundbridge Part of the Floating Mass Transducer (FMT) is outside the t ympanic membrane (arrow) Fig 14.165 Another example of extrusion of a Vibrant Soundbridge, placed at the same stage of a radical m astoidectomy for a recurrent cholesteatoma The cavit y is discharging and the conductor link with the FMT is extruded Hearing rehabilitation with implantable devices has been introduced since more than 50 years with cochlear im plants In case of discharging cavities or cholesteatoma, we prefer to stage the procedures and perform a subtotal petrosectomy, to be radical in disease clearance and avoid extrusion of the implant Fig 14.166 Right ear Otoscopy after cochlear implantation The electrode of the implant is inserted in the round window through a posterior tympanotomy, after having performed a closed mastoidectomy Fig 14.167 Left ear Extrusion of a cochlear implant The receiverstimulator is in contact with the skin of the posterior canal wall References References References Am en d ola S, Falcion i M, Caylan R, San n a M Recurren t ch olesteatom a in open vs closed tech nique t ym pan oplasties an d its surgical m an agem en t Proceedin gs of th e Fifth In 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Am J Otol 1986; 7(4):289–293 Zölln er F Tym pan oplast y In : Coates G, Sch en ck HP, Miller MV, eds Otolar yn gology Vol Hagerstow n : Prior; 1959 335 Index Note: Page n um bers set bold or ita lic in dicate h eadin gs or figures, respectively – as surgical com plication 297, 301 ––– tran sotic approach in 184, 185– – com plication s w ith 136, 136, 137– 138 – congen ital 118, 162–166 186 – retraction pocket vs 118 – surgical t reatm en t of 139, 141–145, Eczem a, of extern al auditor y can al 25, 25 En doscope 3, 3–4 A –– classification of 160, 160–161 –– defin ed 160 – t ym pan oplast y in Exostosis 16–20 Aberran t carotid arter y 260, 260 –– h earin g loss in 160, 162–163 –– closed – defin ed 14 ABI, see Auditor y brain stem im plan t –– petrous bon e ch olesteatom a ––– w all dow n 145, 147–152 – osteom a vs 14 ––– w all up 118, 139, 141–145 – surger y for 21, 21, 22–24 (ABI) an d 160 147–152, 154–156, 157, 157 E Adh esive otitis m edia 82, 82, 83–92 –– progression of 160 –– epit ym pan ic 124, 127, 136 Extern al aud itory can al Am pulla, in pet rous bon e ch olesteato- – cystic retrot ym pan ic 128 –– m esotym pan ic 130–131 – carcin oid tum ors in 40, 40, 41 – defin ed 118 – w ith atelectasis 134, 134, 135 – carcin om a of 50, 51–52, 52–63 – dr y 126 Ch olesterol gran ulom a 76, 76, 77–80 – ch olesteatom a of 37, 38–40 – h earin g loss in 132 Ch on drosarcom a of jugular fora- – clean in g of 2, m a 183 An eur ysm , in tern al carotid artery 261, 261, 262 An giography, of t ym pan ojugular paragan gliom a 198, 202 – in ch ron ic supp urative otit is m edia 120, 121–129 m en 249, 249, 250 Ch orda t ym pan i – eczem a of 25, 25 – exostosis an d osteom as in 14, 14, 16–24 An n ulus 8–9 – in m yrin goplast y 301 Ch ron ic otitis m edia An terior t ym pan ic arter y – in tem poral bon e fracture 49 – m astoidectom y in 122 – facial n er ve t um ors in 44, 45 Atelectasis 82, 82–84, 86–90, 92 – in t ym pan oplast y 302, 310–312 – m yrin goplast y in 88, 112, 112, 113– – fibrous dysplasia in 49 – ch olesteatom