Week 2: Tympanoplasty & Otorrhea Flashcards
Blunting is a phenomenon characterized by ____.
scarring in the anterior sulcus region that bridges the anterior graft and the anterior canal wall.
Which otological procedures account for the highest number of iatrogenic facial nerve injuries?
Tympanoplasty and mastoidectomy
The lateral grafting tympanoplasty technique is favored over the medial grafting technique for ____ perforations and ___.
The lateral grafting tympanoplasty technique is favored over the medial grafting technique for very large perforations and complicated revision cases.
Disadvantages of the lateral grafting technique for tympanoplasty include:
1.
2. Increased risk of cholesteatoma
3. Greater technical demands
4. Longer healing times
5. lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
- Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
2. - Greater technical demands
- Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma - (due to incomplete squamous epithelial removal)
- Greater technical demands
- Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
3. - Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
- Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
4. - lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
- Longer healing times
- lateralization
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
- Longer healing times
5.
Disadvantages of the lateral grafting technique for tympanoplasty include:
- Post-op blunting
- Increased risk of cholesteatoma
- Greater technical demands
- Longer healing times
- lateralization
While performing a tympanoplasty to address a 40% posterior perforation on a 21M w/chronic Eustachian tube dysfxn it is discovered that the ossicles are fixated due to diffuse tympanosclerosis. The incus is not in continuity w/the stapes and the lenticular process is eroded. After removal of tympanosclerosis, the stapes remains immobile. What is the most appropriate decision in the management of this situation.
Remove the incus, place a graft for repair of the TM, and return for 2nd stage stapedectomy and ossiculoplasty.
(A stable middle ear space should be established before proceeding with stapedectomy and ossiculoplasty).
What technique helps to decrease the incidence of post-op blunting with a lateral grafting tympanoplasty technique?
Removal of the anterior canal wall bulge & Avoiding direct placement of the graft over the anterior canal bone
Blunting of the angle at the anterior sulcus following lateral graft tympanoplasty technique typically occurs due to ___.
Failure to preserve the tympanomeatal angle, thus creating a “dead space” for scar tissue to form in and create a more obtuse angle than the physiologic norm.
Type I Wullstein Tympanoplasty Classification:
TM is grafted to an intact ossicular chain
Type II Wullstein Tympanoplasty Classification:
Malleus is partially eroded, so TM is grafted to the incus
Type III Wullstein Tympanoplasty Classification:
Malleus and incus are eroded.
TM is grafted to the stapes suprastructure
Type IV Wullstein Tympanoplasty Classification:
Stapes suprastructure is eroded but footplate is mobile.
TM is grafted to a mobile footplate.
Type V Wullstein Tympanoplasty Classification:
TM is grafted to a fenestration in the horizontal SCC.
45M develops R-conductive HL following temporal bone trauma attributed to malleoincudal separation. He undergoes tympanoplasty w/placement of a partial ossicular replacement prosthesis (PORP) without complication. His hearing returns to baseline w/no further conductive hearing loss. 6mos later he develops severe R otalgia, ear popping and subsequent HL that does not improve. CT shows a displaced PORP w/o contact to the stapes. No inner ear or otoscopic abnormalities are present. What would his expected HL be in dB?
Dislocation of the ossicular prosthesis (resulting in complete ossicular discontinuity) + intact TM
MAXIMAL conductive hearing loss (which is typically 60dB)
25M w/recurrent foul smelling L otorrhea. He has no h/o recurrent ear infxn. but did have one severe episode of acute otitis media that resulted in a perforated TM as a child. On PE you see a white mass behind the TM and no appreciable retraction of the TM. A CT of the temporal bone is performed and is below. What is the likely dx?
Secondary acquired cholesteatoma
(the patient has the introduction of epithelial cells into the middle ear, in this case, from TM rupture, but more commonly through pressure equalization tube placement or other penetrating trauma.
