Download Update on Cholesteatoma Educational Objectives Faculty Disclosure

AUDIO-DIGEST OTOLARYNGOLOGY 44:16
Volume 44, Issue 16
DIZZINESS AND BALANCE DISORDERS
DIZZINESS AND BALANCE DISORDERS
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1. Which type of cholesteatoma most commonly occurs in the anterosuperior quadrant of the middle ear?
(A) Primary acquired
(B) Secondary acquired
(C) Congenital
(D) External auditory canal
2. Which of the following should be performed for every patient who presents with an ear problem?
(A) Computed tomography
(B) Microscopy
(C) Pneumatic otoscopy
(D) Audiometry
3. Which of the following describes a posterior epitympanic cholesteatoma?
(A)
(B)
(C)
(D)
Can extend to the geniculate ganglion
Spreads up and back into the mastoid
Generally destroys the long process of incus
Invades the sinus tympani
4. In cholesteatoma cases, magnetic resonance imaging should be obtained for which of the following reasons?
(A)
(B)
(C)
(D)
Destruction of tegmen
Suspected sigmoid sinus thrombosis
As a postoperative test to replace a second-look operation
All of the above
5. Which of the following procedures is most appropriate for a patient with an acquired cholesteatoma in an onlyhearing ear?
(A) Transcanal atticotomy
(B) Postauricular tympanoplasty
(C) Canal-wall-up procedure
(D) Canal-wall-down procedure
6. When using a laser to remove residual disease during surgery for cholesteatoma, which of the following should be
avoided?
(A) Horizontal canal if erosion present
(B) Facial nerve
(C) Round window
(D) A, B, and C
7. Diet and lifestyle changes can improve vertigo symptoms in approximately _______ of patients with Meniere
disease.
(A) 15%
(B) 25%
(C) 66%
(D) 95%
8. For patients with Meniere's disease, a low-sodium diet is necessary.
(A) True
(B) False
9. What percentage of patients with Meniere disease who receive intratympanic gentamicin experience a relapse after
2 yr?
(A) 5%
(B) 25%
(C) 35%
(D) 50%
10. Which of the following treatments for Meniere disease is supported by at least one placebo-controlled trial?
(A) Meniett pump
(B) Betahistine
(C) Lipoflavonoids
August 21, 2011
(D) VertigoHeel
Answers to Audio-Digest Otolaryngology Volume 44, Issue 15: 1-C, 2-B, 3-D, 4-C, 5-B, 6-D, 7-A, 8-B, 9-A, 10-C
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Update on Cholesteatoma
Hamid R. Djalilian, MD, Director of Neurotology and
Skull Base Surgery, and Associate Professor of Otolaryngology and Biomedical Engineering, University of California, Irvine, Orange, CA
Classification: external auditory canal; congenital (usually in
middle ear); primary acquired — from retraction pocket;
usually posterosuperior quadrant and pars flaccida; secondary acquired — from perforation; results in keratin-producing epithelium implanted in middle ear
External auditory canal: uncommon; requires treatment if
very deep or patient young; most commonly seen in older
adults; definition — erosion of canal bone and normal squamous epithelium; if superficial, clean and instruct patient to
clean with alcohol and vinegar 2 times per week; treat
older patients at risk from surgery conservatively; completely remove deep cholesteatomas; then obliterate space;
shave bit of mastoid bone with bone pate, cartilage, and
fascia; rotate some normal skin from canal over that area to
ensure good closure
Congenital: most commonly occurs in anterosuperior quadrant; definition — white mass behind normal tympanic
membrane (TM); normal pars flaccida and pars tensa; no
history of otorrhea or perforations; original definition included no history of otitis media; no longer grounds for exclusion; can occur in petrous apex, extradurally in
retrosigmoid region, and in mastoid region
Primary acquired: generally driven by eustachian tube dysfunction; 3 possible causes — anatomy (ie, small eustachian tube); allergic rhinitis; laryngopharyngeal reflux;
must look for and treat reflux; instruct patients with reflux
to take medications before dinner (not before breakfast);
study — nasopharyngeal pH test on patients with eustachian
tube dysfunction; highest acid production occurred at
night; poor middle ear gas exchange another possible issue;
