Acta Oto-Laryngologica. 2014; 134: 455–461
ORIGINAL ARTICLE
Analysis of differences in facial nerve dehiscence and ossicular injury in chronic otitis media and cholesteatoma
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SUN A CHOI, HO MIN KANG, JAE YONG BYUN, MOON SUH PARK & SEUNG GEUN YEO Department of Otorhinolaryngology, Kyung Hee University School of Medicine, Seoul, Korea
Abstract Conclusion: Facial nerve dehiscence (FND) and ossicular injury occurred more frequently in patients with cholesteatomatous than non-cholesteatomatous otitis media. Objective: FND and ossicular injury commonly occur intraoperatively in patients with otitis media, both with and without cholesteatoma. This study was designed to analyze differences in FND and ossicular injury between patients with cholesteatomatous and non-cholesteatomatous otitis media. Methods: Patients who underwent tympanomastoidectomy due to otitis media from January 2010 to July 2012 were analyzed retrospectively. Clinical features (age, sex, bacteria, and severity of preoperative hearing loss) and intraoperative findings (FND and state of ossicular injury) were compared in patients with cholesteatomatous and non-cholesteatomatous otitis media. Results: Of 212 patients with otitis media, 148 (69.8%) had non-cholesteatomatous and 64 (30.2%) had cholesteatomatous otitis media. Of these groups, 88.6% and 88%, respectively, had positive bacterial cultures. Facial nerve dehiscence was detected in 41 patients (27.7%) with non-cholesteatomatous and 41 (64.0%) with cholesteatomatous otitis media. Dehiscence of the tympanic segment was most frequently observed in both groups. Ossicular injury was detected in 52 (35.1%) and 51 patients (78.1%), respectively. Erosion was most frequent in the incus, followed by the stapes and malleus.
Keywords: Ossicular injury, tympanomastoidectomy, erosion
Introduction Otitis media, the general term for all inflammatory changes in the inner ear, is one of the most common diseases in otorhinolaryngology. Based on clinical findings, otitis media has been classified into acute otitis media, otitis media with effusion, and chronic otitis media, with the latter subclassified as chronic otitis media with or without cholesteatoma. Inflammatory lesions in the tympanum can lead to various complications, including tympanic membrane perforation, destruction of ear ossicles and conductive hearing loss, facial palsy, meningitis, subdural abscess, brain abscess, mastoiditis, and damage to surrounding bone structures. Long-term chronic mastoid and eustachian tube dysfunction can weaken the tympanum, resulting in the formation of atelectatic ear or cholesteatoma. Cholesteatoma is characterized by the
disruption of bone tissue, due to the accumulation of keratin and the invasion by keratinized stratified squamous epithelium into the tympanum, which is lined with a mucous membrane. Complications occur more frequently in patients with cholesteatomatous otitis media (Chol) than noncholesteatomatous otitis media (COM). Among the intraoperatively detected complications are facial nerve dehiscence (FND), labyrinthine fistula, dural exposure, and absence of a stapedial suprastructure. FND is most frequently observed in the tympanic segment, and is present in a high percentage of patients with Chol [1,2]. Ossicular disruption can also be identified intraoperatively. The severity of hearing loss in patients with chronic otitis media is affected by the size and location of tympanic membrane perforation, the state of the ossicular chain, and motility. The complete disruption of the ossicular
Correspondence: Seung Geun Yeo MD, Department of Otorhinolaryngology Head & Neck Surgery, School of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea. Tel: +82 2 958 8474. Fax: +82 2 958 8470. E-mail: [email protected]
(Received 27 August 2013; accepted 24 October 2013) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2013.860654
456
S. A. Choi et al.
chain could result in a hearing loss of about 60 dB [3,4]. Although FND is one of the most frequent complications of chronic otitis media, previous studies have mainly investigated its occurrence in patients with Chol. This study was therefore designed to analyze differences in FND and ossicular injury between patients with COM and Chol.
Acta Otolaryngol Downloaded from informahealthcare.com by University of Connecticut on 06/11/14 For personal use only.
Material and methods Patients with chronic otitis media or cholesteatomatous otitis media, as confirmed by biopsy, and who underwent tympanomastoidectomy due to this condition from January 2010 to July 2012 were retrospectively investigated. Patients with preoperative facial palsy, who had undergone previous otologic operation, or who had a temporal bone fracture or a tumor were excluded. Patients were divided into two groups, with COM or Chol, and their clinical and demographic findings were compared, including sex distribution, age, preoperative pure-tone audiometry (PTA) results, and intraoperative findings, including facial nerve exposure and state of ossicular injury. We assessed a total of 212 patients, of mean age 52.7 ± 14.0 years (range 9–78 years), including 97 males (45.8%) and 115 females (54.2%). The patient cohort consisted of 7 children (3.3%), aged 0.05). Pseudomonas was the
Table I. Facial nerve dehiscence rates stratified clinically. No. of ears with FND Clinical variable Sex
Male Female
Total no. of ears
Yes
No
97
32
65
115
50
65
Age (years)
10 years (n = 28)
4
4
5
15
Present (n = 23)
5
3
4
11
Absent (n = 41)
3
15
8
15
Yes
2
11
7
21
No
6
7
5
5
Ossicular injury No
Otorrhea
FND
Acta Otolaryngol Downloaded from informahealthcare.com by University of Connecticut on 06/11/14 For personal use only.
