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Complications of chronic otitis media with cholesteatoma during a 10-year period in Kosovo

Authors:
  • Institute of Labour Medicine Kosovo

Abstract and Figures

We review and discuss the results of treatments for complications of cholesteatomatous chronic otitis media (CCOM) in a tertiary health care center. In a retrospective study, the medical records of patients with complications of CCOM who had undergone surgical treatment at the ENT Clinic of the University Clinical Center of Kosovo for the period 1994-2004 were reviewed. From a total of 1,803 patients suffering from CCOM, in 91 patients, 55 (60.4%) men and 36 (39.6) women, one or two complications are recorded. The mean age of the subjects was 30 years, and the age range was from 1 to 76 years. Extracranial (EC) complications were observed in 52 cases (57.1%), and intracranial (IC) complications were seen in 29 patients (31.9%). Twelve patients (11%) had multiple complications. For the EC cases, we found that subperiostal mastoidal abscess occurred in 26% of the all patients, facial nerve palsy was seen in 16.48% and labyrinthine fistula occurred in 10%. For the IC cases, meningitis (19.7%) and perisinusal abscess (15.3%) were the most common complications. The most often isolated pathogen from ear swabs was Proteus mirabilis in 33.3% of cases. The most frequent radiological diagnostic procedures were mastoid tip X-rays, which were performed in 77% of the patients, and computed tomography in 24%; magnetic resonance imaging was not performed on any of the patients during the study period. Patients with EC complications were treated in the ENT Clinic, whereas patients with IC complications, after otologic surgical procedures, were transferred to the Neurosurgery Clinic or to the Clinic for Infectious Diseases. In this series, three patients (3.3%) died as a result of complications, while the remaining 96.7% survived. Complications of COM with cholesteatoma can represent life-threatening conditions, and close cooperation between otosurgeons, neurosurgeons and infectious disease specialists is mandatory.
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Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-008-0707-8
123
OTOLOGY
Complications of chronic otitis media with cholesteatoma
during a 10-year period in Kosovo
A. Mustafa · A. Heta · B. Kastrati · Sh. Dreshaj
Received: 4 December 2007 / Accepted: 30 April 2008
© Springer-Verlag 2008
Abstract We review and discuss the results of treatments
for complications of cholesteatomatous chronic otitis media
(CCOM) in a tertiary health care center. In a retrospective
study, the medical records of patients with complications of
CCOM who had undergone surgical treatment at the ENT
Clinic of the University Clinical Center of Kosovo for the
period 1994–2004 were reviewed. From a total of 1,803
patients suVering from CCOM, in 91 patients, 55 (60.4%)
men and 36 (39.6) women, one or two complications are
recorded. The mean age of the subjects was 30 years, and
the age range was from 1 to 76 years. Extracranial (EC)
complications were observed in 52 cases (57.1%), and
intracranial (IC) complications were seen in 29 patients
(31.9%). Twelve patients (11%) had multiple complica-
tions. For the EC cases, we found that subperiostal mastoi-
dal abscess occurred in 26% of the all patients, facial nerve
palsy was seen in 16.48% and labyrinthine Wstula occurred
in 10%. For the IC cases, meningitis (19.7%) and perisinu-
sal abscess (15.3%) were the most common complications.
The most often isolated pathogen from ear swabs was Pro-
teus mirabilis in 33.3% of cases. The most frequent radio-
logical diagnostic procedures were mastoid tip X-rays,
which were performed in 77% of the patients, and com-
puted tomography in 24%; magnetic resonance imaging was
not performed on any of the patients during the study period.
Patients with EC complications were treated in the ENT
Clinic, whereas patients with IC complications, after oto-
logic surgical procedures, were transferred to the Neurosur-
gery Clinic or to the Clinic for Infectious Diseases. In this
series, three patients (3.3%) died as a result of complica-
tions, while the remaining 96.7% survived. Complications
of COM with cholesteatoma can represent life-threatening
conditions, and close cooperation between otosurgeons, neu-
rosurgeons and infectious disease specialists is mandatory.
Keywords Complications of cholesteatoma ·
Chronic otitis media · Surgical treatment
Introduction
Cholesteatoma is an epithelial-lined growth containing
mainly cellular debris in which cholesterol crystals can
generally be found. Cholesteatomas are benign and occur
mainly in the middle ear and mastoid region, and through
pressure, cause destruction of surrounding structures [1].
Once established in the middle ear, mastoid or petrous
bone, cholesteatoma is a destructive lesion that gradually
expands and destroys adjacent structures, leading to com-
plications. The pathogenesis is diverse, with diVerent path-
ways leading to the same destructive lesion [2]. The
majority view of pathogenesis now favors retraction of
Shrapnel’s membrane or the posterosuperior quadrant of
the pars tensa, which develops into a gradually expanding
cyst containing epithelial debris having locally erosive
properties [3].
Although the incidence of complications due to otitis has
decreased in recent decades, they still pose a challenge for
A. Mustafa (&) · A. Heta
ENT Clinic, University Clinical Center of Kosovo,
rr. Spitalit pn, 10000 Prishtina, Kosovo/UNMIK
e-mail: aziz_mustafa2000@yahoo.com
B. Kastrati
Neurosurgery Clinic, University Clinical Center of Kosovo,
Prishtina, Kosovo/UNMIK
Sh. Dreshaj
Clinic for Infectious Disease,
University Clinical Center of Kosovo, Prishtina, Kosovo/UNMIK
Eur Arch Otorhinolaryngol
123
clinicians, because the complications have an insidious pre-
sentation that is usually hidden by the indiscriminate use of
antibiotics [4]. The objective of surgery for chronic otitis
media with cholesteatoma and chronic otomastoiditis is to
eradicate the disease and create anatomic conditions to pre-
vent recurrence and complications. To achieve this pur-
pose, two surgical techniques exist: canal wall-up (CWU)
and canal wall-down (CWD) mastoidectomies [5].
