As autophony can be accompanied by several conditions, it is important to find co-morbidities. This paper reports a patient with Kennedy's disease (spinobulbar muscular atrophy, an X-linked, hereditary, lower motor neuron disease) having autophony as the first symptom.

A 62-year-old male presented to the otorhinolaryngology department with autophony that began 2 years previously and worsened after losing weight 3 months prior to presentation. Otoscopic examination demonstrated inward and outward movement of the tympanic membrane, synchronised with respiration. Although he had no other symptoms, facial twitching was found on physical examination. In the neurology department, lower motor neuron disease, with subtle weakness of the tongue, face and upper limbs, and gynaecomastia, were confirmed. He was diagnosed with Kennedy's disease based on genetic analysis.

Autophonia was presumed to be attributed to bulbofacial muscle weakness due to Kennedy's disease, and worsened by recent weight loss. Patients with autophony require a thorough history-taking and complete physical examination to assess the nasopharynx and the integrity of lower cranial function.

This research compares the efficacy of subcutaneous soft tissue and temporalis fascia in tympanic membrane grafting for large tympanic membrane perforations.

A retrospective cohort study compared tympanic membrane graft success rate and hearing outcomes in 248 patients who underwent tympanoplasty using subcutaneous soft tissue (n = 118) or temporalis fascia (n = 130) via the post-auricular approach.

Comparable results were observed in both groups. Tympanic membrane graft success rate was 98.3 per cent (116 ears) in the subcutaneous soft tissue group and 98.5 per cent (128 ears) in the temporalis fascia group. The rate of air–bone gap closure within 20 dB was 54.2 per cent (64 ears) and 60.0 per cent (78 ears) in the soft tissue and temporalis fascia groups, respectively (p = 0.360).

Subcutaneous soft tissue is a reliable and readily available tympanic membrane graft material in both revision and primary tympanoplasty for large tympanic membrane perforations.

Granular myringitis is characterised by de-epithelialisation of the tympanic membrane. Patients present with intermittent otorrhoea, otalgia or itching. With improper or inadequate treatment, granular myringitis could cause ear canal fibrosis and stenosis. There are no standard topical ear drops for granular myringitis. Treatments have inconsistent success rates and variable timelines. This study aimed to compare the effectiveness of treating granular myringitis with 1 and 2 per cent acetic acid solutions for two weeks.

This double-blind, randomised, controlled trial enrolled and randomly allocated 47 participants to 2 groups between October 2021 and June 2022.

After two weeks, the groups’ treatment success rates did not differ significantly. There was a 10 per cent recurrence rate 8 weeks after treatment completion. All patients tolerated the diluted vinegar.

There is no difference in the efficacy of 1 and 2 per cent diluted vinegar in treating granular myringitis for two weeks.

This study aimed to compare the effect of pneumatised and non-pneumatised mastoid on the success of tympanoplasty in terms of rate of graft uptake and air–bone gap improvement.

A comprehensive electronic search of PubMed Medline, Scopus, Web of Science and Cochrane Library was conducted in August 2020 for articles from 1990 to 2020. Selected studies were published in the English language, were conducted on human patients, were concerned with evaluating pre-operative mastoid pneumatisation on tympanoplasty success, were not laboratory studies and were not opinion studies. Five studies were included with 178 patients in the pneumatised group and 97 patients were included in the non-pneumatised group. Comparison between both groups was performed in terms of graft uptake rate and air–bone gap improvement.

Although the pneumatised group showed better graft uptake rate than the non-pneumatised group, there was no statistically significant difference between the two groups in the success rate of tympanoplasty.

Pneumatisation of the mastoid does not significantly affect the success rate of tympanoplasty.

Advice to patients following grommet insertion and waterproofing can vary from clinician to clinician. A laboratory based experiment was performed to determine at what depth water contamination would occur through various grommet tubes.

A novel experimental ear model was developed using an artificial tympanic membrane and ventilation tubes. Water contamination was identified using an effervescent solid that reacts when in contact with water. Measures of dispersion were used to describe the results.

The average depth of water contamination was: 19.64 mm (range = 11–33 mm, standard deviation = 5.55 mm) using a Shepard grommet; 20.84 mm (range = 18–26 mm, standard deviation = 1.97 mm) with a titanium grommet; and 21.36 mm (range = 18–33 mm, standard deviation = 3.03 mm) using a T-tube. Water contamination was possible at depths of 11–33 mm. The average pressure at water effervescent activation was 0.20 kPa.

Submersion underwater at any depth with grommets is likely to lead to middle-ear contamination. These findings are concordant with clinical studies.

To determine the outcomes of tympanoplasty surgery using porcine-derived small intestinal submucosa.

