Abstract Otology 2000 B13-1

Muaaz Tarabichi MD

Section of Otolaryngology American Hospital Dubai UAE-Dubai

Direct line access to cholesteatoma is necessary in microscopic procedures and is usually provided through postauricular approach. In contrast, the wide-angle view of the endoscope allows transcanal access to the attic and antrum and transforms the advancing cholesteatoma sac into a mere extension of middle ear disease. This report describes transcanal endoscopic management and surveillance of cholesteatoma. 83 ears with acquired cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and completely remove the sac. After removal of disease, reconstruction with composite tragal graft were performed in the majority of patients. In patients with extensive disease, access to the attic and antrum were further enlarged and the cavities were packed open. Most patients were done under local anesthesia and on an outpatient basis. 3 cases were converted into postauricular tympanomastoidectomy. There were no iatrogenic facial nerve injuries. Bone thresholds were stable, except in one patient with perilymphatic fistula. 19 ears were followed for five years with 6 ears requiring revision surgery. Endoscopic technique allows transcanal, minimally invasive, management and surveillance of cholesteatoma with long term results that compare well to postauricular methods. Continuous postoperative office based endoscopic surveillance and procedures are critical to the success of this approach.

Abstract Otology 2000 B13-2

Yasuyuki Hinohira MD, Naoaki Yanagihara MD

Department of Otolaryngology Takanoko Hospital 525-01 Takanoko-cho J-Ehime-ken

Because of its excellent magnified view on the TV screen endoscope assissted middle ear surgery is useful particularly for cholesteatoma operation to remove the matrix in the blind area under a conventional operation microscope. This video shows our surgical technique of the cholesteatoma surgery using endocscope which enables the operation less invasive and secures safe and complete removal of the matrix keeping the bony external ear canal. We use endoscopes of 0 or 30 degrees with a diameter of 1.9 mm incorporated with a 3CCD camera. Through a retroauricular incision a guide hole is created on the mastoid cortex which allows the endoscopic view of the antrum and posterior aspect of the attic and the ossicular chain. When there is no cholesteatoma beyond the aditus, a transcanal removal of the cholesteatoma matrix in the attic is possible with the aid of endoscope. When cholesteatoma extends deep into the antrum, a mastoidectomy with a posterior hypotympanotomy is made and the incus together with the head of malleus is removed. With the endoscope all the hidden area is inspected and a sheet of silastic is placed beneath the ear drum to create an aerated middle ear cavity. After about 9 months a second stage operation is performed. The endoscopic exploration to check a residual or a recurrent disease is extremely important to prevent future recurrence.

Abstract Otology 2000 B13-3

Ch. Milewski MD

Department of ENT/HNO Julius-Maximilians-Universität D-Würzburg

In cholesteatoma surgery complete removal of the disease and preservation of anatomic structures are conflicting counterparts. Mostly it is not predictable from the otoscopic aspect of the ear, how far the cholesteatoma has grown. Mainly two approaches had been advocated for eradication. In canal up technique the intact canal wall provides better hearing results and easy postoperative care, taking a higher rate of residual cholesteatoma into purchase. On the other side canal down technique may result in a discharging cavity and incomplete closure of air-bone gap in several cases. The Attico-Antrotomy, proposed by Wullstein, followes the cholesteatoma sac from inside out. Bone is as much removed from the posterior canal wall as is needed to expose the sac, starting from the posterior upper quadrant of the eardrum. After cholesteatoma removal the wall is reconstructed with cartilage, i.e. Perichonrium/cartilage-island technique (PCI). Only in cases with extended cholesteatoma a radical cavity has to be created. The surgical technique as well as anatomical and functional results with a follow up of 10 years will be presented. The Attico-Antrotomy of Wullstein together with modern cartilage reconstruction combines the security of an open approach with the advantages of the closed technique.