not well understood; inhaled allergens that affect nose also
affect ear; examine pars flaccida in all patients; look for retraction, destruction of scutum, and accumulation of keratin; Tos classification — Tos I, mild retraction of pars
flaccida; Tos II, pars flaccida attached to malleus neck; Tos
III, head of malleus visible due to scutum destruction; Tos
IV, cholesteatoma; Tos 0, normal
Diagnosis: use microscope on every patient with ear problem; look in all areas, especially pars flaccida; remove everything from TM; speaker uses either suction or sharp
hook placed between debris and TM; if in doubt, use blunt
side of hook to gently palpate; if hard, cartilage or tympanosclerosis; if soft, must evaluate
Cholesteatoma spread: generally predictable, depending on
site of origin; most commonly in pars flaccida; posterior epitympanic cholesteatoma — will spread up and back into mastoid; stapes generally spared; on computed tomography (CT),
look for extension anterior to malleus; if present, generally
will require canal-wall-down approach; anterior epitympanic
cholesteatoma — anterior, around ossicles, and comes back;
can affect geniculate ganglion; difficult to completely remove
with canal-wall-up approach; posterosuperior quadrant
cholesteatoma — generally destroys long process of incus; can
destroy stapes; can spread to oval window, sinus tympani, and
facial recess; examine those areas intraoperatively
Patient evaluation: granulation tissue on TM cholesteatoma
until proven otherwise; obtain patient history; obtain operative reports from previous surgery; head and neck examination; examine nasopharynx and larynx for nasopharyngeal
tumor or reflux; microscopy; pneumatic otoscopy to look
for fistula (speaker does not perform; uses microscope with
16X to 25X magnification to look for fluid); audiometry to
look for mixed hearing loss; CT imaging — thin cuts with
axial, coronal, and sagittal views; look for fistula, facial
nerve issues, tegmen problems, sigmoid sinus plate destruction, and long process of incus; always personally review CT images; magnetic resonance imaging (MRI) —
request T1 pre- and postgadolinium, T2, and diffusionweighted images; diffusion-weighted images valuable to
look for recurrence of cholesteatoma; can detect cholesteatoma 5 mm; cholesteatoma appears white; when to obtain
MRI — destruction to tegmen (look for abscess); in case of
facial paralysis, rule out tumor; suspected sigmoid sinus
thrombosis; as postoperative test instead of second look operation in most patients;
Conservative management: for patients with very small mastoid cells and area open into ear canal; possible to reach bottom of retraction to clean out; generally for older patients
Management of congenital cholesteatomas: dictated by extent; if limited to middle ear, postauricular tympanoplasty;
speaker separates TM from malleus to allow for straight-on
look; also avoids excessive manipulation of incus; generally uses laser; puts gelatin sponge (eg, Gel foam) with
dexamethasone in round window to reduce impact of any
sensorineural hearing loss; recommends otoendoscopy during surgery to obtain all-around view; if mastoid involved,
Educational Objectives
Faculty Disclosure
The goal of this program is to improve the management of
cholesteatoma and Meniere disease. After hearing and assimilating this program, the clinician will be better able to:
1. Review the classifications of cholesteatomas.
2. Perform evaluation and diagnosis of patients with cholesteatoma.
3. Choose and perform the appropriate surgical procedure
for a cholesteatoma.
4. Employ conservative treatment methods for patients
with Meniere disease.
5. Utilize invasive therapies for patients with persistent
vestibular dysfunction due to Meniere disease.
In adherence to ACCME Standards for Commercial Support,
Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Djalilian owns
stock in Mind:Set Technologies. Dr. Rauch has received research grant support from Otonomy, Inc. The planning committee reported nothing to disclose. In their lectures, Drs.
Djalilian and Rauch present information that is related to the
off-label or investigational use a therapy, product, or device.