Complications of CCOM are classiWed as extracranial
(EC) or intracranial (IC). EC complications are recorded
more often than IC complications, but IC complications are
more severe and lethal. Consequently, studying EC and IC
complications is clinically important.
The goal of the present study was to analyze the manage-
ment of complications of cholesteatoma for a 10-year
period at our center retrospectively. Because the University
Clinical Center of Prishtina is the only referral center for
otogenic complications in Kosovo, the incidence of compli-
cations due to cholesteatoma can be estimated accurately.
The present study, which included all patients hospitalized
for complications of cholesteatoma over a 10-year period,
describes the diagnosis and treatment of complications due
to CCOM. In particular, we focus on the cause and duration
of chronic ear signs and symptoms and discuss otosurgical
approaches.
Material and methods
We reviewed the clinical records of patients diagnosed as
having CCOM and treated at the ENT/Head and Neck Sur-
gery Clinic, University Clinical Center, Prishtina, Kosovo,
from January 1994 through December 2003. The diagnosis
of a complication of CCOM was established by experi-
enced otolaryngologists based on the clinical examination,
otomicroscopy and radiology examinations and was con-
Wrmed during the surgical procedures. Cases with COM
without an intraoperative Wnding of cholesteatoma were
excluded from the study.
The demographic data included sex, age and residence
(rural or urban). Signs and symptoms on admission, white
blood count (WBC), erythrocyte sedimentation rate (ESR)
and the results of middle ear aspirate culture obtained on
admission were also recorded. In all cases with a suspected
complication, X-rays of the mastoid were performed, and
occasionally, computed tomography (CT) of the temporal
bone, brain and neck was performed. The surgical proce-
dures were recorded, and materials were harvested for
pathology conWrmation.
With regard to patient consent, we obtained written per-
mission from the clinic director to conduct research on this
topic, because our institution lacks an institutional review
board. In addition, every patient admitted to the clinic must
sign a consent form giving permission to conduct all diag-
nostic and therapeutic procedures, including the publication
of images or other medical records.
Results
During the 10-year period from January 1994 to December
2003, 1,803 patients were admitted with diagnosis of otitis
media. We found that 92% of these patients had COM,
while 8% had acute otitis media. From a total of 1,803
patients, in 272 of them, an intraoperative cholesteatoma is
conWrmed. From this 272 patients with CCOM, 91 (33.5%)
came to the clinic with either one or two complications. We
also found that complications of COM (without cholestea-
toma) occurred in only 6.7% of cases.
The number of patients with complications of cholestea-
toma decreased during the last 5 years of the study period as
shown in Fig. 1. This decrease corresponds to the end of the
military conXict in Kosovo in 1999 and was likely due to the
subsequent rapid reconstruction of the health care system,
which improved primary health care and medical education.
The detailed data of 91 patients with complications of
CCOM included in the study are presented in the Table 1,
where 55 (60.4%) were men and 36 (39.6%) women, that
presents statistically signiWcant diVerence (
2
test = 3.97,
P < 0.05). The mean age was 30 years, with a standard
deviation (SD) of 16.5 years (SD § 16.54), ranging from 1
to 70 years. The percentage of pediatric patients (<15 years
old) was 20.9%. According to residence, urban versus rural,
there were no signiWcant diVerence: 50.5% versus 49.5%
(
2
test = 0.01, P >0.05).
The duration of disease, from the Wrst visit to the ENT
doctor to the moment of surgery, is presented in Table 2.
The mean duration of disease was 8.6 years, with a stan-
dard deviation of 8.9. Only 17.6% of patients carried the
cholesteatoma for less than 1 year. The same percentage of
patients had episodes of exacerbation for more than
Fig. 1 Complications of CCOM by year
13
9
8
9
8
7
10
12
11
4
0
2
4
6
8
10
12
14
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Eur Arch Otorhinolaryngol
123
15 years. Most of the patients (38.5%) carried the choleste-
atoma from 1 to 5 years.
Types of complications of CCOM are shown in Table 3.
EC complications occurred in 52 patients (57.1%), IC com-
plications in 29 (31.9%) and multiple complications
(IC + EC) in 10 patients (11%). In IC group, there were two
cases (2.2%) with multiple complications (IC + EC), con-
sidering sepsis as result of an intracranial complication. For
the EC cases, we found that subperiostal mastoidal abscess
(SMA) occurred in 26% of the all patients, facial nerve
palsy (FNP) was seen in 16.48% and labyrinthine Wstula
occurred in 10%. For the IC cases, meningitis (19.7%) and
perisinusal abscess (15.3%) were the most common com-
plications. In group of multiple complications (IC + EC),
combination of perisigmoid sinus abscess and SMA was
the one that most often occurred (4.4%). Meningitis and
SMA was the second most often occurred one.
