Objective: To detect the presence of bacteria in mastoid granulations and compare its prevalence in both types of chronic suppurative otitis media (CSOM). To find out if stage of disease activity, age, duration of disease, and aditus patency relate to obtaining positive cultures.

Study design and setting: A prospective, parallel group study done at a tertiary care referral centre. Mastoid granulations from 79 patients with CSOM undergoing mastoidectomy were processed for anaerobic and aerobic bacteria.

Results: Aerobes were isolated from 57.55 per cent of the tubotympanic and 74.4 per cent of atticoantral disease (p = 0.18). Anaerobic cultures were positive in one case from each group. Monomicrobial growth was detected in 37.5 per cent of tubotympanic and 48.5 per cent of atticoantral disease. Polymicrobial growth occurred in 20 per cent and 25.6 per cent in the tubotympanic and atticoantral groups, respectively. The predominant aerobic isolate was coagulase negative Staphylococcus, followed by Pseudomonas aeruginosa, Staphylococcus aureus, non-fermenting Gram-negative bacteria, Enterobacter and Enterococcus, Proteus species, Citrobacter, non-pathogenic Neisseria, aerobic spore formers were grown only in atticoantral disease. A single isolate of Aspergillus was grown. Correlating the state of disease activity of the ears with positive mastoid granulation cultures, six out of the eight inactive ears were culture positive along with seven out of the nine active and 10 out of the 23 quiescent ears. Positive mastoid granulation cultures were obtained in 60 per cent of those with blocked aditus and 42.9 per cent with patent aditus.

Conclusion and significance: In this study, we found that mastoid granulations are not sterile but harbour polymicrobial pathogens. Positive cultures were obtained irrespective of stage of disease activity, age, duration of disease and aditus patency. The pattern of organisms cultured from safe and unsafe CSOM and also from ears in active, quiescent and inactive stages, were similar. These findings suggest that these organisms may be responsible for mastoid granulations. We also noted that positive cultures had no statistical correlation with aditus patency and duration of disease. We suggest further studies to evaluate the significance of asymptomatic mastoid granulations harbouring organisms and whether opening the mastoid antrum and achieving aditus patency, irrespective of the stage of disease activity, will help improve the long-term surgical outcome and also prevent recurrence of ear discharge.

There has been a steady increase in the number of cases of methicillin-resistant Staphylococcus aureus (MRSA) otorrhoea; this is a growing concern. The purpose of this study was to evaluate the efficacy of topical vancomycin treatment in patients with MRSA otorrhoea. Fifty-five patients with MRSA otorrhoea were prospectively enrolled into the study. Thirty-five patients were treated with vancomycin eardrops as outpatients. The concentration of the locally prepared vancomycin solution was 25 mg/ml. The dose of vancomycin was two drops three times daily for 10 days. As a control group, 20 patients were treated with gentamicin 0.3% solution. Data were analysed by the Mann-Whitney U test to compare the efficacy of vancomycin eardrops and gentamicin eardrops. In the vancomycin group, the otorrhoea was significantly reduced in 33 ears (94%); in the gentamicin group, in four ears (20 per cent); this reduction was statistically significant (P < 0.03). The use of topical vancomycin treatment was effective for patients with MRSA otorrhoea refractory to conventional antibiotic treatment.

A labyrinthine fistula is a frequent complication of long-standing unsafe chronic suppurative otitis media. It is characterized by a slowly progressive erosion of the bony labyrinth. In this paper we present our observations regarding the diagnosis and management in 50 patients with unsafe chronic suppurative otitis media with labyrinthine fistula.

The aim of this study was to determine the effect of surgical approach, intact canal wall (ICW) or canal wall down (CWD), upon the success of revision surgery for chronicotitis media (COM). A retrospective analysis of 367 patients (including 65 children aged <15years) who underwent revision tympanoplasty because of persistent disease was performed. Single-staged tympanoplasty was performed, preserving the canal wall when present. Hearing was reconstructed with allograft incus. Follow-up ranged from one to 15 years. Hearing was determined by pre- and post-operative air-bone gaps.

Post-operative re-perforation, aural discharge and/or cholesteatoma rates were similar for CWD and ICW. Cholesteatoma could present following the revision, even though it was not apparentat surgery. Following tympanoplasty, the final hearing was not significantly affected by the surgical approach or presence of cholesteatoma. Improvement in hearing was adversely affected by cholesteatoma or an absent stapes suprastructure.

Revision ICW and CWD operations were both successful in controlling signs of COM. Cholesteatoma is a peripheral risk in COM and may become apparent after revision surgery.

