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Assessment of Bone Conduction Thresholds After Surgical Treatment in Patients with Labyrinthine Fistula Turkish Archives of Otorhinolaryngology Turk Arch Otorhinolaryngol 2018; 56(2): 89-94 89 Türk Otorinolarengoloji Arşivi Assessment of Bone Conduction Thresholds After Surgical Treatment in Patients with Labyrinthine Fistula Müzeyyen Yıldırım Baylan1 , Ümit Yılmaz1 , Zeki Akkuş2 , İsmail Topçu1 1Department of Otorhinolaryngology, Dicle University School of Medicine, Diyarbakır, Turkey Original Investigation 2Department of Biostatistics, Dicle University School of Medicine, Diyarbakır, Turkey Abstract Objective: This study aimed to analyze the bone con- years. In the post-operative period, it was possib- duction thresholds before and after surgery in chronic le to conduct audiological follow-up on 20 patients. otitis media patients with cholesteatoma who had In these follow-ups, 16 patients showed no change labyrinthine fistula and whose cholesteatoma matrix in bone conduction thresholds, two patients showed had been completely cleaned. worsening, and two showed improvement. When Methods: The study was performed between 2013 pre- and post-operative bone conduction thresholds to 2017 with 23 chronic otitis media patients who at each frequency were compared separately, no sig- had labyrinthine fistula with cholesteatoma and who were operated at the Department of Otorhinolar- nificant difference was found (p=0.937). No statis- yngology of Dicle University School of Medicine. tically significant difference was found between the Patients were assessed by anamnesis and examina- pre- and post-operative means at the four frequencies tion and when necessary, by temporal computerized (p=0.712). tomography and diffusion magnetic resonance ima- Conclusion: In this study, we found that to reduce ging. Bone conduction thresholds at frequencies of complications relating to cholesteatoma, it might be 500, 1000, 2000, and 4000 Hz were determined by audiometric examination and they were compared necessary to completely remove the matrix especially before and after surgery. in the case of type 1 and 2 labyrinthine fistulas. Results: Of the 23 patients, 12 were female and 11 Kewords: Cholesteatoma, labyrinthine fistula, masto- ORCID IDs of the authors: M.Y.B. 0000-0002-7537-1733; were male; their age range was 10–55 (26.04±14.13) idectomy, hearing loss Ü.Y. 0000-0003-1227-153X; Z.A. 0000-0002-6161-3666; İ.T. 0000-0002-6192-1546. Introduction open-cavity technique because of the risk of hear- Labyrinthine fistula is formed by the erosion of ing loss in patients with labyrinthine fistula (1, 2). Cite this article as: Yıldırım Baylan M, Yılmaz Ü, Akkuş Z, Topçu İ. Assessment of the bony labyrinth. Erosion of the cochlea, vesti- However, we have realized on the basis of our clin- Bone Conduction Thresholds After Surgical bule or semicircular canals is regarded as labyrin- ical experience that cholesteatoma recurs in pa- Treatment in Patients with Labyrinthine Fistula. Turk Arch Otorhinolaryngol 2018; thine fistula and often occurs because of choleste- tients in whom the matrix remains and problems 56(2): 89-94. atoma (1, 2). The treatment of chronic otitis media relating to cholesteatoma such as ear discharge, This study was presented at the 5th National with cholesteatoma is entirely surgical, but when dizziness, and hearing loss continue. Therefore, Otology and Neurotology Congress, May 4-7 2017, Antalya, Turkey. labyrinthine fistula is present, removing the cho- now the cholesteatoma matrix is cleaned as much lesteatoma matrix on the fistula carries the risk of as possible in our patients and the mastoid cavity Corresponding Author: Müzeyyen Yıldırım Baylan; muzeyyenyldrm@ sensorineural hearing loss (1, 2). obliteration technique is preferred. hotmail.com Received Date: 19.01.2018 Accepted Date: 21.03.2018 A number of studies have discussed the surgical This study aimed to analyze the bone conduction © Copyright 2018 by Official Journal of the Turkish approach on patients with labyrinthine fistula. thresholds before and after surgery in chronic oti- Society of Otorhinolaryngology and Head and Neck Surgery Available online at However, there is still no consensus on the surgical tis media patients with cholesteatoma who had www.turkarchotolaryngol.net method to be used. Some surgeons advocate that the labyrinthine fistula and whose cholesteatoma ma- DOI: 10.5152/tao.2018.3238 matrix should not be removed and recommend the trix had been completely cleaned. 