Diagnostic procedures applied for this series of patients
was not standardized and diVers from patient to patient. For
some procedures, e. g. CT scans, determinative was avail-
ability. For the period 1994–2003, CT was not available in
our center in all cases and is done only in 24% of cases;
pure tone audiometry can be performed only in conscious
patients. The Table 4 shows the percentage of diagnostic
procedures performed in patients of our series. Laboratory
analyzes, erythrocyte sedimentation rate (ESR) and white
blood count (WBC) was taken in all cases and elevated
values indicated developing complications. In 70.3% of
patients, mastoid tip X-rays were performed; in cases
Table 1 Patient by gender, residence and age
Number N (%) P value
Gender
Men 55 (60.4%) 0.046
Women 36 (39.6%)
Residence
Urban 46 (50.5%) 0.917
Rural 45 (49.5%)
Age (years)
Mean § SD 29.90 § 16.54
Rank 1–70
<15 years 19 (20.9%)
Table 2 Duration of disease (CCOM)
Duration in years Number (N) Percent (%)
<1 16 17.6
1–5 35 38.5
6–10 17 18.7
11–15 5 5.5
>15 16 17.6
No data 2 2.2
Total 91 100.0
Mean 8.6 years
SD 8.9
Table 3 Types of CCOM complications
SMA subperiostal mastoid abscess, FNP facial nerve paralysis
Type of complication Number
(N)
Percent
(%)
Extracranial complications
SMA 24 26.4
FNP 13 14.3
Perilabyrinthine Wstula 9 9.9
Acute mastoiditis 4 4.4
Zygomatitis/perizygomatic abscess 1 1.1
Bezold’s abscess 1 1.1
Total 52 57.1
Intracranial complications
Meningitis 11 12.1
Perisigmoid sinus abscess 10 11.0
Cerebral abscess 3 3.3
Meningoencephalitis 2 2.2
Subdural abscess 1 1.1
Perisigmoid sinus abscess + sepsis 1 1.1
Meningitis + sepsis 1 1.1
Total 29 31.8
Multiple (IC/EC) complications
Perisigmoid sinus abscess + SMA 4 4.4
Meningitis + SMA 2 2.2
Cerebral abscess + FNP 1 1.1
Meningitis + petrositis 1 1.1
Meningitis + FNP 1 1.1
Perisigmoid sinus abscess +
jugular vein thrombophlebitis + SMA
11.1
Total 10 11.0
Total 91 100.0
Table 4 Diagnostic procedures
E
SR erythrocyte sedimentation rate, WBC white blood count, CT com-
puted tomography, PTA pure tone audiometry
Total number of patientsn =91
N %
ESR 91 100.0
WBC 91 100.0
CT 22 24.2
Mastoid X-rays 64 70.3
PTA 44 48.4
Ear swabs 44 48.4
Eur Arch Otorhinolaryngol
123
suspected of IC complications, CT scans were performed.
PTA shows conductive hearing loss in diseased ears.
The microbiology analysis results are shown in Table 5.
Swabs from draining ears, myringotomy incisions or the
mastoid cavity were only taken in 44 patients, and patho-
genic bacteria were isolated in only 33 patients. The most
frequently isolated pathogens were Proteus mirabilis in
33.3%, Staphylococcus aureus in 15% and Pseudomonas
sp. and Proteus vulgaris in 12% of the 44 cases.
The surgical procedures for the treatment of complica-
tions are summarized in Table 6. CWD radical tympano-
mastoidectomy (RTM) was performed in 86.8% of the
patients and was the most frequently applied procedure.
CWU procedures were only applied in 13.2% of the
patients.
The modiWcations of the CWD procedure in each of the
79 applicable cases were diVerent and depended on the
spread of disease and the type of complications. The modi-
Wcations of the CWD procedure are listed in Table 7. The
most common open techniques applied were RTM in
34.2% of the patients, RTM with middle fossa dura expo-
sure in 14% and RTM with lateral sinus exposure in 11.4%.
The end results regarding the management of this series
of patients were the following: seventy-seven patients
(84.6%) were cured and followed as outpatients for at least
1 year. Conversely, 10 patients (11%) were transferred to
other departments, three died and one patient left our
department. In addition, one patient was transferred to the
Abdominal Surgery Department because of acute abdomi-
nal distress. The three patients who died had intracranial
complications: two had meningitis and one had meningitis
and a brain abscess.
Discussion
Adam Politzer in 1869 (published in 1909) clearly identi-
Wed the potential seriousness of otitis media in the preanti-
biotic era based on the anatomic location and boundary
with vital structures by stating that “the temporal bone has
four sides: the outside is bounded by life, from which there
comes the opening of the auditory canal, one form of our
appreciation of what life means; on the other three sides
this bone is bounded by death”. The advent of antimicrobi-
als, an increasing of awareness of physicians and the public
regarding the potential seriousness of disease and diagnos-
tic methods yielding earlier identiWcation and treatment
immensely reduced the incidence of lethal complications
[6, 7].
With regard to the prevalence and incidence of compli-
cations, many studies have counted the prevalence of
patients having COM with cholesteatoma who develop
complications, because calculating the incidence was not
appropriate. The results of large series of patients have
shown a similar rate of otogenic complications compared to
the results of our series. During a 9-year period (1990–
Table 5 Isolated bacteria from ear swabs
Bacteria Number (N) Percent (%)
Proteus mirabilis 11 33.3
Staphyloccocus aureus 5 15.2
Proteus vulgaris 4 12.1
Pseudomonas spp. 4 12.1
Citrobacter 39.1
E
scherichia coli 39.1
Streptoccocus pneumoniae 13.0
Klebsiella pneumoniae 13.0
M
organella morganii 13.0
Total 33 100.0
Table 6 Surgical procedures applied in patients with complications
Surgical procedure Number (N) Percent (%)
Radical tympano-mastoidectomy 79 86.8
Simple mastoidectomy +
tympanoplasty
66.6
Mastoidectomy 5 5.5
Antrotomy 1 1.1
Total 91 100.0
Table 7 The modiWcations of CWD procedures applied in 79 patients
with cholesteatoma complications
R
TM radical tympano-mastoidectomy, MFDE middle fossa dura expo-
sure, SSE sigmoid sinus exposure, TOT tympanoplasty in open tech-
nique
CWD procedure Number (N) Percent (%)
RTM 27 34.2
RTM + MFDE + SSE 12 15.2
RTM + MFDE 11 13.9
RTM + SSE 9 11.4
RTM + labyrinthine Wstula closure 7 8.9
ModiWed RTM 3 3.8
Revision RTM 3 3.8
RTM + facial canal plasty 2 2.5
TOT 1 1.3
TOT + craniotomy 1 1.3
RTM + perizygomatic
abscess incision
11.3
RTM + SSE + Bezold’s
abscess evacuation
11.3
RTM + Middle fossa
extradural abscess evacuation
11.3
Total 79 100.0
Eur Arch Otorhinolaryngol
123
1999), of 2,890 patients with acute and chronic otitis
media, Osma et al. found 93 cases involving complications,
which consisted of 57 IC cases (59%) and 39 EC cases
(41%), suggesting that 3.22% of all patients with middle
ear infections develop a complication [8]. Kangsaranak
et al. reviewed 17,000 patients with COM and found 102
cases with IC and EC complications; they calculated the
prevalence of complications as 0.69% among populations
with suppurative COM [9]. This same group reviewed
another series of 24,321 patients from a 13-year period and
found 87 cases with 140 IC complications; they calculated
a prevalence of 0.36% for IC complications [10]. As a com-
parison, we found complications in 5% of the cases in our
series (91 out of the 1,803 patients with acute and chronic
otitis media). Our prevalence was high because our series
consisted of inpatients. If we had included the outpatients
with COM, we would likely have obtained a much lower
prevalence that was similar to the results in the literature.