A 43M presents w/ear pain and drainage and retrobulbar pain. On physical exam, you note purulent fluid in the middle ear and abducens nerve palsy.
These symptoms indicate an what dx?
Gradenigo’s syndrome (petrous apicitis)
(This is a complication of a middle ear infxn., patients have symptoms of pain and drainage from the ear).
A 43M presents w/ear pain and drainage and retrobulbar pain. On physical exam, you note purulent fluid in the middle ear and abducens nerve palsy.
These symptoms indicate an infxn in which location?
Petrous apex of the temporal bone:
- Irritation of the trigeminal n. In Meckel’s cave explains the retro-orbital pain.
- VI (abducens n.) travels through Dorello’s canal, which also abuts the petrous apex, explaining the palsy of this n.)
The signs and symptoms of Gradenigo’s syndrome (Petrous Apicitis) can be easily remembered with the mnemonic “EAR:”
E - ear drainage
A - abducens nerve palsy
R - retrobulbar pain
53M presents for eval of chronic unilateral otorrhea, HL, and occasional vertigo x2yr. The patient denies prior ear surgery. On exam an attic retraction pocket cholesteatoma is noted. CT reveals scutum erosion and thinning of the lateral semicircular canal wall. During surgery, cholesteatoma matrix is identified over the lateral SCC w/ and underlying bluish coloration. Which procedure would be most appropriate for patient who is adamant about not undergoing >1 surgery?
Canal-wall down mastoidectomy
A finding of mounds of granulation tissue at the isthmus of the EAC is pathognomonic for ___.
Malignant otitis externa (MOE)
39F w/HL. She has a brother who had hearing loss in his early 40s. She has a h/o recurrent b/l ear infxns as a child and underwent placement of a single pair of pressure equalization tubes b/l. On PE her b/l TMs are sclerotic and cannot visualize beyond the TM. The Audiogram is shown below, and stapedial reflex is absent. What form of HL is shown on the audiogram?
Mixed HL in the R ear, w/gap btwn air and bone conduction, indicating conductive HL, which closes at 2,000 Hz.
39F w/HL. She has a brother who had hearing loss in his early 40s. She has a h/o recurrent b/l ear infxns as a child and underwent placement of a single pair of pressure equalization tubes b/l. On PE her b/l TMs are sclerotic and cannot visualize beyond the TM. The Audiogram is shown below, and stapedial reflex is absent. What is the most likely dx?
Otosclerosis
The “Carhart notch,” an artificial drop in the bone conduction line due to disruption of ossicular resonance, is consistent w/otosclerosis, and other disorders such as ossicular chain discontinuity.
25M presents w/otorrhea for the last few months as demonstrated in the picture. What is the most common microorganism source of otitis externa.
Pseudomonas aeruginosa = most common bacterial cause of otitis externa
A positive fistula test where positive pressure is administered w/positive pressure in the ear canal, which elicits nystagmus. A positive test is indicative of ___?
A perilymphatic leak or Hennebert’s sign
Malignant otitis externa (aka necrotizing otitis externa) presents with which findings?
- Long standing otalgia (>4wks)
- Otorrhea
- Granulation tissue at the bony cartilaginous junction
Based on the CT below, if the indicated structure were damaged in surgery, what would be the likely outcome?
Facial paralysis.
The indicated structure is the tympanic segment of the facial nerve.
A child presents to the ED w/fever and a L posterior periauricular painful mass x1d. Her mother reports that she has been complaining of hearing loss, and feeling dizzy. Other than well-child checks, she has never been to the doctor. The ear is shown below. What of the following is true regarding the treatment of the suspected diagnosis?
Tx of mastoiditis requires IV Abx. The choice of initial agent is dependent upon whether there is a preceding h/o recurrent acute otitis media or recent antibiotic therapy.
For children w/o a h/o recurrent episodes of acute otitis media or recent Abx, the recommended 1st line agents are Vanc or Linezolid.