AUDIO-DIGEST OTOLARYNGOLOGY 44:16
canal-wall-up or canal-wall-down procedure possibly necessary
Management of acquired cholesteatomas: speaker avoids transcanal approach; if very small, leave alone; postauricular approach; atticotomy—curette or drill some bone in attic to get
access to and remove cholesteatoma; reconstruct lateral attic
wall with bone or cartilage; good for limited cholesteatomas; indications for canal-wall-down mastoidectomy—significant disease in anterior epitympanum (ie, anterior to cog, between
malleus and incus); significant disease going to eustachian tube
(ie, anterior disease); very small mastoids; very low tegmen; anterior sigmoids; if large destruction of canal wall, speaker obliterates and it remains wall up; if disease not separable from facial
nerve, leave on facial nerve and allow exteriorization; cholesteatoma in only-hearing ear; unreliable patient
Canal-wall-down procedure: traditional — remove everything down to facial nerve; create large cavity; sometimes
use skin grafts; cut mastoid tip; perform large meatoplasty;
have patient return every 6 mo; poor cosmetic result;
speaker's technique — remove only bone that needs removing (generally posterosuperior quadrant); obliterate cavity
entirely with cartilage and bone pate; remove diseased mucosa; minimal meatoplasty; use otoendoscopy and lasers
when necessary; use preoperative CT to determine where
to remove bone
Canal-wall-up procedure: traditional — remove everything
(air cells, retrofacial cells); drill facial recess; speaker's
technique — open; remove only diseased mucosa; no need to
skeletonize sigmoid; allow aeration of diseased mucosa; facial recess needed only if involved in cholesteatoma; always
use otoendoscopy; minimum requirements — 0° and 30° endoscope (shorter than nasal endoscope); camera; monitor;
Telischi curved suctions (#3 and #5); study — endoscope
used after microscopic cleaning; 23% had residual disease;
study — incidence of residual cholesteatoma decreased from
50% to 5% after starting to use otoendoscopy; most commonly found in sinus tympani, facial recess, and undersurface of scutum; technical pearls — keep field dry; hold scope
in nondominant hand; steady hand against patient; steady
shaft of scope on ear canal or mastoid; keep camera in same
direction (top of image anterior)
Prevention: treat allergic rhinitis and laryngopharyngeal reflux; follow patient with retraction; Valsalva maneuver; ear
popper device (not too often); if popping not possible, tube
placement before retraction fused with malleus or incus; if
end of retraction not visible, explore surgically
Intraoperative considerations: plan next operation during
first operation; note every site of cholesteatoma, chorda status, ossicular chain, whether bone over facial nerve, horizontal canal, and whether bony shelf over round window
destroyed; facial nerve dehiscence — use facial nerve monitoring; once facial nerve separated, cover it with bone pate
or silastic sheeting; horizontal canal dehiscence — leave
until last part of operation; use 24 suction with finger off
hole to raise cholesteatoma; gently separate; cover canal
with bone pate and fascia; tegmen dehiscence — if small,
cover with bone pate; if medium-sized, cartilage graft; if
large, use middle cranial fossa approach or obliterate mastoid with fat to prevent herniation; sigmoid injury — place
gelatin sponge and hold pressure for 2 min
Novel techniques: reversible canal-wall-down — canal-wallup approach with facial recess; use saw to cut canal wall out;
perform surgery; put canal wall back with bone cement;
lengthy procedure; requires large facial recess; retraction
into facial recess possible later; canal wall reconstruction —
remove canal wall; obliterate space with bone pate, closing
off attic; 5-to 6-hr operation; 2-night hospital stay; patients
receive intravenous antibiotics; all patients have second-look
surgery
Laser: useful for residual disease in deep crevices; good to
use if cholesteatoma attached to ossicles (especially stapes); reduce power and use in defocus mode; use curved laser in epitympanum; do not use near facial nerve, on