The highlight of our results is the Wnding that CCOM
developed complications in 33.5% of the cases in our
patient series, whereas COM without cholesteatoma devel-
oped complications in only 2% of the cases.
The duration from the onset of disease to the appearance
of complications was important in our work. In our series, the
mean duration of disease was 8.6 years. More than 62% of
the patients reported a duration of 1–15 years, while 17% had
duration of less than 1 year, which was similar to the percent-
age of patients with disease duration of more than 15 years.
Studies on the complications of cholesteatoma have
found diVerent percentages of the men-to-women ratio. In
the series of Osma et al. involving 93 patients [8], the
authors found a signiWcant diVerence in the men-to-women
ratio of 2:1. In contrast, Keles et al. in a series of 51 patients
did not Wnd a signiWcant diVerence in the men-to-women
ratio, observing that 57% of the patients were men and 43%
were women [11]. In our series, of the 91 patients with
complications from cholesteatoma, we found that 60%
were men and 40% were women.
Complications due to cholesteatoma can occur in
patients of all ages, from infants to older adults [812]. In
our series, the age structure of the patients was diVerent,
with a slight domination in the 11- to 20-year-old group.
The mean age was 30 years, and the patients ranged in age
from 1 to 70 years.
COM is a suppurative bacterial infection, and its causa-
tive agents can be isolated using ear swabs. This is impor-
tant because primary surgical therapy must always be
complemented with antibiotic therapy chosen according to
the microbiology lab results. In a meta-analysis of seven
publications, of a total of 280 patients, Dhooge et al. found
that Streptococcus pneumoniae was the most commonly
isolated causative agent, occurring in 23% of cases. Staphy-
lococcus coagulase-positive bacteria were seen in 19% of
cases. Streptococcus -hemolyticus group A was seen in
16% of cases, and Haemophilus inXuenzae was detected in
2% of the cases. They also found that 20% of cases did not
show pathogenic bacteria in the cultures [13]. Other studies
have suggested that Pseudomonas aeruginosa is the leading
causative pathogen in COM with cholesteatoma [14, 15]. In
our series, material for microbiology analyses was only
taken from 33 patients, and the most frequently isolated
bacterial agent was from the Proteus group as follows: Pro-
teus mirabilis
from 33% of the swabs, Staphylococcus
aureus from 15%, Proteus vulgaris from 12% and Pseudo-
monas spp. from 12%. Streptococcus pneumoniae was only
isolated from 3% of the swabs. Antibiotic therapy in cases
with microbiology lab results is determined by an antibio-
gram, whereas antibiotic therapy is determined by empiri-
cal evidence in cases without lab results. In cases with
meningitis, therapy is given after consultation with an
infectious disease specialist.
Although the clinical history and clinical exam play
important roles in the diagnosis of complications, the main
diagnostic tool is clinical imaging. The gold standard is CT,
because this imaging provides a good view of bony struc-
tures; magnetic resonance imaging (MRI) is better for the
visualization of soft tissue pathologic changes. According
to the protocols of many centers, the suspicion of a compli-
cation necessitates a CT scan within the Wrst 24 h of admit-
tance, in coronal and axial cuts at 1-mm slices, using a high
resolution of 30–50 mA.
When an intracranial complication is suspected, a con-
trast CT scan must be performed. MRI T-1- and turbo T-2-
weighted scans allow better visualization of brain soft tis-
sue and blood vessels in coronal and axial sections with or
without contrast [16]. The sensitivity of CT in the current
diagnosis of intratemporal complications is reported to be
87–100% [17, 18]. In our series, the majority of patients did
not receive CT scans for the diagnosis of complications,
because these devices were not prevalent in Kosovo in the
late 1990s. Temporal bone plain X-rays were applied in
77% of the patients in our series, and CT scans were only
applied in 24%. MRI was not applied to any patient. The
other diagnostic procedures included laboratory Wndings
(ESR, WBC) and the results of lumbar puncture.
A wide range of surgical techniques are used for the
treatment of complications due to cholesteatoma, but the
only eVective treatment is surgery. For EC complications,
otosurgeons must be fully trained to deal with all possible
complications and to adapt the approach and surgical
method to achieve a clean and dry ear for a long time dur-
ing the follow-up. For IC complications, close cooperation
between otosurgeons and neurosurgeons is mandatory [19].