Abstract Otology 2000 B13-4

Yoshio Honda MD

ENT Dept Ohta General Hospital J-Kawasaki, Kanagawa

Severe tympanic membrane lateralization occurs in association with canal-up surgery, and we recommend the method below to treat it based on the results of trying a variety of different operations. 1. Removal of the existing tympanic membrane. 2. Enlargement of the external ear canal and preservation of the tympanic annulus. 3. Opening of the attic, and mastoid lowering the facial ridge. 4. Making the remnant ossicle the stapes or foot plate alone. 5. Making a flat protuberance in the attic with bone pate and using it as the bed of the new tympanum. After carrying out the above preparations, we proceed to reconstruct themiddle ear and the external ear canal. 6. Next we use fascia to create a new tympanic membrane, and make it flat by using the tympanic annulus, the bone pate ridge, and the facial ridge. Naturally, we perform ossiculoplasty at ht same time. 7. In order to prevent relateralization of the new tympanic membrane and recurrent cholesteatoma, we create a posterior wall by standing the auricular cartilage plate on the lateral aspect of the ridge of bone pate and the lateral aspect of the facial ridge and filling the back of the auricular cartilag plate with bone pate. 8. We transplant several small free grafts in the skin defect area of the external ear canal, and ensert a tampon into the canal for three weeks. The postoperative self-cleansing activity of the external ear canal is favorable, and hearing also improves. The important parts are shown in the video.

Abstract Otology 2000 B13-5

Walter Livi MD, N. Zuccarini MD, D. Limoni MD, Desiderio Passàli MD

ENT Dept University Hospital I-Siena

Stapedotomy is considered one of the best surgical procedure to treat otosclerosis because of the lowest incidence of cochlear damage. Since 1987 the Authors (A.A.) performed this technique instead of stapedectomy. Stapedotomy can be performed using both the classic and innovative changed technique "with inversion of surgical steps". This one is to be preferred to the classic for some advantages. First of all, basing on our experience, beside an excellent improvement of hearing loss, this technique allows to discharge the patient the morning after surgery because the post-surgical vertigo is very rare. In this video the A.A. present: 1)surgical highlights of stapedotomy with inversion of surgical steps (Rosen endoaural approach; tympanomeatal flap; atticotomy; stapedotomy with Shea microdrill "Skeeter" 0,6 mm; Sanna's (Steel Wire-Fluoroplastic Shaft 0,5 mm) and Causse's prostheses (Fluoroplastic piston 0,4 mm) and 2) their results basing on the evaluation of 684 patients (231 males, 453 females; age range 8-79 years) operated from January 1987 to December 1998. Considering all available prostheses, the A.A. prefer the Causse's and Sanna's because of their weight (3,2 mg and 2,4 mg respectively) and morphometric peculiarities. The post-surgical functional results were measured by analyzing the average air-bone gap at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz in five different group of patients. Furthermore, performing this technique for several years they did not find early post-surgical complications as vertigo and cochlear damage. Thus the A.A. prefer stapedotomy with inversion of surgical steps because of the best results (audiological and clinical findings); this is due to the fact of place the prosthesis in a rigid system substained by the anterior branch of the stapes.

Abstract Otology 2000 B13-6

Wolfgang Draf MD, PhD, FRCS, Frauke Hilterhaus MD, Evelyn Bryson MD

Department of ENT-Diseases, Head Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda

Besides complete tumor removal and maintainance of facial nerve function preservation of hearing in general is an important goal of acoustic neuroma surgery. Early diagnosis and hearing preservation may become essential if the ipsilateral ear is the last hearing one or if as in neurofibromatosis the acoustic tumor is bilateral. The video demonstrates two exemplary cases treated successfully by the enlarged middle fossa approach.

Abstract Otology 2000 B13-7

Danko Cerenko MD, PhD, Jacques Dion MD

Department of Otolaryngology Emory University Hospital USA-Atlanta GA

Immediatelly after the incision was made while performing the right ear myringotomy in a 5 year old male, profuse bleeding occured and the ear canal was packed. Following removal of the packing the next day, intermittent oozing of blood was observed by the parents on a daily basis for almost two months. CT of temporal bones was then obtained which suggested presence of a right aberrant internal carotid artery (ICA). At our University Hospital, clinical exam demonstrated blood clots and a pulsating reddish mass filling most of the external ear canal. The angiogram confirmed presence of a pseudoaneurysm in the middle ear and external ear canal originating from an aberrant ICA. The pseudoaneurysm was immediatelly occluded with detachable platinum coils, thus eliminating imminent danger of rupture. Three days later the child passed the balloon test occlusion of the right ICA without developing clinical signs of neurological impairment, while the SPECT study was less then 10% asymmetric. When contemplating the definitive treatment, the permanent occlusion of the ICA, and surgical excision were considered. Based on excellent contralateral circulation, permanent occlusion of the right ICA below and above the pseudoaneurysm was performed, which the child tolerated without any neurological deficits. One month later the child underwent resection of the pseudoaneurysm, removal of the coils, and tympanoplasty. More then a year later, the child is experiencing normal hearing and development, and has an intact tympanic membrane.