Introduction: Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well. Materials and Methods: Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention. Results: Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression. Conclusion: Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.
Background: Our tertiary otology center treats facial weakness and paralysis after motor vehicle crashes. We evaluate these patients with physical exam, audiogram, Schirmer's test, and CT scan. Our protocol for management of the facial weakness provides good results for our patients.Methods: Our protocol begins with oral steroids, and serial evaluations. Indications for decompression and our unique transcanal approach to identify the sites for decompression are described. A retrospective review of the medical record presents our patients treated between 1998 and 2017.Results: One hundred and forty one patients with grade 4 or more weakness underwent decompression. Mean pre-operative and post-operative House-Brackmann (HB) scores were HB5 and HB2, respectively. Fourteen of 104 patients (13%) presenting with HB5 and 6 still had HB5 or HB6 after decompression. Eighty-three of thee 104 patients (80%) achieved HB1 or HB2 at 6 months. Post-operative bone levels were unchanged. Post-operative air levels were improved in cases of perigeniculate fractures (84%).Conclusion: This Bangalore protocol facilitates advantageous improvement in facial function and conductive hearing loss after traumatic facial nerve crush injuries. The surgical technique, albeit challenging, helps identify the fracture lines, facilitates reconstruction of disrupted ossicles, and avoids craniotomy.
Introduction Although attic retractions have previously been classified into Grades 0 through IV, it is often not possible to assign attic retraction pockets into a single specific category. The present study describes an improved classification system based on otoscopic and endoscopic visualization of the retraction pocket fundus, the ossicular status in the attic, degree of scutal erosion, and the presence or absence of cholesteatoma. Materials and Methods One hundred and fifty‐four patients (200 ears) with different grades of attic retraction pockets who were seen by a tertiary referral otology center between August 2015 and July 2018 were selected for this study. Observations The new classification system (Grades I, IIa, IIb, IIIa, IIIb, IIIc, IVa, IVb, IVc, and V) was applied to these retraction pockets. Pure tone audiometry was obtained. Results All attic retraction pockets could be classified precisely using the new classification system. Forty‐four of 200 (22%) of ears showed Grade I Attic retraction, 18 ears showed Grade IIa (9%), 14 showed Grade IIb (7%), 28 showed Grade IIIa (14%), 12 showed IIIb (6%), 20 showed Grade IIIc (10%), 16 showed grade IVa (8%), 12 showed grade IVb (6%), 28 showed grade IVc (14%), and eight showed grade V (4%) attic retraction pockets. Grades I, IIa, IIb, IIIa, and IVa had no significant hearing loss. Average hearing loss was 42 dB and 52 dB in Grades IIIb and IIIc, 44 dB and 58 dB in Grades IVb and IVc, and 61 dB in Grade V. Level of Evidence 5 Laryngoscope, 130: 2034–2039, 2020
Objective. Attic retraction pockets, classified by degree of invasion and erosion, are reconstructed here as outlined by attic retraction pocket grade. Method. Attic retraction pocket grade, surgical management, subsequent conditions of tympanic membrane and middle ear, and improvement of air-bone gap pure tone average were recorded. Results. Our management strategy, based on attic retraction pocket grade, was applied to 200 ears: 44 grade I ears had non-surgical management and 156 grade II-V ears had surgical management. All 200 ears were followed up for 36-240 months, showing only 1 attic retraction pocket reformation and 1 adhesive otitis media (complication rate of 1 per cent), and improved air-bone gaps ( p < 0.05). An earlier series of 50 grade IV attic retraction pockets used atticotomy with epitympanic reconstruction. These showed attic retraction pocket recurrence or cholesteatoma onset in 34 ears (68 per cent). When these ears were revised per protocol, there was no evidence of cholesteatoma thereafter. Conclusion. Reconstruction of the ossicles and scutal defect according to attic retraction pocket grade shows long-term stability of the tympanic membrane, middle ear and hearing.
Objectives: Iatrogenic removal of intra-temporal disease processes, such as cholesteatoma and keratosis obturans, can be challenging when the facial nerve (FN) is involved. Despite this concern about possible FN injury during these procedures, our clinical observation has been that the diseased growth can be cleaned quite easily from the vertical FN epineurium. Therefore, we designed a cadaveric protocol to measure thickness of the FN sheath (epineurium) in horizontal, second genu and vertical FN segments and to correlate these measurements with surgical management of FN disorders. Methods: Fifty non-fixated (wet) cadaveric temporal bones were dissected over 1 year’s time. The intra-temporal FN sheath epineurium was harvested from the mid-horizontal, second genu, and mid-vertical segments. Using a digital micrometric technique, the thickness of each sample was measured. Data analysis was performed using student’s two-tailed, dependent t-test. Results: Epineurial nerve sheath thickness was the least in the horizontal segment (mean 0.9 mm, range 0.040-0.140 mm), greater at the second genu (mean 0.19 mm, range 0.010-0.280 mm), and greatest in the vertical segment (mean 0.29 mm, range 0.170-0.570 mm). These differences were statistically significant. Conclusion: In cases of cholesteatoma and keratosis obturans involving the vertical FN, the disease process can be separated from the FN sheath because of the sheath thickness in this region. Disease in the horizontal segment involves a thinner sheath and separating the disease process from the nerve is more difficult in this area.
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