ORIGINAL ARTICLE
Analysis of differences in facial nerve dehiscence and ossicular injury in chronic otitis media and cholesteatoma
Acta Otolaryngol Downloaded from informahealthcare.com by University of Connecticut on 06/11/14 For personal use only.
SUN A CHOI, HO MIN KANG, JAE YONG BYUN, MOON SUH PARK & SEUNG GEUN YEO Department of Otorhinolaryngology, Kyung Hee University School of Medicine, Seoul, Korea
Abstract Conclusion: Facial nerve dehiscence (FND) and ossicular injury occurred more frequently in patients with cholesteatomatous than non-cholesteatomatous otitis media. Objective: FND and ossicular injury commonly occur intraoperatively in patients with otitis media, both with and without cholesteatoma. This study was designed to analyze differences in FND and ossicular injury between patients with cholesteatomatous and non-cholesteatomatous otitis media. Methods: Patients who underwent tympanomastoidectomy due to otitis media from January 2010 to July 2012 were analyzed retrospectively. Clinical features (age, sex, bacteria, and severity of preoperative hearing loss) and intraoperative findings (FND and state of ossicular injury) were compared in patients with cholesteatomatous and non-cholesteatomatous otitis media. Results: Of 212 patients with otitis media, 148 (69.8%) had non-cholesteatomatous and 64 (30.2%) had cholesteatomatous otitis media. Of these groups, 88.6% and 88%, respectively, had positive bacterial cultures. Facial nerve dehiscence was detected in 41 patients (27.7%) with non-cholesteatomatous and 41 (64.0%) with cholesteatomatous otitis media. Dehiscence of the tympanic segment was most frequently observed in both groups. Ossicular injury was detected in 52 (35.1%) and 51 patients (78.1%), respectively. Erosion was most frequent in the incus, followed by the stapes and malleus.
Keywords: Ossicular injury, tympanomastoidectomy, erosion
Introduction Otitis media, the general term for all inflammatory changes in the inner ear, is one of the most common diseases in otorhinolaryngology. Based on clinical findings, otitis media has been classified into acute otitis media, otitis media with effusion, and chronic otitis media, with the latter subclassified as chronic otitis media with or without cholesteatoma. Inflammatory lesions in the tympanum can lead to various complications, including tympanic membrane perforation, destruction of ear ossicles and conductive hearing loss, facial palsy, meningitis, subdural abscess, brain abscess, mastoiditis, and damage to surrounding bone structures. Long-term chronic mastoid and eustachian tube dysfunction can weaken the tympanum, resulting in the formation of atelectatic ear or cholesteatoma. Cholesteatoma is characterized by the
disruption of bone tissue, due to the accumulation of keratin and the invasion by keratinized stratified squamous epithelium into the tympanum, which is lined with a mucous membrane. Complications occur more frequently in patients with cholesteatomatous otitis media (Chol) than noncholesteatomatous otitis media (COM). Among the intraoperatively detected complications are facial nerve dehiscence (FND), labyrinthine fistula, dural exposure, and absence of a stapedial suprastructure. FND is most frequently observed in the tympanic segment, and is present in a high percentage of patients with Chol [1,2]. Ossicular disruption can also be identified intraoperatively. The severity of hearing loss in patients with chronic otitis media is affected by the size and location of tympanic membrane perforation, the state of the ossicular chain, and motility. The complete disruption of the ossicular
Correspondence: Seung Geun Yeo MD, Department of Otorhinolaryngology Head & Neck Surgery, School of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea. Tel: +82 2 958 8474. Fax: +82 2 958 8470. E-mail: [email protected]
(Received 27 August 2013; accepted 24 October 2013) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2013.860654
456
S. A. Choi et al.
chain could result in a hearing loss of about 60 dB [3,4]. Although FND is one of the most frequent complications of chronic otitis media, previous studies have mainly investigated its occurrence in patients with Chol. This study was therefore designed to analyze differences in FND and ossicular injury between patients with COM and Chol.
Acta Otolaryngol Downloaded from informahealthcare.com by University of Connecticut on 06/11/14 For personal use only.
Material and methods Patients with chronic otitis media or cholesteatomatous otitis media, as confirmed by biopsy, and who underwent tympanomastoidectomy due to this condition from January 2010 to July 2012 were retrospectively investigated. Patients with preoperative facial palsy, who had undergone previous otologic operation, or who had a temporal bone fracture or a tumor were excluded. Patients were divided into two groups, with COM or Chol, and their clinical and demographic findings were compared, including sex distribution, age, preoperative pure-tone audiometry (PTA) results, and intraoperative findings, including facial nerve exposure and state of ossicular injury. We assessed a total of 212 patients, of mean age 52.7 ± 14.0 years (range 9–78 years), including 97 males (45.8%) and 115 females (54.2%). The patient cohort consisted of 7 children (3.3%), aged 0.05). Pseudomonas was the
Table I. Facial nerve dehiscence rates stratified clinically. No. of ears with FND Clinical variable Sex
Male Female
Total no. of ears
Yes
No
97
32
65
115
50
65
Age (years)
10 years (n = 28)
4
4
5
15
Present (n = 23)
5
3
4
11
Absent (n = 41)
3
15
8
15
Yes
2
11
7
21
No
6
7
5
5
Ossicular injury No
Otorrhea
FND
Acta Otolaryngol Downloaded from informahealthcare.com by University of Connecticut on 06/11/14 For personal use only.