90 Yıldırım Baylan et al. Bone Conduction Thresholds in Labyrinthine Fistula Turk Arch Otorhinolaryngol 2018; 56(2): 89-94 Methods Bone conduction thresholds at frequencies of 500, 1000, 2000, The study was performed between 2013 to 2017 with 23 chronic and 4000 Hz were determined by audiometric examination. otitis media patients who had labyrinthine fistula with choleste- Audiometric examinations were performed before and three atoma and who were operated at the Department of Otorhino- months after the surgery in the same department using the laryngology of Dicle University School of Medicine. This study same equipment (Clinical Audiometer AC33 Interacoustics was approved by the Ethics Committee of Dicle University A/S, Assens, Denmark). Before and after the surgery, frequen- School of Medicine, and written informed consent was obtained cy-specific bone conduction thresholds were recorded on au- from all the patients. diograms. In the audiological measurements, bone conduction means were taken at frequencies of 500, 1000, 2000, and 4000 Cholesteatoma stage assessment was conducted on the basis of Hz. The data were compared statistically. Also, the post-opera- European Academy of Otology and Neurotology and Japanese tive bone conduction mean (the mean of the threshold at four Otological Society (EAONO/JOS) (3). The type of fistula was frequencies) showing a reduction of more than 10 dB com- determined according to Dornhoffer and Milewski classifica- pared with the pre-operative value was classified as better, an tion (4) (Table 1). In addition, the locations of the fistulas were increase of more than 10 dB as worse, and a change of less than recorded as lateral semicircular, posterior, superior semicircular 10 dB as unchanged. canal, round window, or cochlea-vestibule. Patients were as- sessed by anamnesis and examination and when necessary, by Statistical analysis computerized tomography and diffusion magnetic resonance The Shapiro–Wilk test was used to analyze the distribution imaging. Audiometric examination was performed on all pa- of the results. The non-parametric Wilcoxon test was used to tients. Operations were performed under general anesthesia by a compare the results because the distribution of the pre- and single surgeon. During surgery, the cholesteatoma matrix on the post-operative bone conductions was not normal. Mean±stan- fistula was completely cleaned in the final stage, and the fistula dard deviation was used to analyze the age and sex distribution. was covered with autograft materials such as temporal muscle All statistical analyses were performed using the SSPS software fascia, bone pate, and cartilage. (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) Table 1. Dornhoffer and Milewski classification (4) Results The study included 23 patients with labyrinthine fistula because Type of fistula they had chronic otitis media with cholesteatoma. Overall, 12 Type 1 Erosion of the bony labyrinth but intact endosteum patients were female and 11 were male, and their age range was Type 2 Erosion of the endosteum but membranous labyrinth is 10–55 (26.06±14.03) years. intact According to EAONO/JOS (1), all of the patients had ac- (2a: intact perilymhatic space, 2b: erosion of the perilymhatic space) quired cholesteatoma, 19 at stage 3 and three at stage 4. In three of the patients with stage 3 cholesteatoma, there was also Type 3 Erosion of the membranous labyrinthine space the presence of House–Brackmann stage 4 and 5 facial paral- Table 2. Type and number of labyrinthine fistulas* Type of fistula Number of fistulas (n) Locations of fistulas Other concomitant complications **Type 1 5 LSC(4/5) None SSC(1/5) **Type 2a 12 LSC(10/12) SSC(2/12) Cerebellar abscess (n=1) Cochlea basal turn- vestibule (1/12) Sigmoid sinus thrombosis (n=1), Round window(1/12) Hydrocephalus (n=1) Type 2b 4 LSC(4/4) Facial paralysis (n=1) **Type 3 3 LSC, Cochlea/vestibule (1/3), Facial paralysis (n=2) LSC, PSC, SSC, Cochlea/vestibule (1/3) LSC and PSC(1/3) LSC: Lateral semicircular canal; SSC: Superior semicircular canal; PSC: Posterior semicircular canal *Information from 23 patients was used **There was more than one type of the fistula in the same patient Turk Arch Otorhinolaryngol 2018; 56(2): 89-94 Yıldırım Baylan et al. Bone Conduction Thresholds in Labyrinthine Fistula 91 ysis. In the three patients with stage 4 cholesteatoma, there provement had only lateral semicircular canal fistulas classi- was cerebellar abscess, sigmoid sinus thrombosis, and hydro- fied as type 1 and type 2a (Table 3). cephalus. Labyrinthine fistulas were found in a single area in 17 patients and in more than one area in five patients. Fistulas When pre- and post-operative bone conduction thresholds at were present in the lateral semicircular canals of 19 patients, each frequency were compared separately, no significant differ- in the superior semicircular canals of four patients, in the pos- ence was found (p=0.937) (Table 4). In addition, no statistically terior semicircular canals of two patients, in the cochlea-ves- significant difference was found between pre- and post-opera- tibule
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