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Middle Ear Pathophysiology and Management Viewed from Pressure

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Middle Ear Pathophysiology and Management Viewed from Pressure PS 1 Middle Ear Pathophysiology and Management Viewed from Pressure-Regulation Function Haruo Takahashi Department of Otolaryngology – Head and Neck Surgery, Nagasaki University Graduate School of Biomedical Sciences It is well known that the middle ear (ME) pressure should be always kept atmospheric in order to maintain its efficient sound conductive function. For this purpose, there are two ME pressure-regulation systems; one is the eustachian tube (ET) and the other is transmucosal gas exchange, mainly in the mastoid. The ET function is known comparatively well, but the gas exchange function is not known so well. In my presentation, I first explain briefly the normal physiology of the gas exchange function, and then what happens to this important function under the condition of various ME diseases such as otitis media with effusion or cholesteatoma, and what happens to this function after ME surgery. Finally, I would like to propose the algorism of appropriate choice of ME surgical procedures according to pathophysiological conditions of the ME as well as to surgical intervention to the mastoid. PS 2 Otic Capsule Dehiscence Syndrome: Clinical Features, Comparison to Superior Semicircular Canal Dehiscence Syndrome and Longitudinal Cognitive Recovery with Surgery P. Ashley Wackym1, Carey D. Balaban2, Heather T. Mackay1, Dale M. Carter1, David A. Siker1, Scott J. Wood3 1Ear and Skull Base Center, Portland, OR 2University of Pittsburgh, Pittsburgh, PA 3Azusa Pacific University, Azusa, CA, USA Objective: (1) To longitudinally study two patient cohorts with superior semicircular canal dehiscence syndrome (SSCDS): one with radiographically confirmed superior semicircular canal dehiscence (SCD); and the other with no identified otic capsule dehiscence (no-iOCD). (2) Patients with peripheral vestibular dysfunction due to gravitational receptor asymmetries have cognitive dysfunction and assumed neurobehavioral sequelae. Pre- and postoperatively quantitatively measurement in a cohort of patients with superior semicircular canal dehiscence syndrome (SSCDS) symptoms with: superior canal dehiscence (SCD); and otic capsule defects not visualized with imaging and repaired with round window reinforcement (RWR); or both was completed. Study design: Two prospective patient series. Setting: Tertiary referral center. Patients: (1) Eleven adults and one child with SSCDS were identified, surgically managed and followed: six had radiologically confirmed SCD; and six had no-iOCD. Six adult patients with SCD underwent a middle cranial fossa approach with plugging procedures. Five adult patients and one child underwent round window reinforcement (RWR) surgery. One SCD patient developed a no-iOCD 1.5 years after SCD surgery and underwent RWR surgery. (2) There were 13 adult and 4 pediatric patients with superior semicircular canal dehiscence syndrome (SSCDS) who had completion of neuropsychology test batteries pre- and every 3 months postoperatively. Eight had RWR exclusively, 5 had SCD plugging exclusively, and 4 had both. Interventions: (1) Prospective structured symptomatology interviews, diagnostic studies, 3D high-resolution temporal bone CT data and retrospective case review. (2) Completion of a neuropsychology test battery preoperatively and at 3, 6, 9 and 12 months postoperatively that included: Beck Depression Inventory-II (BDI); Wide Range Intelligence Test (WRIT FSIQ) including average verbal (crystallized intelligence) and visual (fluid intelligence); Wide Range Assessment of Memory and Learning (WRAML), including the four domains of verbal memory, visual memory, attention/ concentration and working memory; and Delis-Kaplan Executive Function System (D-KEFS). Main outcome measures: (1) Patient symptomatology, including video documentation; and results of diagnostic studies. (2) Quantitative and statistical analysis of their cognitive and neurobehavioral function. Results: (1) The mean age for the SCD group was 41.8, with a range of 29.5 to 54 years at first surgery. The mean age for the no-iOCD group was 32.2, with a range of 13.2 to 51.6 years at first surgery. There were 10 females (83%) and two males (17%). One male was in each group. The symptomatology preoperatively was no different between the groups, other than the character of the migraine headaches. Resolution of the symptoms of SSCDS ultimately occurred in all patients. Both SCD and no-iOCD groups showed highly significant improvement in postural control following treatment (Wilcoxon Signed Rank, p<0.001). (2) There was a significant decrease in the BDI for all groups. For the WRAML, there was a statistically significant improvement for visual memory and verbal memory for the