A retrospective audit was conducted in a hospital setting. Thirty-five adult and paediatric patients who received a small intestinal submucosa graft as part of tympanoplasty surgery were retrospectively reviewed. Patients underwent either simple tympanoplasty (n = 26) or complex tympanoplasty as part of a concurrent otological procedure such as atticotomy and mastoidectomy. The main outcome measures were rate of tympanic membrane closure and change in four-frequency mean air–bone gap.

Thirty-one patients had a follow-up period of longer than two months. Closure was obtained in 22 patients (71 per cent). The mean air–bone gap improved from 20.7 to 12.3 dB HL in the simple tympanoplasty group and from 22.3 to 12 dB HL in the complex tympanoplasty group.

Tympanoplasty surgery with small intestinal submucosa is a viable option for patients where autologous graft is not available or in order to minimise donor site morbidity.

Injectable anaesthetic agents, topical creams and aqueous solutions have previously been used to anaesthetise the tympanic membrane for minor ear procedures. Topical creams take 20–30 minutes to work and injectable anaesthetics can cause canal swelling. The effectiveness of lidocaine spray has not previously been investigated in patients undergoing minor ear procedures.

Eighteen participants attending for out-patient grommet insertion or intratympanic steroid injection were prospectively recruited for this study over six months. Post-operatively, they were asked about their perceived level of pain and overall experience.

The median level of pain measured on an 11-point visual analogue scale was 2 out of 10. Forty-four per cent reported the overall experience as pleasant, with the remainder selecting slightly unpleasant (66 per cent). All participants stated they would undergo the procedure again.

Xylocaine spray is simple to administer, rapid-acting and well tolerated by patients for anaesthesia of the tympanic membrane during minor ear procedures in the out-patient setting.

Epithelial migration has been associated with the self-cleansing mechanism of the ear. The rate and pattern of epithelial migration in healthy and pathological ears are reviewed.

Two authors independently screened articles over one month using the following search terms: epithelial migration, epithelial, tympanic membrane, external auditory canal and mastoidectomy cavity.

Ten studies were included. The fastest rate of epithelial migration was observed in the external auditory canal, with a mean of 144.75 μm per day, whereas the slowest epithelial migration was seen in post-mastoidectomy cavities, with a rate of 20 μm per day. Epithelial migration was present in both studies involving post-mastoidectomy cavities.

Epithelial migration is faster in healthy tympanic membrane than in pathological tympanic membrane. The rate of epithelial migration in the external auditory canal was higher in the pathological group than in the healthy group. Epithelial migration is present in post-mastoidectomy cavities.

Decades of clinical observation have led our subspecialty team to suspect that negative nasopharyngeal pressure is associated with attic retraction pocket formation. Furthermore, LaPlace's law, which states that the pressure within a sphere varies with the inverse of the radius, provides the dynamic explanation for why the attic area of the tympanic membrane tends to retract more frequently than the pars tensa.

The attic retraction pockets of 154 patients were classified into grades of severity (grades I–V). Impedance audiometry of middle-ear pressure was measured in the resting state, and after sniffing, swallowing and the Valsalva manoeuvre.

Negative nasopharyngeal pressure (sniffing) caused a diminution of middle-ear pressure of −5 daPa on average in normal ears, and of −24 daPa to −45 daPa for tympanic membranes with attic retraction pockets of grade I to grade V.

Attic retraction pockets are associated with greater collapse of middle-ear volume when negative pressure is created in the nasopharynx. LaPlace's law, and the composition of the pars flaccida, suggests an explanation for why the attic region retracts more than the pars tensa.

This study aimed to evaluate the effect of size, location and shape of tympanic membrane perforations on hearing levels of a large study group treated in a tertiary referral centre.

Medical data of 458 patients with tympanic membrane perforations were evaluated.

A total of 336 patients had normal middle-ear findings during the surgical procedures. There was a significant difference in terms of mean pure tone average and air–bone gap values between posterior-inferior and anterior-inferior perforations (p = 0.005 and p = 0.044, respectively). The mean air–bone gap value of kidney-shaped perforations was significantly higher. Posterior-superior and posterior perforations were significant indicators for ossicular chain defects (p < 0.001; odds ratio, 14.2 and p = 0.004; odds ratio, 3.4, respectively).

Perforations located in the posterior-inferior quadrant caused the greatest hearing loss. The difference between posterior-inferior and anterior-superior or inferior perforations was statistically significant. Posterior perforations had a significant relationship with ossicular chain pathologies. Kidney-shaped perforations caused higher pure tone average and air–bone gap values than annular, elliptical or pinpoint perforations.

