A 3 yo girl was referred to the ENT clinic after her PCP noticed an abnormal TM on the left.
She has a history of a 2 ear infections prior to presentation. She is asymptomatic, with no pain and no drainage from her TM. Her audiogram was normal. Her physical eventually revealed the presence of a relatively large keratin pearl on her TM, without obvious middle ear effusions. After a short period of observation the family decided to have it removed.
The case was performed endoscopically in a trans-canal approach. The lesion was dissected mainly with a straight pick. The fibrous layer underneath was found to be intact and no myringoplasty was necessary.
The patient was was seen again 2 months post-op and her TM was found to be normal with a normal audiogram.
Objective tinnitus is a rare phenomenon whereby a patient perceives sound in the absence of external auditory stimuli, that is also observed by the examiner. Unlike subjective tinnitus which is thought to be somatosensory and usually difficult to cure, objective tinnitus is more likely to have an identifiable cause amenable to treatment. The differential for objective tinnitus includes aberrant vascular anatomy affecting the temporal bone, patulous eustachian tube function, and abnormal myoclonic activity of the palatal or middle ear muscles.1
We present a 16-year-old female who presented for evaluation of objective tinnitus. On physical examination, an intermittent rhythmic clicking was identified. Visualization of both the tympanic membrane and palate during active audible tinnitus was observed and found to be normal. A hearing test was performed demonstrating normal hearing and speech thresholds as well as normal tympanogram. Acoustic reflex testing demonstrated absent decay in both ears and spontaneous discharge for the right ear in response to both high and very low stimulus indicating abnormal stapedial and tensor tympani function. MRA demonstrated normal vascular anatomy and MRI was obtained demonstrating normal anatomy without lesions of the brainstem, cochleovestibular nerves, or ear or mastoid pathology. The patients was subsequently diagnosed with isolated middle ear myocolonus (MEM). Treatment options including medical versus surgical therapy were discussed as has previously been described. The patient ultimately elected for surgical tenotomy of the stapedial and tensor tympani tendons. Using endoscopic technique, a middle ear exploration was performed. Canal injection was performed with standard tympanomeatal flap elevation was assisted with epinephrine pledgets. The Annular ligament was identified and the middle ear was entered. Additional dissections was performed superiorly, and the chorda tympani nerve was identified and preserved. The stapedial tendon was visualized emanating from the pyramidal eminence to the posterior crus of the stapes. Balluci scissors were used to sharply incise the tendon and the remaining ends were reflected using a Rosen needle to prevent re-anastamosis. Additional dissection along the malleus was performed to gain access to the tensor tympani tendon. A 30 degree angled endoscope was utilized to visualize the tensor tympani tendon extending forward from the cochleariform process to the neck of the malleus. The angled 6400 Beaver blade was used to sharply incise the tendon, requiring multiple passess due to the thickness of the tendon. The sharply incised ends of both tendons were clearly visualized. The tympanomeatal flap was re draped and secured with gel foam packing. The patient was seen in follow up three weeks post operatively with a well healed ear drum, resolution of her objective tinnitus, normal hearing, and absent stapedial reflexes. The patient and mother were happy. Endoscopic stapedial and tensor tympani tenotomy is a feasible technique for isolated MEM in the pediatric population.
Vestibular schwannomas (acoustic neuromas) develop due to mutations in Schwann cells that cause uncontrolled cell division. As a result, a tumor forms. As these tumors grow, they can compress the cochlear nerve causing unilateral hearing loss and tinnitus. Vestibular schwannomas may cause imbalance and occasionally vertigo. Intralabyrinthine schwannomas account for about 10% of vestibular schwannomas in centers that specialize in temporal bone imaging. Intracochlear schwannomas are the most common type of intralabyrinthine schwannomas. In this video, we describe an endoscopic transcanal transpromontorial approach to intracochlear schwannoma removal.
This surgery was performed by James Prueter, DO, of Southwest Ohio ENT Specialists in Dayton, OH.
Video editing was performed by Austin Miller, OMS-II, Ohio University Heritage College of Osteopathic Medicine.
Covid -19 Pandemic has changed the way we provide our healthcare services to our patients. ENT / Otolaryngology is one of the high risk speciality for contracting Covid infection. We as professionals has to take maximum precautions not only to protect our patients but also all our healthcare staff working with us in to minimise the risk of contracting the virus ((Krajewska).
Unfortunately our patients do need appropriate necessary treatment for their otological problems during this pandemic. Drilling mastoid bone will generate significant aerosol during the procedure, putting everyone in the operating theatre at risk (Prof P Rae). Though every patient who undergoes any surgical procedure should have Covid test, self isolate and free from Covid symptoms. There is risk of contracting Covid infection from asymptomatic patient or staff. We should try and take every step to minimise the risk of contracting Covid infection either from Covid positive / negative Or symptomatic / asymptomatic patient or staff.
There are few techniques been tried by our colleagues around the world to minimise aerosol during major ear surgery. We tried to use of the technique proposed by our colleagues in UK ( W. Hellier), as it was too cumbersome during the procedure, we propose the modified technique to drape the surgical site during major ear surgery to reduce the aerosol.
Title: Lateral Graft Tympanoplasty
Description: A lateral graft tympanoplasty is performed to demonstrate the utility of this technically challenging approach. The technical pearls that contribute to the high success rate of this graft are highlighted.
Learning Points: The lateral graft tympanoplasty was popularized by Sheehy in the 1960s. Although technically more demanding than underlay graft techniques, the lateral graft is an essential method for Otologists to have in their armamentarium. The lateral graft is especially useful in cases of total perforation or anterior marginal perforation as well as revision tympanoplasty. Potential disadvantages of this technique include graft lateralization and anterior blunting as well as keratin pearl formation. When performed by an experienced surgeon, the results of lateral grafting are excellent. The technical considerations that promote successful lateral grafting are highlighted in this video.
Stapedotomy is used to treat conductive hearing loss caused by a fixed stapes footplate. The procedure is traditionally performed via a surgical microscope. In recent years an endoscopic approach has been increasingly utilized due to several advantages that it offers over the microscopic approach, chiefly the excellent visualization of middle ear structures provided by the endoscope. In this video we describe our technique for stapedotomy via an endoscopic approach.
This surgery was performed by James Prueter, DO, of Southwest Ohio ENT Specialists in Dayton, OH.
Video editing was performed by Wesley Greene, MS-4 Wright State University Boonshoft School of Medicine with assistance from Britney Scott, DO, PGY-3 Kettering Health Network Otolaryngology Surgery.
Tympanoplasty is used to repair persistent perforations of the tympanic membrane. The procedure has traditionally been performed via a surgical microscope. In recent years an endoscopic approach has been increasingly used due to several advantages that it offers over the microscopic approach, chiefly the excellent visualization of middle ear structures provided by the endoscope. In this video we describe our technique for endoscopic tympanoplasty using a tragal cartilage graft in a pediatric patient.
This surgery was performed by James Prueter, DO, of Southwest Ohio ENT Specialists in Dayton, OH.
Video editing was performed by Wesley Greene, MS-4 Wright State University Boonshoft School of Medicine with assistance from Britney Scott, DO, PGY-3 Kettering Health Network Otolaryngology Surgery.
The Osia System is a transcutaneous bone anchored hearing aid which can be used for the correction of both conductive and sensorineural hearing loss. This video depicts the implantation of the Osia in a pediatric patient with a history of right-sided microtia.