a w ith 134, 134, 135 – m esotym pan ic 129, 129, 130–133 Auditor y brain stem im plan t (ABI) 329 – m odified Bon dy’s tech n ique for 124, Aural speculi 153, 154–156, 157, 157 115 – t ym pan ic m em bran e perforation 95– 96, 104–105 – forun colosis in 27, 104 – h ist iocytosis X in 41, 41 – in flam m ator y diseases of 25, 25, 26– 37 – of extern al auditor y can al 37, 38–40 –– an terior 97, 97, 98–99 B – petrous bon e 118 –– ch aracterist ics of 94 –– am pulla in 183 –– h ealin g of 94, 97–98 BAHI, see Bon e-an ch ored h earin g im - –– apical 169 –– h earin g loss in 94, 104 – m en in giom as in 42, 42, 43–44 plan t (BAHI) –– brain stem com pression in 181 –– in gran ulom atous otit is m edia 106 – m yrin gitis in 29, 29, 30–33 Billeau ear loop –– cerebrospin al fluid leak in 194 –– in otorrh ea 104–105 – n eurofibrom a in 48 Bon dy’s tech n ique 124, 153, 154–156, –– classification of 168–170 –– in t ym pan osclerosis 105–107, 107, – n eurom a in 47 157, 157, 321, 321, 322–323 Bon e-an ch ored h earin g im plan t (BAHI) 329 Brow n’s sign 197 C Can al w all dow n t ym pan oplast y 145, 147–152 Can al w all up t ym pan oplast y 139, 141–145 – See a lso Tym pan oplast y –– clivus 170, 180–181, 188 –– coch lear involvem en t in 173, 175– 176, 186, 188, 190, 193 108–109 – low er cran ial n er ve sch w an n om a in 46, 46, 47 – otit is extern a in 25, 26–27 –– in ferior 99, 99, 100 – otom ycosis in 27, 27, 28 –– posterior 94, 95–97 – path ologies exten din g to 40, 40, 41– 49 –– defin ed 168 –– post raum atic 102, 102, 103–104 –– facial n er ve in 174, 176, 184, 187, –– subtotal 101–102 – pleom orph ic aden om a in 48 –– total 101–102, 104 – post in flam m ator y sten osis surger y 189, 192, 193, 193 in 33, 34–37 –– h earin g loss in 174 – t ym pan osclerosis in 105–106, 107 –– h earin g preservation w ith 193 –– h earin g loss in 111 – sten osis gradin g 14 –– in cerebellopon tin e an gle 182 –– path ogenesis of 107 – tem poral bon e fracture in 49, 50 –– in congen ital ch olesteatom a 160 –– t ym pan ic m em bran e perforat ion –– in in tern al auditor y can al 174, 180, 186 in 105–107, 107, 108–109 –– w ith in tact t ym pan ic m em - F Facial n er ve Can alplast y –– in otoscopy 168 – for exostosis an d osteom a 17, 20–21, –– in fralabyrin th in e 169, 174–175 – w ith skin in m iddle ear 104–105 – in an atom y –– in fralabyrin th in e–apical 169 Ch ron ic suppurative otit is m edia, see – in can alplast y 21 21, 22–24 – for m yrin gitis 29, 31 – for tem poral bon e paraganglio- –– in tern al carotid artery in 188–189, 194 bran e 110, 110, 111–112 Ch olesteatom a – ch olesteatom a in 120, 121–129 – in petrous bon e ch olesteatom a 174, 176, 184, 187, 189, 192, 193, 193 –– in t radural 170, 185 –– m esotym pan ic 129, 129, 130–133 – in t ym pan oplast y 140, 146 – in m od ified Bon dy’s tech n ique 153 –– jugular bulb in 194 – retraction pocket in 119–120 – t um ors 44, 45, 250, 250, 251–260, – in t ym pan oplast y 147 –– labyrin th ectom y in 179 CI, see Coch lear im plan t (CI) Carcin oid tum ors 40, 40, 41 –– lateral sem icircular can al in 177, Clean in g, of extern al auditor y can al 2, m a 210 Carcin om a, of extern al aud itory can al 50, 51–52, 52–63 180 –– m assive 169, 179, 189 Carotid artery, aberran