Understanding the relationship between the anatomy of the fallopian canal and a variety of ear diseases is necessary. In this study, our purpose was to identify the incidence of facial nerve dehiscence in patients undergoing surgery for a variety of chronic ear diseases.

The operative records of 219 patients were reviewed retrospectively for dehiscence of the facial canal. The diagnoses were cholesteatoma (n = 49), tympanosclerosis (n = 51), adhesive otitis media (n = 38), and chronic otitis media (n = 81). Only 17 of 219 who underwent tympanoplasty without mastoidectomy were excluded from the calculations.

Dehiscence of the facial canal was encountered in 18 (8.9 per cent) of 202 patients. The dehiscence rate was highest with cholesteatoma, followed by adhesive otis media, chronic otis media and tympanosclerosis (p<0.01). The canal dehiscence was mainly seen in the tympanic segment and second genu, and was rare in the mastoid segment. Labyrinthine fistula was the most common pathology that coexisted with the dehiscence. It was encountered in two (11.1 per cent) of 18 patients. In conclusion, the likelihood of dehiscent bone covering the tympanic segment of the fallopian canal is significantly higher in cholesteatoma than the other chronic ear diseases. The surgeon can feel somewhat more confident while performing surgery for tympanosclerosis as far as the dehiscence in the fallopian canal is concerned.

A potentially life-threatening case of recurrent left-sided thyroid abscess formation secondary to a fourth branchial arch sinus fistula is presented. The patient developed a reversible left vocal fold palsy during an acute episode of suppurative thyroiditis requiring a temporary tracheostomy due to a compromised airway. Investigations commonly used to demonstrate this anomaly may fail to confirm the diagnosis as in the case presented and exploratory surgery with excision of the fistulous tract should still be considered. We describe a method of repairing the pharyngeal opening to reduce the risk of recurrence or pharyngeal leak.

Twenty-two cases of perforated tympanic membrane due to fungal otitis externa were observed over a five-year period.

The diagnosis of fungal otitis externa was made on clinical grounds due to the obvious presence of fungal bloom in the external ear canal. Some perforations were noted at the first treatment after the fungal debris had been removed from the external ear canal using a microscope. Other perforations were observed to develop over a few days. Initially, a discrete area of the tympanic membrane appeared white and opaque. As time progressed the white area disintegrated, forming a perforation. Once the otitis externa had resolved most perforations healed spontaneously. Two that were observed to develop during treatment required a myringoplasty. Another one closed significantly but a tiny persistent perforation required cauterization with trichloracetic acid to encourage it to close over completely. The only residual hearing loss was in a case with almost total disintegration of the tympanic membrane requiring a myringoplasty.

Treatment of fungal otitis externa for the patients in this series was aural toilet using suction under a microscope and insertion of a gauze wick saturated in a combination of hydrocortisone, clotrimazole, framycetin and gramicidin.

Burow’s solution has been found to inhibit the in vitro growth of most commonly occurring bacteria found in the discharging ear. These organisms were inoculated onto appropriate agar plates that contained serial dilutions of aluminium acetate. Results show that the lowest dilution able to inhibit the growth of these organisms lies between a 1:80 and a 1:160 dilution of Burow’s solution.

Burow’s solution (13 per cent aluminium acetate) has been found to inhibit in vitro the growth of most commonly occurring bacteria found in the discharging ear. An in vitro study has shown that the minimum inhibitory concentration of Burow’s solution for these organisms lies between a 1:80 and a 1:160 dilution. This paper reports on a clinical trial that incorporated 67 discharging ears to establish the most effective strength of aluminium acetate solution. There was no statistical difference in the effectiveness of full strength Burow’s solution compared to 3.25 per cent aluminium acetate solution (a quarter strength Burow’s solution). Response rates of 80.8 per cent and 75 per cent respectively following a two-week treatment period were achieved using these two solutions. A 1.3 per cent aluminium acetate solution (1/10 strength Burow’s solution) was found to be markedly inferior. Bacteriological and audiological profiles were recorded for each patient.

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.

Debate has currently re-emerged following a renewed warning issued from the Committee on the Safety of Medicines (CSM) regarding the relative risk of ototoxicity from the use of aminoglycoside-containing drops in patients with tympanic membrane perforations. We present the findings of a survey of ENT consultants, questioning their views and current practice, and we add to the debate by means of a review and discussion of the literature.

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.