horizontal canal if erosion present, or on round window;
examine carotid on CT; do not use on eustachian tube if carotid dehiscent; study — intact canal wall surgery; 10 of 33
patients who underwent treatment without laser had recurrence, while only 3 of 36 patients who had laser treatment
had recurrence
Future: new ways of detecting and treating residual cholesteatoma intraoperatively; near-infrared optical coherence tomography (OCT) to distinguish cholesteatoma from mucosa; gene
therapy; photodynamic therapy
Meniere Disease: A Practical Approach to Treatment
Steven D. Rauch, MD, Professor of Otology and Laryngology, Harvard Medical School, and Surgeon in Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA
Inner ear homeostatic systems: production, chemical composition, and recycling of inner ear fluids; incoming and
outgoing nerve supply; incoming and outgoing blood flow;
intercellular signaling; energy metabolism; under normal
circumstances, these systems create stability in inner ear; in
sick or damaged ear, systems may not work properly
Meniere disease: intermittent symptoms affecting hearing
and balance; unstable inner ear; postmortem — hydropic
distention of endolymphatic space; imaging studies cannot
show structural changes in vivo
Conservative treatment
Diet and lifestyle: low-sodium diet not necessary; instead,
keep sodium intake at constant level; benefits —compliance; if patient eats food with high sodium content,
smaller incremental change; speaker advises 1 dose caffeine and alcohol per day; these measures control vertigo
but do not help hearing loss, fullness, or tinnitus; maintain
regular routines (eg, meals, sleep, exercise); encourage good
general health; patients with seasonal allergies, hormonal
problems (due to pregnancy or menopause), thyroid dysfunction, hyperglycemia, hypertension, or other health
problems should address these with their physician; 66%
of patients experience significant improvement from diet
and lifestyle changes after 1 to 2 mo
Diuretics: if diet and lifestyle do not help; hydrochlorothiazide
(HCTZ) and triamterene (eg, Dyazide, Maxzide); potassium
sparing; acetazolamide (carbonic anhydrase inhibitor) also
used; thiazides and acetazolamide may have cross reactivity
in person with sulfonamide allergy; thiazides can aggravate
gout; for patients intolerant of thiazides, speaker may try
triamterene alone; does not use furosemide; HCTZ (25
mg)/triamterene (37.5 mg) — once daily for 1 mo; if vertigo
persists, twice daily; follow-up at 2 mo; 66% of patients
experience significant relief
Vestibular suppressant: speaker prescribes lorazepam (Ativan)
to all patients; off-label use; instructs patients to take 0.5 or
1 mg under tongue at onset of attack; benzodiazepines act
centrally; onset of action 10 min for sublingual lorazepam;
peak, 1 hr; half-life, 10 to 12 hr; patients experience wearing
off effect in 3 to 4 hr; can take 4 times a day; sedation; diet
and lifestyle changes, diuretics, and vestibular suppressants
AUDIO-DIGEST OTOLARYNGOLOGY 44:16
effective for 90% to 95% of speaker’s patients; does not
prescribe meclizine because of side effects
Sac surgery vs intratympanic gentamicin (ITG): sac surgery performed in operating room; ITG in office; sac surgery under general anesthesia; ITG with topical or local
anesthetic; technique — speaker uses topical phenol (couple
dots on ear drum; one dot posteriorly; one dot anteriorly);
anteriorly, poke small hole as air vent; posteriorly, inject 1
mL of 40 mg/mL gentamicin; warm bottle first; draw up in
tuberculin syringe with 1.5 inch 27-gauge needle; slowly
push into posterior part of drum; as drug fills middle ear,
bubbles emerge through vent opening; once full, excess drug
comes through vent opening; excess sits in ear canal and
later seeps in; have patient lie down for 1 hr; sac surgery patients require overnight hospital stay; 4 to 6 wk labyrinthine
upset with both sac surgery and ITG; sac surgery successful
in 66% of patients, ITG in 95%; at 2-yr follow-up, 25%