In recent publications, the authors have agreed that oto-
genic meningitis must be treated with middle ear surgery
(mastoidectomy, simple or radical) in combination with
Eur Arch Otorhinolaryngol
123
antibiotics. For lesions located adjacent to the dura or teg-
mental area, such as extradural abscesses and sigmoid sinus
thrombosis, mastoidectomy performed by an otosurgeon is
the only necessary approach. For deep cerebral and cerebel-
lar abscesses, craniotomy performed by a neurosurgeon
working with otosurgeons is the treatment of choice [20].
In our series, all patients with EC complications were
treated in the ENT Clinic by a senior otosurgeon. No deaths
were recorded among the EC complications group. The IC
complications group was treated primarily in the ENT
Clinic with mastoidectomy alone or in combination with
sigmoid sinus exploration in cases with thrombosis of the
sigmoid sinus. Patients with deep cerebral abscesses were
treated surgically twice: Wrst by mastoidectomy in the ENT
Clinic and second by craniotomy in the Neurosurgery
Clinic. Three deaths occurred in this group: two patients
with otogenic meningitis and one with a cerebral abscess
died, representing a mortality rate of 3.3% among the
patients with complications.
Conclusions
Patients having COM with cholesteatoma develop
complications more often than patients having COM
without cholesteatoma; so the management of patients
with cholesteatoma must be a priority for the ENT
health care system.
The treatment of the complications due to cholestea-
toma is surgical, and trained otosurgeons must be ready
to perform all needed interventions.
Complications of COM with cholesteatoma represent
life-threatening conditions, and close cooperation
among otosurgeons, neurosurgeons and infectious dis-
ease specialists is mandatory.
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... Unfortunately, the recurrence rate was estimated between 30% [32] and 12% [33]. Intriguingly, the recurrence rate is correlated to the inflammatory state of the tissue [34], hence physicians try to reduce the inflammation and secondary infections to prevent the recurrence by application of antibiotics and hydrocortisone. This study is designed to provide a deeper understanding of the process of cholesteatoma formation and recurrence by inflammation utilizing in vitro models. ...
... Taken our experimental results together, the high recurrence upon infection of cholesteatoma [34] might be supported by an enhanced proliferation of ME-CFs and the increased epidermal differentiation of ME-CSCs upon paracrine stimulation of ME-CFs both caused upon TLR4 stimulation. Importantly, we found the TLR4 signalling reacts much more sensitive upon LPS stimulation in ME-CSCs and ME-CFs compared to ACSCs and ACFs resulting in the pathological inflammatory state in cholesteatoma tissue. ...
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Background: Cholesteatoma disease is an expanding lesion in the middle ear. Hearing loss and facial paralysis alongside with other intracranial complications are found. No pharmaceutical treatment is available today and recurrence after surgical extraction occurs. We investigated possible TLR4-based mechanisms promoting recurrence and explore possible treatments strategies. Methods: We isolated fibroblasts and epidermal stem cells from cholesteatoma tissue and healthy auditory canal skin. Subsequently, their expression under standard culture conditions and after stimulation with LPS was investigated by RT-qPCR. Cell metabolism and proliferation were analysed upon LPS treatment, with and without TLR4 antagonist. An indirect co-culture of fibroblasts and epidermal stem cells isolated from cholesteatoma tissue was utilized to monitor epidermal differentiation upon LPS treatment by RT-qPCR and immunocytochemistry. Results: Under standard culture conditions, we detected a tissue-independent higher expression of IL-1β and IL-8 in stem cells, an upregulation of KGF and IGF-2 in both cell types derived from cholesteatoma and higher expression of TLR4 in stem cells derived from cholesteatoma tissue. Upon LPS challenge, we could detect a significantly higher expression of IL-1α, IL-1β, IL-6 and IL-8 in stem cells and of TNF-a, GM-CSF and CXCL-5 in stem cells and fibroblasts derived from cholesteatoma. The expression of the growth factors KGF, EGF, EREG, IGF-2 and HGF was significantly higher in fibroblasts, particularly when derived from cholesteatoma. Upon treatment with LPS the metabolism was elevated in stem cells and fibroblasts, proliferation was only enhanced in fibroblasts derived from cholesteatoma. This could be reversed by the treatment with a TLR4 antagonist. The cholesteatoma fibroblasts could be triggered by LPS to promote the epidermal differentiation of the stem cells, while no LPS treatment or LPS treatment without the presence of fibroblasts did not result in such a differentiation. Conclusion: We propose that cholesteatoma recurrence is based on TLR4 signalling imprinted in the cholesteatoma cells. It induces excessive inflammation of stem cells and fibroblasts, proliferation of perimatrix fibroblasts and the generation of epidermal cells from stem cells thru paracrine signalling by fibroblasts. Treatment of the operation site with a TLR4 antagonist might reduce the chance of cholesteatoma recurrence.
... 2 However unsafe type of this disease, also known as attico-antral type usually presents with marginal perforation having cholesteatoma, which is the hallmark of this affection and also considered as the complication producing element. 3 Bone erosion is an established complication of this type and may involve extracranial and intracranial structures. 1 In the past, people were relatively less aware regarding the complications of this disease and so less effective treatment measures were employed resulting in high rate of complications. 4 In the modern era, frequency of complications is markedly reduced due to proper treatment but still the harmful effects of the unsafe disease may produce disaster. 5 Chronic suppurative otitis media with cholesteatoma can spread beyond middle ear, leading to extra cranial and intracranial complications. ...