t 260, 260 –– m astoidectom y in 178 Carotid body t um ors 196 –– m edial extension of 172 Cerebellopon t in e an gle petrous bon e –– m odiolus in 187 ch olesteatom a 182 Clivus, petrous bon e ch olesteatom a in 170, 180–181, 188 Coch lea, in petrous bon e ch olesteato- 266 Fibrous dysplasia, in extern al aud itory can al 49 Fisch classification 198 Forun colosis 27, 104 Fracture, tem poral bon e 49, 50, 271 m a 173, 175–176, 186, 188, 190, 193 G –– n asoph ar yn x 170 Coch lear im plan t (CI) 329, 330 Cerebellopon t in e an gle tum ors 42 –– pon s involvem en t in 182 Coch leariform process Cerebrospin al fluid leak –– recurren t 178, 194 Con gen ital ch olesteatom a 118, 162– – in low er cran ial n er ve n eurin om a 72 –– residual 183 – in m en in goen ceph alic h ern ia- –– sigm oid sin us in 194 – classification of 160, 160–161 –– sph en oid sin us 170, 181–182 – defin ed 160 –– superior sem icircular can al in 177 – h earin g loss in 160, 162–163 –– supralabyrn th in e 169, 172–174, – petrous bon e ch olesteatom a an d 160 Han d-Sh ü ller- Ch ristian disease 41 – progression of 160 Hartm an auricular forceps t ion 268 – in petrous bon e ch olesteatom a 184, 194 – in tem poral bon e fracture 49 – in t ym pan ojugular paragangliom a 237, 240 Ch olesteatom a – acquired 118 176–177, 184, 191–192 –– surgical m an agem en t of 184, 185– 193 ––– m odified tran scoch lear approach in 184, 185 166 Gran u lom atous otitis m edia, t ym pan ic m em bran e perforation in 106 H Hearin g im plan ts 329, 330 Hearin g loss – in congen ital ch olesteatom a 160, 162–163 337 Index – in m astoidectom y 127 – in ch olesteatom a 122, 135, 139, 147 – in m esotym pan ic ch olesteatom a 132 – in ch ron ic supp urative otit is m e- – in otit is m edia 66, 83–84 – in closed t ym pan oplast y 140 – in t ym pan ic m em bran e perfora- – in lateral tem poral bon e resect ion 51 – in t ym pan osclerosis 111 – in m en in goen ceph alic h ern iation 268 Otorrh ea, t ym pan ic m em bran e perfora- Nasop h ar yn x, petrous bon e ch olesteatom a in 170 Necrotizing extern al otitis 25, 26 – See a lso Ch olesterol gran ulom a – in petrous bon e ch olesteatom a 178 Neurin om a, low er cran ial n er ve 247, High jugular bulb 262, 262, 263–265 – in tran sotic approach to petrous bon e Histology, of t ym pan ic m em bran e 11 – in t ym pan om astoid paragan glio- I Im plan ts, h earin g 329, 330 – postsurgical dition s in 320, 320, Notch of Rivin us Pars flaccida perforation 94 – petrous bon e ch olesteatom a in 174, Pars flaccida retract ion 82 321 In flam m ator y diseases, of extern al – m en in giom as in 42 agangliom a (TBP) Pars flaccida 8, 8–10 Meatoplasty In tern al auditor y can al Paragan gliom a, see Tem poral bon e par- – See a lso Sch w an n om a In cus, in an atom y A 237, 237 n al 48 P – in t ym pan oplast y 147 Meatal sten osis 29, 29, 30–33 In fratem poral fossa approach , t ype Neurofibrom a, in extern al auditor y ca- Oval w in dow Parot idectom y 51–52, 54, 59, 61–62, 64 In cudostapedial join t 9–10, 149 auditor y can al 25, 25, 26–37 247, 248 tion in 104–105 Neurom a, in extern al auditor y can al 47 m a 219 O Pars ten sa – in m od ified Bon dy’s tech n ique 153 Ossiculoplast y PBC, see Petrous bon e ch olesteatom a – in t ym pan