of ITG patients relapse; hearing loss with sac surgery, 5% to
8%; with ITG, 20% to 25% have hearing decrement
Labyrinthectomy vs vestibular neurectomy: hospital stay,
3 to 5 days for both, sometimes less; recovery time, weeks
to months for both; patients can drive in 1 to 2 mo in both
groups; control of vertigo attacks with labyrinthectomy,
98%, slightly lower with neurectomy; 100% of labyrinthectomy patients deaf; neurectomy patients usually not
deaf; risk for permanent cranial nerve VII injury low with
both procedures; cerebrospinal fluid leak can happen with
neurectomy, but not with labyrinthectomy; chronic head-
ache can result with neurectomy, but not with labyrinthectomy; no intracranial complications with labyrinthectomy
Medications: betahistine (Serc)—histamine agonist; not Food
and Drug Administration approved; literature unconvincing;
VertigoHeel —herbal treatment; in comparison study with betahistine, equally effective; lipoflavonoids—B vitamins;
shown effective in small (n=3), uncontrolled case series conducted in 1960s; no convincing clinical evidence for efficacy;
steroids—blunt instrument; anti-inflammatory, immunomodulatory, alter glucose metabolism, alter membrane permeability;
200 proteins in inner ear have glucocorticoid binding capability; questionable whether steroids help Meniere disease;
speaker uses as last resort; speaker prescribes methylprednisolone but pessimistic about effectiveness; intratympanic
steroids—speaker uses for patients who fail medical management and unwilling to have ITG; 10 mg/mL dexamethasone;
off label; 4 doses over 2 wk; same injection technique as for
gentamicin; have patient lie down for 30 min; 33% of patients report improvement
Other treatments: allergy — speaker does not believe allergy can cause Meniere disease; however, disease possibly activated by allergy flares; Meniett pump — barometric
pressure treatment via ear canal; Gates et al (2004) —
placebo-controlled trial; pump used for 5 min 3 times
daily; at 4-mo follow up 66% of patients in active treatment group had significant improvement, compared with
33% in placebo group; device costs $3800; most insurance
companies will not pay
Acknowledgements
Dr Djalilian was recorded at 2011 Head and Neck Surgery Symposium, held June 4, 2011, in Huntington Beach, CA, and sponsored by
Kaiser Permanente. Dr. Rauch was recorded at Update in Otology and Otolaryngology, held June 10-12, 2010, in Boston, MA, and
sponsored by Harvard Medical School and Massachusetts Eye and Ear Infirmary. For future CME events presented by Massachusetts
Eye and Ear Infirmary, Harvard Medical School, and Kaiser Permanente, visit the “upcoming meetings” link at audio-digest.org. The
Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
Suggested Reading
Boleas-Aguirre MS et al: Longitudinal results with intratympanic dexamethasone in the treatment of Meniere's disease. Otol
Neurotol. 2008;29:33-8; Gantz BJ et al: Canal wall reconstruction tympanomastoidectomy with mastoid obliteration. Laryngoscope. 2005;115:1734-40; Gates GA et al: The effects of
transtympanic micropressure treatment in people with unilateral Meniere's disease. Arch Otolaryngol Head Neck Surg.
2004;130:718-25; Hamilton JW: Efficacy of the KTP laser in the
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Audio-Digest Foundation is approved as a provider of nurse practitioner
continuing education by the American Academy of Nurse Practitioners
(AANP Approved Provider number 030904). Audio-Digest designates
treatment of middle ear cholesteatoma. Otol Neurotol. 2005;26:135-9;
McElveen JT, Jr., Chung AT: Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results. Laryngoscope. 2003;113:1027-33; Rauch SD: Clinical hints and precipitating
factors in patients suffering from Meniere's disease. Otolaryngol Clin
North Am. 2010;43:1011-7; Weiser M et al: Homeopathic vs conventional treatment of vertigo: a randomized double-blind controlled
clinical study. Arch Otolaryngol Head Neck Surg. 1998;124:879-85.
each activity for 2.0 CE contact hours, including 0.5 pharmacology CE
contact hours.