RWR only and Both groups, but no mean improvement for the SCD only group. All three groups had improvement in the attention/concentration domain. There was no change in working memory for all groups. The IQ scores were unchanged. Conclusions: (1) The nomenclature of otic capsule dehiscence syndrome more accurately reflects the clinical syndrome of SSCDS since it includes SCD and no-iOCD, as well as posterior and lateral semicircular canal dehiscence; all of which can manifest as SSCDS. (2) Overall there was a marked improvement in cognitive and neurobehavioral function postoperatively. Variability may result from duration of underlying disease before intervention. The initial decrement or delay in performance improvement measured in several patients may represent brain reorganization. Greater longitudinal data and greater subject numbers are necessary to better understand and optimize cognitive recovery. PS 3 Our Experience with the World’s First Middle Ear Implantable Hearing Aid Developed in Japan Naoaki Yanagihara Emeritus Professor Ehime University, Medical School Department of Otolaryngology, Middle Ear Surgical-center, Takanoko Hospital Implantation of a sound-amplifying device in the middle ear is a fascinating way to overcome some of the disadvantages of conventional hearing aids, such as sound distortion, acoustic feedback, discomfort from wearing an earphone, and cosmetic appearance. In 1983, we developed the world’s first implantable hearing aid (IHA), the Rion Ehime (E)-type device. It was a partial implantable type in which the ossicular vibrator element of a piezoelectric ceramic bimorph was coupled directly to the stapes. The vibrator was activated by sound signals that were transmitted through the retroauricular skin using an electromagnetic induction system. The first device was successfully implanted in 1985. Since then, it has been implanted in 53 patients with bilateral deafness at four institutions, in the ears with mixed hearing loss that could not be rehabilitated with routine middle ear surgery. All of the patients were followed for as long as the device continued to function. Although many patients accepted the IHA enthusiastically because of the high quality of sound and easy use, its manufacturer ceased production in 2005 because the company did not profit sufficiently, mainly due to the government regulation of medical products in Japan. Experience with surgery and long- term follow-up studies of the patients prompted us to summarize the IHA project by analyzing the device problems and postoperative difficulties leading to device removal or reimplantation. This presentation focuses on the present status of the patients, device problems, postoperative difficulties, and measures used to counter the problems and difficulties. From the long-term follow-up studies, we learned that: 1. The device can be used to rehabilitate mixed deafness that cannot be rehabilitated satisfactorily with either surgery or a conventional hearing aid. It can function satisfactorily in the ear for up to 23 years. 2. The device provides a natural sound quality without feedback or wearing discomfort. The quality of hearing afforded by the device is very close to that perceived by physiological hearing. 3. No sensorineural hearing loss attributable to long-term use of the device was seen in any of the patients. 4. The implant operation could be repeated safely and the patients found the implant very satisfying. We hope that a review of the long-term data will help with future planning and the design of more sophisticated hearing devices implantable in the middle ear. Ultimately, we hope that a new device will be developed and introduced. RT1 Tympanoplasty: Decision Making Moderator: O. Nuri Ozgirgin, Turkey The surgical techniques for tympanoplasty depends on the disease affecting the middle ear and the mastoid. In case of simple chronic otitis media or non-complicated otitis media with granulation tissue formation it is almost possible performing the intact canal wall technique. Even sometimes the granulation tissue nearby the structures such as facial nerve or oval window can create difficulty this can be managed. Of course it is always preferred performing the surgery after controlling the discharge and active infection. However in case of cholesteatoma the situation is always challenging. The two main issues to be issued are controlling the residual and recurrent Cholesteatoma. The key points to these are; the surgeon should know the pathogenesis of cholesteatoma and the factors contributing to cholesteatoma formation very well, as well as the anatomic structures of the middle ear and how to access there. The most crucial parts where the residual cholesteatoma presents itself are the sinus tympani and the attic area. So the drilling and exploring should be directed to these areas. The ventilation
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