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Objective: To determine the clinical and operative findings of the patients sustaining chronic suppurative otitis media. Patients and Methods: This descriptive cross sectional study of six months duration was conducted at the department of ENT, Head and Neck Surgery, Hayat Medical Complex (HMC), Peshawar-Pakistan from June 2012 to December 2012. All the patients of any age and either gender having discharging ears for more than three months were included. Those patients having aural discharge due to otitis externa or trauma were excluded from study. All patients having otogenic intracranial complications were first treated by neurosurgeon before treating the primary focus in ears. Mastoid surgery was performed according to the nature and type of disease. Results: A total of 93 patients were enrolled who were 67 male and 26 females with male to female ratio of 2.5:1. These patients were in age range from 5 years to 67 years with mean age of 37+13 years. Most of the patients were from lower socioeconomic group (56%). In this study 90 patients (96.78%) had atticoantral type tympanic perforation while 3 patients (3.22%) presented with tubotympanic type tympanic perforation with commonest presentation of ear discharge (100%).In majority of patients (54.71%) there was mild to moderate hearing loss. In 36 patients (38.7%) total perforation was common among atticoantral type while cholesteatoma was the commonest (47.31%) finding in this disease. Conclusion: Otorrhoea is the common presentation of atticoantral type diseased ear that is best treated with mastoidectomy operation to minimize its complications.
... Subdural abscess is an intracranial complication in this case. When there is suspicion of intracranial complications, the CT scan modality becomes the gold standard, as the sensitivity of CT scanning in assessing intracranial complications is reported to be 87%-100% [8] . Erosion and destruction of a portion of the bone in Trautmann's triangle is the access point for intracranial infection ( Fig. 2 ). ...
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Complications of chronic suppurative otitis media (CSOM) are divided into intracranial and extracranial complications. Bezold abscess is a very rare extracranial complication with an incidence of 1.5% of the total complications of CSOM in a study conducted in China, similarly subdural abscess is a rare intracranial complication with an incidence of 0.3% in the same study. If not given proper and immediate treatment, these complications can be fatal. Head and neck computed tomography (CT) scan is the main modality for diagnosing complications of CSOM. We report the case of a 15-year-old girl with CSOM who suffered from multiple rare and life-threatening intracranial and extracranial complications. CT scan of the head and neck revealed multiple complications, including cholesteatoma with the destruction of the ossicles, a Bezold abscess inferiorly and a subdural abscess intracranially. Surgery was performed twice to remove the abscess, accompanied by antibiotic therapy according to the type of bacterial culture.
... Another explanation for the conflicting results in literature is that not all studies were executed according to the general principles of prophylaxis. The principles of SSI prevention state that antibiotic prophylaxis should be optimally administer 4 min before incision, should target the most likely pathogens (Staphylococcus Aureus and Pseudomonas species), and should be discontinued within 24 h (Govaerts, 1998;Koch, 2013;Mangram, 1999;Mustafa, 2008). ...
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Introduction This study aims to describe the occurrence of postoperative complications related to cholesteatoma surgery and to determine factors influencing the most common complication, i.e. postoperative surgical site infection (SSI) in cases with and without mastoid obliteration. Materials and methods Retrospective analyses were performed on surgically treated cholesteatomas in our hospital between 2013 and 2019. Patient characteristics, peri- and postoperative management and complications were reviewed. The cases were divided into two groups based on whether mastoid obliteration was performed or not. Results A total of 336 cholesteatoma operations were performed, of which 248 cases received mastoid obliteration. In total 21 complications were observed, of which SSI was the most common (15/21). No difference in occurrence of any postoperative complication was seen between the obliteration and no-obliteration group (p = 0.798), especially not in the number of SSI (p = 0.520). Perioperative and/or postoperative prophylactic antibiotics were not associated to the development of an SSI in both groups. In the no-obliteration group a younger age (p = 0.015), as well as primary surgery (p = 0.022) increased the risk for SSI. In the obliteration group the use of bioactive glass (BAG) S53P4 was identified as independent predictor of SSI (p = 0.008, OR 5.940). Discussion SSI is the most common postoperative complication in cholesteatoma surgery. The causes of SSI are multifactorial, therefore further prospective research is needed to answer which factors can prevent the development of an SSI in cholesteatoma surgery.
... In severe cases, cranial nerve VII injury may result in facial paralysis in a lower motor neuron pattern 11 . Finally, if left untreated, cholesteatoma has the potential to erode through the tegmen (roof) of the middle ear and cause intracranial complications, such as meningitis or brain abscesses in an estimated 1.6-7.5% of patients 18,19 . This constitutes a significant paediatric cause of morbidity and death in developing regions with limited access to advanced health care [20][21][22] . ...
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Cholesteatoma is a rare condition affecting 9-12.6 adults and 3-15 children per 100,000 per annum [1–4], with a more aggressive presentation in the paediatric population [5]. Intermittent otorrhea (ear discharge) is the presenting complaint in over half of cholesteatoma patients [6, 7]. The peak incidence of cholesteatoma is 5-15 years of age [8] which overlaps significantly with a period of high incidence in otitis media [9] and externa [10], diseases that often present the same way as cholesteatoma. This results in diagnosis that may take several years. Left untreated, cholesteatoma can cause significant lasting damage in the form of deafness, vertigo, facial paralysis, meningitis, and brain abscesses which may prove fatal [11]. Current treatment options are limited to surgical excision with the aim to establish a safe and manageable ear, while maintaining hearing is secondary. Improving surgical instrumentation has allowed a better success rate, however, revision surgeries remain a mainstay of practice. In practical terms, this means that those affected by bilateral disease often undergo surgery 4 or more times [12]. This represents a significant burden for patients. The decision about the exact surgical approach (canal wall up vs canal wall down) is a careful balancing act of safety versus functionality, and the pros and cons must be weighed in light of available evidence and the skill of the surgeon [13].