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CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST OTOLARYNGOLOGY 44:16
canal-wall-up or canal-wall-down procedure possibly necessary
Management of acquired cholesteatomas: speaker avoids transcanal approach; if very small, leave alone; postauricular approach; atticotomy—curette or drill some bone in attic to get
access to and remove cholesteatoma; reconstruct lateral attic
wall with bone or cartilage; good for limited cholesteatomas; indications for canal-wall-down mastoidectomy—significant disease in anterior epitympanum (ie, anterior to cog, between
malleus and incus); significant disease going to eustachian tube
(ie, anterior disease); very small mastoids; very low tegmen; anterior sigmoids; if large destruction of canal wall, speaker obliterates and it remains wall up; if disease not separable from facial
nerve, leave on facial nerve and allow exteriorization; cholesteatoma in only-hearing ear; unreliable patient
Canal-wall-down procedure: traditional — remove everything down to facial nerve; create large cavity; sometimes
use skin grafts; cut mastoid tip; perform large meatoplasty;
have patient return every 6 mo; poor cosmetic result;
speaker's technique — remove only bone that needs removing (generally posterosuperior quadrant); obliterate cavity
entirely with cartilage and bone pate; remove diseased mucosa; minimal meatoplasty; use otoendoscopy and lasers
when necessary; use preoperative CT to determine where
to remove bone
Canal-wall-up procedure: traditional — remove everything
(air cells, retrofacial cells); drill facial recess; speaker's
technique — open; remove only diseased mucosa; no need to
skeletonize sigmoid; allow aeration of diseased mucosa; facial recess needed only if involved in cholesteatoma; always
use otoendoscopy; minimum requirements — 0° and 30° endoscope (shorter than nasal endoscope); camera; monitor;
Telischi curved suctions (#3 and #5); study — endoscope
used after microscopic cleaning; 23% had residual disease;
study — incidence of residual cholesteatoma decreased from
50% to 5% after starting to use otoendoscopy; most commonly found in sinus tympani, facial recess, and undersurface of scutum; technical pearls — keep field dry; hold scope
in nondominant hand; steady hand against patient; steady
shaft of scope on ear canal or mastoid; keep camera in same
direction (top of image anterior)
Prevention: treat allergic rhinitis and laryngopharyngeal reflux; follow patient with retraction; Valsalva maneuver; ear
popper device (not too often); if popping not possible, tube
placement before retraction fused with malleus or incus; if
end of retraction not visible, explore surgically
Intraoperative considerations: plan next operation during
first operation; note every site of cholesteatoma, chorda status, ossicular chain, whether bone over facial nerve, horizontal canal, and whether bony shelf over round window
destroyed; facial nerve dehiscence — use facial nerve monitoring; once facial nerve separated, cover it with bone pate
or silastic sheeting; horizontal canal dehiscence — leave
until last part of operation; use 24 suction with finger off
hole to raise cholesteatoma; gently separate; cover canal
with bone pate and fascia; tegmen dehiscence — if small,
cover with bone pate; if medium-sized, cartilage graft; if
large, use middle cranial fossa approach or obliterate mastoid with fat to prevent herniation; sigmoid injury — place
gelatin sponge and hold pressure for 2 min
Novel techniques: reversible canal-wall-down — canal-wallup approach with facial recess; use saw to cut canal wall out;
perform surgery; put canal wall back with bone cement;
lengthy procedure; requires large facial recess; retraction
into facial recess possible later; canal wall reconstruction —
remove canal wall; obliterate space with bone pate, closing
off attic; 5-to 6-hr operation; 2-night hospital stay; patients
receive intravenous antibiotics; all patients have second-look
surgery
Laser: useful for residual disease in deep crevices; good to
use if cholesteatoma attached to ossicles (especially stapes); reduce power and use in defocus mode; use curved laser in epitympanum; do not use near facial nerve, on
horizontal canal if erosion present, or on round window;
examine carotid on CT; do not use on eustachian tube if carotid dehiscent; study — intact canal wall surgery; 10 of 33
patients who underwent treatment without laser had recurrence, while only 3 of 36 patients who had laser treatment
had recurrence
Future: new ways of detecting and treating residual cholesteatoma intraoperatively; near-infrared optical coherence tomography (OCT) to distinguish cholesteatoma from mucosa; gene
therapy; photodynamic therapy
Meniere Disease: A Practical Approach to Treatment