This case series, conducted during the coronavirus disease 2019 pandemic, investigates the impact of leaving aural foreign bodies in situ for a prolonged period of time, including the risk of complications and success rates of subsequent removal attempts.

A retrospective study of aural foreign body referrals over a six-month period was carried out.

Thirty-four patients with 35 foreign bodies were identified (6 organic and 29 inorganic). The duration of foreign bodies left in situ ranged from 1 to 78 days. Four patients suffered from traumatic removal upon initial attempts. First attempts made by non-ENT specialists (68.8 per cent) all failed and were associated with a high risk of trauma (36.4 per cent).

Because of the coronavirus disease 2019 pandemic, this is the first case series to specifically investigate the relationship between the duration of aural foreign bodies left in situ and the risk of complications. Our data suggest that prolonged duration does not increase the incidence of complications.

This study aimed to compare graft take rate after tympanoplasty between adults and paediatric patients, cartilage and fascia grafts, and overlay and underlay techniques.

Data were analysed in groups according to the technique (underlay vs overlay), age (paediatric patients vs adults) and graft (cartilage vs temporalis fascia). The main outcome measures were full graft take and the incidence of complications.

A total of 198 patients (208 ears) were included. Overall, full graft take was achieved in 200 ears (96 per cent). The success rate was higher in adults compared with paediatric patients (97.5 per cent vs 92.25, respectively) but the difference was insignificant. Similarly, higher but insignificant graft take rate was found in the cartilage group compared with fascia group (98.6 per cent vs 94.9 per cent, respectively).

All cases of overlay tympanoplasty had full graft take (success rate 100 per cent). In the underlay group, successful graft take was achieved in 154 cases (95 per cent). This difference was statistically insignificant.

This study aimed to evaluate the outcome of granular myringitis treatment of 1 per cent diluted vinegar ear drops or 1 per cent chloramphenicol ear drops and to assess the side effects of 1 per cent diluted vinegar.

Twenty-four patients aged over 18 years and diagnosed with granular myringitis grade I or II within 90 days of symptom onset were included. Patients were equally randomised into either the 1 per cent diluted vinegar group or the 1 per cent chloramphenicol group. Outcome of treatment and side effects were compared between groups. The main outcome measure was completely epithelialised tympanic membrane at the eight-week period.

Eleven of 12 patients treated with 1 per cent diluted vinegar had complete recovery. In the 1 per cent chloramphenicol group, 8 of 12 patients recovered. The difference between groups was not statistically significant (p = 0.156). The observed side effects of diluted vinegar included dizziness and mild external auditory canal irritation.

One per cent diluted vinegar is an interesting option for granular myringitis. Other comparative advantages of 1 per cent diluted vinegar include its low price and no induction of antimicrobial resistance.

To investigate hearing and the take rate of crushed cartilage grafts in tympanoplasty.

In this double-blinded, randomised, controlled trial, 46 patients with tympanic membrane perforation were enrolled. A conchal cartilage graft was used for reconstruction in both intervention and control groups. In the intervention group, crushed cartilage was used. The success rate and hearing results were ascertained every four months over a one-year follow-up period.

A total of 36 patients – 20 in the intervention group and 16 in the control group – completed one year of follow up. There were no statistically significant differences between the two groups in mean air–bone gap, bone conduction threshold, speech discrimination score or speech reception threshold.

The reduction in living cells after crushed cartilage tympanoplasty may decrease the rigidity and the volume of the graft, but may not necessarily improve the hearing results.

To explore the feasibility of constructing a proof-of-concept artificial intelligence algorithm to detect tympanic membrane perforations, for future application in under-resourced rural settings.

A retrospective review was conducted of otoscopic images analysed using transfer learning with Google's Inception-V3 convolutional neural network architecture. The ‘gold standard’ ‘ground truth’ was defined by otolaryngologists. Perforation size was categorised as less than one-third (small), one-third to two-thirds (medium), or more than two-thirds (large) of the total tympanic membrane diameter.

A total of 233 tympanic membrane images were used (183 for training, 50 for testing). The algorithm correctly identified intact and perforated tympanic membranes (overall accuracy = 76.0 per cent, 95 per cent confidence interval = 62.1–86.0 per cent); the area under the curve was 0.867 (95 per cent confidence interval = 0.771–0.963).

A proof-of-concept image-classification artificial intelligence algorithm can be used to detect tympanic membrane perforations and, with further development, may prove to be a valuable tool for ear disease screening. Future endeavours are warranted to develop a point-of-care tool for healthcare workers in areas distant from otolaryngology.

The aim of the present study was to evaluate the surgical and functional results of endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty in the treatment of anterior perforation of the tympanic membrane.