... Técnicas de imágenes ponderadas en secuencia de Diffusion-Weighted Imaging (DWI), basadas en la secuencia convencional spin-eco (SE) ponderada en T2, se han vuelto populares en la identificación del colesteatoma debido a su mayor precisión y adquisición más corta en relación con la RM contrastada 16 . La introducción de imágenes non-Echo-Planar Imaging (non-EPI-DWI) ha permitido obtener cortes más delgados con mínimos artefactos, logrando optimizar la detección de lesiones pequeñas, con sensibilidad y especificidad mayor al 90% 7,16,17,[19][20][21] . De este modo, esta sería una técnica confiable para el diagnóstico tanto de colesteatoma y la evaluación de sus complicaciones, contribuyendo al otorrinolaringólogo en la toma de decisiones. ...
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Complicated chronic cholesteatomatous media otitis (CCMO) is an unusual condition nowadays. Complications have traditionally been classified as extracranial and intracranial. The last one entails a higher risk for patients due to high morbi-mortality and neurological consequences associated. Suitable medical care and otorhinolaryngological attention among with preventive measures in pediatric age have decreased the incidence of cholesteatomas and their complications. The following, is the case of a 50-year-old patient treated for CCMO at Guillermo Grant Benavente Hospital in Concepcion (Chile) complicated due to meningoencephalitis and infectious vasculitis without early diagnose due to COVID-19 pandemic. Diagnostic methodology and therapeutic management are exposed.
Article
Objective Cholesteatoma is an aggressive form of chronic otitis media (COM). For this reason, it is important to distinguish between COM with and without cholesteatoma. In this study, the role of artificial intelligence modelling in differentiating COM with and without cholesteatoma on computed tomography images was evaluated. Methods The files of 200 patients who underwent mastoidectomy and/or tympanoplasty for COM in our clinic between January 2016 and January 2021 were retrospectively reviewed. According to the presence of cholesteatoma, the patients were divided into two groups as chronic otitis with cholesteatoma (n = 100) and chronic otitis without cholesteatoma (n = 100). The control group (n = 100) consisted of patients who did not have any previous ear disease and did not have any active complaints about the ear. Temporal bone computed tomography (CT) images of all patients were analyzed. The distinction between cholesteatoma and COM was evaluated by using 80% of the CT images obtained for the training of artificial intelligence modelling and the remaining 20% for testing purposes. Results The accuracy rate obtained in the hybrid model we used in our study was 95.4%. The proposed model correctly predicted 2952 out of 3093 CT images, while it predicted 141 incorrectly. It correctly predicted 936 (93.78%) of 998 images in the COM group with cholesteatoma, 835 (92.77%) of 900 images in the COM group without cholesteatoma, and 1181 (98.82%) of 1195 images in the normal group. Conclusion In our study, it has been shown that the differentiation of COM with and without cholesteatoma with artificial intelligence modelling can be made with highly accurate diagnosis rates by using CT images. With the deep learning modelling we proposed, the highest correct diagnosis rate in the literature was obtained. According to the results of our study, we think that with the use of artificial intelligence in practice, the diagnosis of cholesteatoma can be made earlier, it will help in the selection of the most appropriate treatment approach, and the complications can be reduced.
Article
Introduction: Intracranial Complications (ICC) in patients with Chronic Suppurative Otitis Media-Atticoantral Disease (CSOMAAD) is a life threatening disease. Knowing the microbiological profile of the causative organisms will help in selecting empiric antibiotic. Aim: To determine the demographic pattern and clinical presentation of patients with CSOM-AAD presenting with ICC, and to assess the microbiological profile of causative organisms. Materials and Methods: This was a retrospective study, where medical records of all patients diagnosed with CSOM-AAD and ICC, in a tertiary teaching hospital, Manipal, Karnataka, India, between July 2012 and June 2018 were reviewed. The data regarding demographics, clinical and audiological evaluation, microbiological reports were analysed. Data was entered into Microsoft Excel sheet 2010 and was calculated as mean, median and percentages. Results: Out of total 244 patients with CSOM-AAD, 15 presented with ICC. The age range was between 17-41 years (median age21years). The most common complaint was headache, n=11 (73%) and the most common complication was intracranial abscess, n=10 (67%). In three cases, sampling from different sites isolated different organisms and hence a total of 20 samples (11 from ear swab, six from abscess drained pus, two from cerebrospinal fluid and one from blood culture) were analysed. Gram Negative Bacilli (GNB) were isolated most of the times, n=10 (50%) followed by Gram Positive Cocci (GPC), n=6 (30%) and anaerobes, n=2 (10%). Most of the isolated GNB and GPC were susceptible to carbapenem and vancomycin, respectively. Conclusion: Intracranial complications are usually seen in young adults, and they present with headache, fever and ear discharge. Majority of the complications are caused by GNB. Vancomycin and carbapenem provide empiric cover for GPC and GNB, respectively.