Steven D. Rauch, MD, Professor of Otology and Laryngology, Harvard Medical School, and Surgeon in Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA
Inner ear homeostatic systems: production, chemical composition, and recycling of inner ear fluids; incoming and
outgoing nerve supply; incoming and outgoing blood flow;
intercellular signaling; energy metabolism; under normal
circumstances, these systems create stability in inner ear; in
sick or damaged ear, systems may not work properly
Meniere disease: intermittent symptoms affecting hearing
and balance; unstable inner ear; postmortem — hydropic
distention of endolymphatic space; imaging studies cannot
show structural changes in vivo
Conservative treatment
Diet and lifestyle: low-sodium diet not necessary; instead,
keep sodium intake at constant level; benefits —compliance; if patient eats food with high sodium content,
smaller incremental change; speaker advises 1 dose caffeine and alcohol per day; these measures control vertigo
but do not help hearing loss, fullness, or tinnitus; maintain
regular routines (eg, meals, sleep, exercise); encourage good
general health; patients with seasonal allergies, hormonal
problems (due to pregnancy or menopause), thyroid dysfunction, hyperglycemia, hypertension, or other health
problems should address these with their physician; 66%
of patients experience significant improvement from diet
and lifestyle changes after 1 to 2 mo
Diuretics: if diet and lifestyle do not help; hydrochlorothiazide
(HCTZ) and triamterene (eg, Dyazide, Maxzide); potassium
sparing; acetazolamide (carbonic anhydrase inhibitor) also
used; thiazides and acetazolamide may have cross reactivity
in person with sulfonamide allergy; thiazides can aggravate
gout; for patients intolerant of thiazides, speaker may try
triamterene alone; does not use furosemide; HCTZ (25
mg)/triamterene (37.5 mg) — once daily for 1 mo; if vertigo
persists, twice daily; follow-up at 2 mo; 66% of patients
experience significant relief
Vestibular suppressant: speaker prescribes lorazepam (Ativan)
to all patients; off-label use; instructs patients to take 0.5 or
1 mg under tongue at onset of attack; benzodiazepines act
centrally; onset of action 10 min for sublingual lorazepam;
peak, 1 hr; half-life, 10 to 12 hr; patients experience wearing
off effect in 3 to 4 hr; can take 4 times a day; sedation; diet
and lifestyle changes, diuretics, and vestibular suppressants
AUDIO-DIGEST OTOLARYNGOLOGY 44:16
effective for 90% to 95% of speaker’s patients; does not
prescribe meclizine because of side effects
Sac surgery vs intratympanic gentamicin (ITG): sac surgery performed in operating room; ITG in office; sac surgery under general anesthesia; ITG with topical or local
anesthetic; technique — speaker uses topical phenol (couple
dots on ear drum; one dot posteriorly; one dot anteriorly);
anteriorly, poke small hole as air vent; posteriorly, inject 1
mL of 40 mg/mL gentamicin; warm bottle first; draw up in
tuberculin syringe with 1.5 inch 27-gauge needle; slowly
push into posterior part of drum; as drug fills middle ear,
bubbles emerge through vent opening; once full, excess drug
comes through vent opening; excess sits in ear canal and
later seeps in; have patient lie down for 1 hr; sac surgery patients require overnight hospital stay; 4 to 6 wk labyrinthine
upset with both sac surgery and ITG; sac surgery successful
in 66% of patients, ITG in 95%; at 2-yr follow-up, 25%
of ITG patients relapse; hearing loss with sac surgery, 5% to
8%; with ITG, 20% to 25% have hearing decrement
Labyrinthectomy vs vestibular neurectomy: hospital stay,
3 to 5 days for both, sometimes less; recovery time, weeks
to months for both; patients can drive in 1 to 2 mo in both
groups; control of vertigo attacks with labyrinthectomy,
98%, slightly lower with neurectomy; 100% of labyrinthectomy patients deaf; neurectomy patients usually not
deaf; risk for permanent cranial nerve VII injury low with
both procedures; cerebrospinal fluid leak can happen with
neurectomy, but not with labyrinthectomy; chronic head-
ache can result with neurectomy, but not with labyrinthectomy; no intracranial complications with labyrinthectomy
Medications: betahistine (Serc)—histamine agonist; not Food
and Drug Administration approved; literature unconvincing;
VertigoHeel —herbal treatment; in comparison study with betahistine, equally effective; lipoflavonoids—B vitamins;
shown effective in small (n=3), uncontrolled case series conducted in 1960s; no convincing clinical evidence for efficacy;
steroids—blunt instrument; anti-inflammatory, immunomodulatory, alter glucose metabolism, alter membrane permeability;
200 proteins in inner ear have glucocorticoid binding capability; questionable whether steroids help Meniere disease;