oplast y 152 – displaced in cus in 307 – postsurgical dition s in 327, 327, – in adh esive otitis m edia 92 Petrosectom y, in ch olesteatom a 137 – in atelectasis 83, 85 Petrous bon e ch olesteatom a (PBC) 118 – in ch olesteatom a 125 – am pulla in 183 – in ch ron ic supp urative otit is m e- – apical 169 328–329 Men in giom as 42, 42, 43–44, 242, 242, 243–247, 265 Men in goen ceph alic h ern iation Pars ten sa perforation 94, 136 dia 125 (PBC) – brain stem com pression in 181 – defin ed 268 – in m yrin goplast y 113, 125 – cerebrospin al fluid leak in 194 In tern al carotid artery – etiology of 268 – in t ym pan ic m em bran e perfora- – classification of 168–170 – in petrous bon e ch olesteatom a 188– – im aging of 268, 269–276 180, 186 189, 194 – in t ym pan ojugular paragangliom a 236 In tern al carotid arter y an eur ysm 261, 261, 262 – m iddle fossa approach in 268, 269– 270, 283 – h igh 262, 262, 263–265 – in petrous bon e ch olesteatom a 194 Jugular foram en ch on drosarcom a 249, 249, 250 Jugular foram en sch w an n om a 46, 46 – in t ym pan osclerosis 97, 111–112 – coch lear involvem en t in 173, 175– 176, 186, 188, 190, 193 – defin ed 168 – subtotal petrosectom y in 137, 268, Osteom a 18–19 – facial n er ve in 174, 176, 184, 187, 275, 279, 279, 280–282, 283 – tran sm astoid approach in 276, 276, Jugular bulb – in t ym pan oplast y 303 – clivus 170, 180–181, 188 – retraction after 306 277–282, 283 J t ion 97, 99 – post traum atic 271 – surgical m an agem en t of 276, 276, 277, 283 –– w ith m in icran iotom y 278, 278, 279, 283 Mesot ym pan ic ch olesteatom a 129, 129, 130–133 – exostosis vs 14 189, 192, 193, 193 – surger y for 21, 21, 22–24 – h earin g loss in 174 Otit is extern a 25, 26–27 – h earin g preser vation w ith 193 Otit is m edia – in cerebellopon t in e an gle 182 – acute 66, 74, 74 – in congen ital ch olesteatom a 160 – adh esive 82, 82, 83–92 – in in tern al auditor y can al 174, 180, – ch ron ic –– m yrin goplast y in 88, 112, 112, 113– 115 186 – in otoscopy 168 – in fralabyrin th in e 169, 174–175 Microscope –– t ym pan ic m em bran e perforat ion – in fralabyrin th in e–apical 169 Middle ear im plan ts 329 ––– an terior 97, 97, 98–99 – in tern al carotid artery in 188–189, K Middle fossa app roach 268, 269–270, ––– ch aracterist ics of 94 Keratosis obturan s 37 Modified Bon dy’s tech nique 124, 153, 283 154–156, 157, 157, 321, 321, 322–323 194 ––– h ealin g of 94, 97–98 – in t radural 170, 185 ––– h earin g loss in 94, 104 – jugular bulb in 194 ––– in gran ulom atous otit is m edia 106 – labyrin th ectom y in 179 L Modified Fisch classification 198 ––– in otorrh ea 104–105 – lateral sem icircular can al in 177, 180 Modified Pit tsburgh staging 51 ––– in t ym pan osclerosis 105–107, 107, – m assive 169, 179, 189 Labyrin th ectom y Modiolus, in petrous bon e ch olesteato- – in petrous bon e ch olesteatom a 179 108–109 – m astoidectom y in 178 ––– in ferior 99, 99, 100 – m edial extension of 172 Myrin gitis 29, 29, 30–33, 299 ––– posterior 94, 95–97 – m odiolus in 187 Myrin goplasty ––– post raum atic 102, 102, 103–104 – n asoph ar yn x 170 – an n ulus in 112–113, 114 ––– subtotal 101–102 – pon s involvem en t in 182 – ch olesteatom a after 301 ––– total 101–102, 104 – recurren t 178, 194 