This open-label randomised clinical study was conducted on 71 patients with small- and medium-sized anterior perforations of the tympanic membrane. Graft success rate, hearing results, operative time and complications were analysed.

Graft success rates for endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty were 94.1 and 91.8 per cent, respectively (p > 0.05). Post-operative air–bone gap values significantly improved in both the endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty groups. The average operative time was significantly shorter in the endoscopic butterfly-inlay cartilage myringoplasty group (31.5 minutes) compared to the endoscopic push-through myringoplasty group (41.7 minutes; p < 0.05).

When compared with the endoscopic push-through myringoplasty, the endoscopic butterfly-inlay cartilage myringoplasty technique, which is technically easier to perform, does not require packing and has a shorter operating time. It is a reasonable approach for repair of anterior perforations of the tympanic membrane.

Anteriorly located tympanic membrane perforations can negatively affect surgical success rates. This study aimed to present, using our case series results, endoscopic triple-C (composite chondroperichondrial clip) tympanoplasty as an alternative method in the repair of tympanic membrane anterior quadrant perforations.

This study included patients with a perforation sized greater than 3 mm, who had an anterior quadrant dominant perforation where the anterior portion could not be seen during microscopic examination; all underwent endoscopic triple-C tympanoplasty.

Operating time was 30–79 minutes (mean, 46.6 minutes). The post-operative graft success rate at six months was 92 per cent (23 out of 25). Mean post-operative follow-up duration was 21.5 ± 7.3 months (range, 11–40 months), and no intratympanic cholesteatoma was observed.

Endoscopic triple-C tympanoplasty is a comfortable, minimally invasive alternative method to repair anterior tympanic membrane perforations. The graft success rate and the degree of recovery from hearing loss were in accordance with the literature. However, more reliable results may be obtained in a larger series with longer follow-up times.

A systematic review was conducted to investigate the effectiveness of fibroblast growth factor-2 on the regeneration of tympanic membrane perforation.

The PubMed database was searched for relevant studies. Experimental studies, human randomised controlled trials, prospective single-arm studies and retrospective studies reporting acute and chronic tympanic membrane perforations in relation to two healing outcomes (success rate and closure time), were selected.

All 11 clinical studies investigating the effect of fibroblast growth factor-2 on traumatic tympanic membrane perforations in humans reported a success rate of 89.3–100 per cent, with a closure time of around 2 weeks. Three studies of fibroblast growth factor-2 combined with Gelfoam showed that the success rate of chronic tympanic membrane perforation was 83–98.1 per cent in the fibroblast growth factor-2 group, but 10 per cent in the gelatine sponge groups.

Fibroblast growth factor-2 with or without biological material patching promotes regeneration in cases of acute and chronic tympanic membrane perforation, and is safe and efficient. However, the best dosage, application time and administration pathway of fibroblast growth factor-2 are still to be elucidated.

To determine the diagnostic performance of diffusion-weighted magnetic resonance imaging in the assessment of patients with suspected, but not clinically evident, cholesteatoma.

A retrospective analysis of a prospectively collected database of non-echo-planar diffusion-weighted magnetic resonance imaging studies (using a half-Fourier single-shot turbo-spin echo sequence) was conducted. Clinical records were retrospectively reviewed to determine indications for imaging and operative findings. Seventy-eight investigations in 74 patients with suspected cholesteatoma aged 5.7–79.2 years (mean, 41.7 years) were identified. Operative confirmation was available in 44 ears. Diagnostic accuracy of the imaging technique was calculated using operative findings as a ‘gold standard’. Sensitivity of the investigation was examined via comparison with clinically evident cholesteatoma.

The accuracy of diffusion-weighted magnetic resonance imaging in assessment of suspected cholesteatoma was 63.6 per cent. The imaging technique was significantly less accurate in assessment of suspected cholesteatoma than clinically evident disease (p < 0.001).

Computed tomography and diffusion-weighted magnetic resonance imaging may be complementary in assessment of suspected cholesteatoma, but should be used with caution, and clinical judgement is paramount.

The provision of healthcare education in developing countries is a complex problem that simulation has the potential to help. This study aimed to evaluate the effectiveness of a low-cost ear surgery simulator, the Ear Trainer.

The Ear Trainer was assessed in two low-resource environments in Cambodia and Uganda. Participants were video-recorded performing four specific middle-ear procedures, and blindly scored using a validated measurement tool. Face validity, construct validity and objective learning were assessed.

The Ear Trainer provides a realistic representation of the ear. Construct validity assessment confirmed that experts performed better than novices. Participants displayed improvement in all tasks except foreign body removal, likely because of a ceiling effect.

This study validates the Ear Trainer as a useful training tool for otological microsurgical skills in developing world settings.