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p> Background: Chronic otitis media is the most common disease dealt by an otologist, the cases of complication of which are remarkably low. The use of antibiotics and mastoidectomies have resulted in the fall of the fatal complications. COVID-19 pandemic called for restrictions which lead to medical care delay. Methods: This study was conducted in the department of otolaryngology of GMC and associated hospitals, Jammu from June 2020 and May 2021. The data was retrospectively collected the data from March 2018 to June 2020. The study group included the patients diagnosed with Chronic suppurative otitis media (CSOM) on otoscopy and the patients with complications of CSOM were evaluated for the symptoms of complication, type of complication, bacteriology, treatment and hospital stay. Results: The 38 (7.5%) patients among these were diagnosed with one or other complication, out of which 29 (76.3%) cases occurred during the COVID pandemic. The extra-cranial complications were more common and young to middle age group was more commonly involved. Conclusions: COM is a common otological disease, the occurrence of which should not be taken lightly. Without timely and accurate treatment, the complications ensue which are difficult to treat and require expertise.</p
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The aim of this study was to investigate the incidence, mortality and morbidity of complications due to chronic otitis media (COM). During the nine-year period 1990-1999, 2890 cases of COM were reviewed, 93 (3.22 per cent) having 57 (1.97 per cent) intracranial complications (IC) and 39 (1.35 per cent) extracranial complications (EC). In three patients more than one complication was observed. Meningitis and brain abscess were common in the IC group. Subperiosteal abscess (mastoid and Bezold's abscess) was a common complication in the EC group. Cholesteatoma and granulation/polyp in the middle ear/mastoid were the major findings in both groups. Fifteen patients died from IC. Overall, the mortality rate was 16.1 per cent in all patients having complications, and in patients with IC it was 26.3 per cent. In all of the patients with complications, the morbidity rate was 11.8 per cent. Our study supports the finding that meningitis and brain abscess are the common complications of COM and the main reason for mortality.
Article
Objectives: To determine the complications of otitis media, and to evaluate its diagnosis and treatments.
Article
During the eight-year period, 1983-1990, 102 cases of intracranial (IC) and extracranial (EC) complications from 17 144 suppurative otitis media were reviewed. The prevalence of each complication was 0.24 and 0.45 per cent respectively. Facial paralysis, subperiosteal abscess and labyrinthitis were the common complications among the EC group, while meningitis and brain abscess were common in the IC group. Twenty five per cent of the EC group and 44 per cent of the IC group had more than two complications. The reliable warning signs and symptoms for IC complications were fever, headache, earache, vestibular symptoms, meningeal signs and impairment of consciousness. Proteus spp., Pseudomonas aeuruginosa and Staphylococcus spp. were the commonest organisms isolated from both groups. Cholesteatoma and granulation/polyp in the middle ear/mastoid were the major findings in both patient groups. Mortality rate in the IC group was 18.6 per cent. Morbidity rate in each group was 14.3 per cent (EC) and 27.9 per cent (IC) respectively. Epidemiological presentations, clinical features and the result of treatment are discussed.
Article
Among 24,321 patients with otitis media treated at the Otolaryngology Department of Chiang Mai University Hospital from 1978 through 1990, 87 patients had 140 central nervous system complications (0.36%). Multiple complications existed simultaneously in almost 45% of the patients. The group developing the complications were mainly in their second decade of life. Meningitis occurred in 43 patients, brain abscess in 29, perisinus abscess in 23, lateral sinus thrombosis in 16, and extradural abscess in 12 patients. The most striking symptoms and signs were increasing otorrhea, visible cholesteatoma and/or granulations, fever, headache and otalgia, and vestibular symptoms. Proteus mirabilis, Pseudomonas aeruginosa, and staphylococcal organisms were found in almost 80% of patients. Overall mortality was 18.4% with brain abscess being the main cause (31%). Epidemiologic presentation, clinical features, and results of treatment for each disease are compared and contrasted to those of previous studies.
In this study we report our experience with 24 patients with acute mastoiditis treated at the University Hospital in Ghent, Belgium. The most common presenting signs and symptoms of acute mastoiditis were an abnormal tympanic membrane (21/24), otorrhea (17/24) and earache (13/24). Postauricular edema and erythema with protrusion of the ear, often used as a diagnostic criterion, was present in only 3 patients. Demineralisation of the trabeculae was the most frequent radiological finding (13/24). Based on CT findings a distinction was made between two groups: acute incipient mastoiditis (13/24) and acute coalescent mastoiditis (5/24). Thirteen patients recovered with conservative therapy consisting of IV antibiotics and early myringotomy with or without placement of a ventilation tube. Mastoidectomy was required in 11 patients. Nine patients presented with a complication of infection extending beyond the mastoid compartment. The results are discussed and the value of CT scanning as a diagnostic tool and decisive element in the choice of therapy is analysed.
Article
The purpose of this study was to determine the factors that are important for the early diagnosis of intracranial and intratemporal complications of otitis media. The study design was a retrospective follow-up study. The study took place at a tertiary referral center. The medical history of 23 patients with intracranial and intratemporal complications of otitis media was analyzed. Diagnostic and therapeutic procedures were performed. Age, initial diagnosis, final diagnosis, early presenting symptoms, otoscopic findings, time interval between the first manifestation of symptoms and the start of therapy, and follow-up status were measured. In almost all patients, early symptoms included persisting fever and headache. High morbidity and mortality were correlated to a prolonged time interval between the early symptomatology and start of treatment. Doctor's delay was regarded as the most significant delaying factor. Early diagnosis of otogenic complications of otitis media based on the early symptoms persisting fever and headache can reduce morbidity and mortality associated with these complications.
In recent years, a rise in the incidence of intratemporal and intracranial complications of acute otitis media (AOM) has been mentioned in the literature. Lack of a well-developed immune system and difficulties in diagnosing AOM, can account for part of the rise in the incidence of complications of purulent middle ear infections in young children. Antibiotic treatment of AOM is certainly not an absolute safeguard against the development of complications. Antibiotic therapy may have a masking effect on significant signs and symptoms of complications, causing delay in diagnosis. Myringotomy, especially in young children, should not be forgotten for drainage and to provide material for culture. Increased virulence of the causative pathogens cannot be ruled out, but to date there is no evidence suggesting it. We have to maintain a high level of clinical awareness. If there is insufficient improvement of the patient with the appropriate conservative treatment, radioimaging followed by the necessary surgical procedures should be performed.
To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics. A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. Nine secondary or tertiary academic or non-academic referral centers. Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy). Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.