Lateralization 298–299 – com plication s in 297, 297, 298–301 –– t ym pan ic m em bran e perforat ion – residual 183 Let ter-Siw e disease 41 – failures in 297, 297, 298–301 Low er cran ial n erve n eurin om a 247, – in ch ron ic otitis m edia 88, 112, 112, – in tran sotic approach to petrous bon e ch olesteatom a 185 Lateral tem poral bon e resect ion (LTBR) 51 247, 248 Low er cran ial n erve sch w an n om a 46, 46, 47 LTBR, see Lateral tem poral bon e resection (LTBR) m a 187 M Malign an t otit is extern a 25, 26 in 95–96, 104–105 – sigm oid sin us in 194 –– t ym pan osclerosis an d 105–106, 107 – sph en oid sin us 170, 181–182 –– t ym pan osclerosis in – superior sem icircular can al in 177 – in exostoses 20, 31 ––– h earin g loss in 111 – supralabyrn th in e 169, 172–174, – in m yrin gitis 31 ––– path ogenesis of 107 – in otorrh ea 104 ––– t ym pan ic m em bran e perforat ion 113–115 – in t ym pan ic m em bran e perforation 95–100, 103, 104, 104 338 Otom ycosis 27, 27, 28 N – in m od ified Bon dy’s tech n ique 153 ch olesteatom a 185 73 – ven t ilation tube for 66 Hem osiderin 76 Hist iocytosis X 41, 41 –– secon dar y to n eoplasm 69, 69, 70– w ith 286 dia 122, 127, 135 – in petrous bon e ch olesteatom a 174 tion 94, 97–98, 104 Myrin gotom y, postsurgical dition s – in t ym pan osclerosis 96, 99–100, 112 – postsurgical dition s w ith 293, 294–297, 299, 301 in 105–107, 107, 108–109 ––– w ith in tact t ym pan ic m em bran e 110, 110, 111–112 176–177, 184, 191–192 – surgical m an agem en t of 184, 185– 193 –– m odified tran scoch lear approach in 184, 185 –– w ith skin in m iddle ear 104–105 –– tran sot ic approach in 184, 185–186 – gran ulom atous, t ym pan ic m em bran e Ph otography 3, Malleus, an atom y 8–10 – prin ciples of 112, 112, 113–115 Mastoidectom y – skin curettage in 106 – h earin g loss in 66, 83–84 – h earin g loss in 127 – sten osis after 300–301 – secretor y 66, 66, 67–73, 90 perforation in 106 Pleom orph ic aden om a, in extern al auditor y can al 48 Index Pon s, in petrous bon e ch olesteatom a 182 Post in flam m ator y sten osis surger y 33, 34–37 Postoperat ive ch olesteatom a 37 – in petrous bon e ch olesteatom a 184 Subtotal tem poral bon e resect ion (STBR) 51, 61–62 Superficial parot idectom y 51, 54, 64 Supratubaric recess 10 – See a lso Ch olesteatom a Postoperat ive m yrin gitis 299 Postsurgical dition s – in h earin g im plan ts 329, 330 – in m astoidectom y 320, 320, 321 – in m eatoplast y 327, 327, 328–329 – in m od ified Bon dy’s tech n ique 321, 321, 322–323 – in m yrin goplast y 293, 294–297 – jugular foram en ch on drosarcom a 249, 249, 250 – low er cran ial n er ve n eurin om a 247, 247, 248 – m en in giom as 42, 42, 43–44, 242, 242, 243–247, 265 Tym pan ojugular paragan gliom as (TJPs) 196 – See a lso Tem poral bon e paragangliom a (TBP) – classification of 198, 199–204 – clin ical presen tation of 197 T – n eurofibrom a 48 – im aging of 197, 221, 221, 222–236 – n eurom a 47 – in an giography 198, 202 TBP, see Tem poral bon e paragangliom a – otit is m edia secon dary to 69, 69, 70– – in com puted tom ography 197, 201 (TBP) Tem poral bon e carcin om a 50, 51–52, 52–63 Tem poral bon e ch olesterol gran u lom a 76, 76, 77–80 73 – pleom orph ic aden om a 48 – in m agn etic reson