We present a case report which describes a rare cause of a common clinical problem; eustachian tube dysfunction. A seven-year-old child presented with a history of chronic draining ears, despite rigorous medical therapy and multiple ventilation tubes. At myringotomy a mass was noted in the middle ear, and she was taken to the operating room for exploration. The patient was found to have a pedunculated lipoma arising from the anterior medial aspect of the middle-ear cleft producing intermittent obstruction of the eustachian tube orifice. This case represents the fourth case of a middle-ear lipoma in the world literature. We present a review of the literature and an exploration of possible aetiologies of this unusual entity in the differential diagnosis of eustachian tube dysfunction.

Acute otitis media and otitis media with effusion (OME) have often been observed in children with bacterial meningitis. OME has also been proposed as the mechanism of reversible hearing loss after meningitis. In this controlled study, children with acute bacterial meningitis were studied using auditory brainstem responses (ABR), otoacousticemissions, tympanometry and otoscopy. An age- and sex- matched control was recruited for each patient and the incidence of acute otitis media and OME was compared between the twogroups. One hundred and twenty-four children with meningitis were studied. Ninety-two children (74 per cent) had meningococcal meningitis. Five patients (4 per cent) had conductive hearing loss (ABR threshold≥30 dB HL) at the time of discharge from hospital. None of the patients or controls had acute otitis media. Patients and controls were well matched for risk factors for OME and the prevalence of middle ear effusion in patients and controls was 7.2 per cent and 11.3 per cent respectively. The relative risk of OME in the children with meningitis was 0.64 (95 per cent confidence interval 0.29 to 1.42). After nine months, three of the five children with meningitis and conductive hearing loss had regained normal hearing.

In contrast to previous reports, there was no relationship between bacterial meningitis and acute otitis media or OME in this study. Nevertheless, coincidental conductive hearing defects were identified as the cause of reversible hearing loss in three patients.

This retrospective study was undertaken to review the short- and long-term results of 70 revision and 16 re-revision myringoplasty operations. Of the former, 43 cases (61.4 per cent) had initial success, six weeks following surgery. The leading causes of immediate failure (27 cases) were associated with a complete no- take of thegraft, infection with graft necrosis and poor anterior adaptation of the graft in decreasing order. Six out of the 43 patients developed late re-perforations during the follow-up period, thus reducing the success rate of revision myringoplasty to 52.8 per cent. Late re-perforations were attributed to insidious atrophy of the tympanic membrane or episodes of acute otitis media. Sixteen patients underwent re-revision myringoplasty and their success rate was 62.5 per cent. The overall success rate of revision and re-revision myringoplasty was 54.7 per cent. It has been concluded that results of revision myringoplastywere independent of patients' age, location and size of perforation and the seniority of the surgeon.

After a mean follow-up period of 7.3 years, a recurrence was found in 43 (12.3 percent) out of 349 consecutive patients undergoing surgical treatment for acquired cholesteatoma. The great majority of residual cholesteatomas detected in the ‘second-look’ operations arose from the oval window area.Chronic otorrhoea and a reperforation were the most common signs of late recurrences. In eight ears a recurrent cholesteatoma developed from a retraction pocket. The recurrence rate was higher in children than in adults. The type of surgical technique had no significant effect on recurrence rate. Recurrences were more frequent in pre-operatively discharging ears than in dry ears. Some suggestions have been made to improve the results of surgery for cholesteatoma.

Standard recommended treatment for patients with intracranial complications from otitis media, has been radical mastoidectomy, whether cholesteatoma is present or not. This was established in the pre-antibiotic era to improve survival. Over a six-year period, from January 1985 to December 1990, 268 patients were admitted with intracranial and extracranial complications of otitis media. The prospective treatment consisted of antibiotics and surgery. Surgery entailed mastoidectomy and drainage of intracranial collections of pus in all patients.

However, prospectively in these patients the ear pathology and not the complication dictated the type of mastoidectomy performed. Cortical mastoidectomy was performed in non-cholesteatomatous ears and radical mastoidectomy in cholesteatomatous ears.

Recurrence of intracranial complications occurred in only four patients (two per cent), a temporal lobe cerebritis in the non-cholesteatomatous ear group, and, a temporal lobe abscess, posterior fossa abscess and subdural empyema in the cholesteatomatous ear group. The temporal lobe cerebritis settled on intravenous antibiotics whilst the temporal lobe abscess, posterior fossa abscess and subdural empyema required redrainage. In none of these was the ear surgery revised.

There were 15 deaths (eight per cent), all occurring in patients with intracranial complications, 12 associated with brain abscess, two with subdural empyema and one with meningitis. Eight were from the non-cholesteatomatous group and seven from the cholesteatomatous group. The mortality was directly related to the patients consciousness level on admission and not to the type of ear pathology.

It can therefore be concluded that radical mastoidectomy is unwarranted in the non-cholesteatomatous ear, even with an otogenic intracranial complication.