an ce im aging 198, 203 – sch w an n om a – in tern al carotid ar tery in 236 –– as cerebellopon t in e an gle tum or 42 – low er cran ial n er ves in 236 –– as facial n er ve t um or 44 – surgical m an agem en t of 236 Tym pan om astoid paragangliom a, see – in m yrin gotom y 286, 299–300 Tem poral bon e fract ure 49, 50, 271 –– of low er cran ial n er ves 46, 46, 47 – in stapes surger y 290, 290, 291–293 Tem poral bon e paragan gliom a (TBP) – tem poral bon e paragangliom a – in t ym pan oplast y 301, 302–308, – carotid body 196 –– carotid body 196 – clin ical presen tation of 197 – classification of 198, 199–204 –– classification of 198, 199–204 – im aging of 213, 214–218 – clin ical presen tation of 197 –– clin ical presen tation of 197 – surgical m an agem en t of 218, 218, – defin ed 196 –– defin ed 196 – m yrin gitis as 299 – exam in ation fin din gs w ith 196 –– exam in ation fin din gs w ith 196 Tym pan oplast y Prom on tor y 8, 10 – gen etics of 196 –– gen etics of 196 – ch olesteatom a after 302, 310–312 Pyram idal em in en ce – im aging of 197 –– im aging of 197 – closed 118 – in fratem poral fossa approach to 237, –– in fratem poral fossa approach –– can al w all dow n 145, 147–152 315–319 – in ven t ilation t ube in ser tion 286, 286, 287–290 R Retraction pocket 82–84, 88–92, 118, 119–120 237 – surgical m an agem en t of 208, 208, 209–213, 218, 218, 219–221, 236 to 237, 237 –– surgical m an agem en t of 208, 208, 209–213, 218, 218, 219–221, 236 Tem poral bon e paragan gliom a (TBP) 219–221 –– can al w all up 139, 141–145 – facial n er ve in 140, 146 – failures an d com plication s in 308, – t ym pan ic 205, 205, 206–207 –– t ym pan ic 205, 205, 206–207 – ch olesteatom a vs 118 –– im aging of 205, 205, 206–207 ––– im aging of 205, 205, 206–207 – in ch olesteatom a Retrot ym pan ic m ass(es) –– surgical m an agem en t of 208, 208, ––– surgical m an agem en t of 208, 208, –– epit ym pan ic 124, 127, 136 – aberran t carotid artery as 260, 260 209–213 209–213 309–319, 324, 324, 325–327 –– m esotym pan ic 130–131 – dition s presen tin g as 242 – t ym pan ojugular 196 –– t ym pan ojugular 196 – m eatoplast y in 152 – facial n er ve t um ors as 44, 45, 250, –– classification of 198, 199–204 ––– classification of 198, 199–204 – m en in goen ceph alic h ern iation –– clin ical presen tation of 197 ––– clin ical presen tation of 197 –– im aging of 197, 221, 221, 222–236 ––– im aging of 197, 221, 221, 222–236 –– in an giography 198, 202 ––– in an giography 198, 202 153, 154–156, 157, 157, 321, 321, –– in com puted tom ography 197, 201 ––– in com puted tom ography 197, 201 322–323 –– in m agn etic reson an ce im aging 198, ––– in m agn etic reson an ce im ag- 250, 251–260, 266 – h igh jugular bulb as 262, 262, 263– 265 – in tern al carotid artery an eur ysm as 261, 261, 262 – jugular foram en ch on drosarcom as as 249, 249, 250 – low er cran ial n er ve n eurin om as as 247, 247, 248 – m en in giom a as 242, 242, 243–247, 265 Roun d w in dow 8, 10 203 in g 198, 203 after 269, 272, 274 – m odified Bon dy’s tech n ique 124, – open 118 – postsurgical dit ion s in 301, 302– –– in tern al carotid artery in 236 ––– in tern al carotid ar tery in 236 –– low er cran ial n er ves in 236 ––– low er cran ial n er ves in 236 –– surgical m an agem en t of 236 ––– surgical m an agem en t of 236 – t ym pan om astoid –– t ym pan om astoid Tym pan osclerosis –– clin ical presen tation of 197 ––– clin ical presen tation of 197 – h earin g loss in 111 –– im aging of 213, 214–218 ––– im aging of 213, 214–218 – path ogenesis of 107 –– surgical m an agem en t of 218, 218, ––– surgical m an agem en t of 218, 218, – retract ion pocket in 119 308, 315–319 – postsurgical dit ion s w ith 301, 302–308 219–221 219–221 – vagal 196 –– vagal 196 Sadè classification 82, 82 Ten sor t ym pan i Tym pan ic m em bran e – w ith in tact t ym pan ic m em - Sch w an n om a TJP, see Tym pan ojugular paragan glio- – an atomy 8, 8, 9–10 bran e 110, 110, 111–112 S – as cerebellopon t in e an gle tum or 42 m as (TJPs) Tym pan osclerotic plaque 98, 100 Type A in fratem poral fossa ap - Total parotidectom y 52, 61–62, 64 – physiology of 11 – of low er cran ial n er ves 46, 46, 47 Total tem poral bon e resect ion Tym pan ic m em bran e perforation Sigm oid sin us, in petrous bulb ch olesteatom a 194 Sph en oid sin us, petrous bon e ch olesteatom a in 170, 181–182 Stapedius ten don Stapes 10 Stapes surgery, postsurgical dit ion s w ith 290, 290, 291–293 (TTBR) 52 – ch aracteristics of 94 ceph alic h ern iation 276, 276, 277, – h ealin g of 94, 97–98 283 – h earin g loss in 94, 104 283 Traum a, t ym pan ic m em bran e perforation in 102, 102, 103–104 proach 237, 237 – an terior 97, 97, 98–99 Tran sm astoid app roach , in m en in goen - – w ith m in icran iotom y 278, 278, 279, in 105–107, 107, 108–109 – h istology of 11 – as facial n er ve tum or 44 Sh rapn ell's m em bran e – t ym pan ic m em bran e perforat ion U Um bo 9–10 – in gran ulom atous otitis m edia 106 – in otorrh ea 104–105 – in t ym pan osclerosis 105–107, 107, 108–109 V Vagal paragan gliom a 196 – in ferior 99, 99, 100 Ven t ilation t ube – posterior 94, 95–97 – for ch olesterol gran ulom a 76 Tum ors, see Ch olesteatom a – post raum atic 102, 102, 103–104 – for otit is m ed ia 66, 91, 92 Sten osis gradin g 14 – carcin oid 40, 40, 41 – subtotal 101–102 – in atelectasis 92 Subtotal petrosectom y – carcin om a, of extern al auditor y ca- – total 101–102, 104 – postsurgical dit ion s w ith 286, STBR, see Subtotal tem poral bon e resect ion (STBR) – in m en in giom a 42–43 – in m en in goen ceph alic h ern iat ion 137, 268, 275, 279, 279, 280– 282, 283 TTBR, see Total tem poral bon e resect ion (TTBR) n al 50, 51–52, 52–63 Tym pan ic paragan gliom a – ch olesterol gran ulom a 76, 76, 77–80 – im aging of 205, 205, 206–207 – facial n er ve 44, 45, 250, 250, 251– – surgical m an agem en t of 208, 208, 260, 266 286, 287–290 Video system 209–213 339 ... Color At las of Endo-Ot oscopy Exam inat ion–Diagnosis–Treat m ent Mar io San n a, MD Professor of Otolar yngology Depart m en t of Head an d Neck Surger y Un iversit y of Ch ieti... to th e low est part of th e h an dle of th e m alleus Most of Fig 2.1 Right ear Normal t ympanic mem brane 1, pars flaccida; 2, short process of the malleus; 3, handle of the malleus; 4, umbo;... short process of the handle of the m alleus, the umbo, the cone of light, the annulus, and the pars flaccida are seen Note also the presence of early exostosis in the superior wall of the external