speaker uses as last resort; speaker prescribes methylprednisolone but pessimistic about effectiveness; intratympanic
steroids—speaker uses for patients who fail medical management and unwilling to have ITG; 10 mg/mL dexamethasone;
off label; 4 doses over 2 wk; same injection technique as for
gentamicin; have patient lie down for 30 min; 33% of patients report improvement
Other treatments: allergy — speaker does not believe allergy can cause Meniere disease; however, disease possibly activated by allergy flares; Meniett pump — barometric
pressure treatment via ear canal; Gates et al (2004) —
placebo-controlled trial; pump used for 5 min 3 times
daily; at 4-mo follow up 66% of patients in active treatment group had significant improvement, compared with
33% in placebo group; device costs $3800; most insurance
companies will not pay
Acknowledgements
Dr Djalilian was recorded at 2011 Head and Neck Surgery Symposium, held June 4, 2011, in Huntington Beach, CA, and sponsored by
Kaiser Permanente. Dr. Rauch was recorded at Update in Otology and Otolaryngology, held June 10-12, 2010, in Boston, MA, and
sponsored by Harvard Medical School and Massachusetts Eye and Ear Infirmary. For future CME events presented by Massachusetts
Eye and Ear Infirmary, Harvard Medical School, and Kaiser Permanente, visit the “upcoming meetings” link at audio-digest.org. The
Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
Suggested Reading
Boleas-Aguirre MS et al: Longitudinal results with intratympanic dexamethasone in the treatment of Meniere's disease. Otol
Neurotol. 2008;29:33-8; Gantz BJ et al: Canal wall reconstruction tympanomastoidectomy with mastoid obliteration. Laryngoscope. 2005;115:1734-40; Gates GA et al: The effects of
transtympanic micropressure treatment in people with unilateral Meniere's disease. Arch Otolaryngol Head Neck Surg.
2004;130:718-25; Hamilton JW: Efficacy of the KTP laser in the
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treatment of middle ear cholesteatoma. Otol Neurotol. 2005;26:135-9;
McElveen JT, Jr., Chung AT: Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results. Laryngoscope. 2003;113:1027-33; Rauch SD: Clinical hints and precipitating
factors in patients suffering from Meniere's disease. Otolaryngol Clin
North Am. 2010;43:1011-7; Weiser M et al: Homeopathic vs conventional treatment of vertigo: a randomized double-blind controlled
clinical study. Arch Otolaryngol Head Neck Surg. 1998;124:879-85.
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Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST OTOLARYNGOLOGY 44:16
Volume 44, Issue 16
DIZZINESS AND BALANCE DISORDERS
DIZZINESS AND BALANCE DISORDERS
To test online, go to www.audiodigest.org and sign in to online services.
To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. Which type of cholesteatoma most commonly occurs in the anterosuperior quadrant of the middle ear?
(A) Primary acquired
(B) Secondary acquired
(C) Congenital
(D) External auditory canal
2. Which of the following should be performed for every patient who presents with an ear problem?
(A) Computed tomography
(B) Microscopy
(C) Pneumatic otoscopy
(D) Audiometry
3. Which of the following describes a posterior epitympanic cholesteatoma?
(A)
(B)
(C)
(D)
Can extend to the geniculate ganglion
Spreads up and back into the mastoid
Generally destroys the long process of incus
Invades the sinus tympani
4. In cholesteatoma cases, magnetic resonance imaging should be obtained for which of the following reasons?
(A)
(B)
(C)
(D)
Destruction of tegmen
Suspected sigmoid sinus thrombosis
As a postoperative test to replace a second-look operation
All of the above
5. Which of the following procedures is most appropriate for a patient with an acquired cholesteatoma in an onlyhearing ear?
(A) Transcanal atticotomy
(B) Postauricular tympanoplasty
(C) Canal-wall-up procedure
(D) Canal-wall-down procedure
6. When using a laser to remove residual disease during surgery for cholesteatoma, which of the following should be
avoided?
(A) Horizontal canal if erosion present
(B) Facial nerve
(C) Round window
(D) A, B, and C
7. Diet and lifestyle changes can improve vertigo symptoms in approximately _______ of patients with Meniere
disease.
(A) 15%
(B) 25%
(C) 66%
(D) 95%
8. For patients with Meniere's disease, a low-sodium diet is necessary.
(A) True
(B) False
9. What percentage of patients with Meniere disease who receive intratympanic gentamicin experience a relapse after
2 yr?
(A) 5%
(B) 25%
(C) 35%
(D) 50%
10. Which of the following treatments for Meniere disease is supported by at least one placebo-controlled trial?
(A) Meniett pump
(B) Betahistine
(C) Lipoflavonoids
August 21, 2011
(D) VertigoHeel
Answers to Audio-Digest Otolaryngology Volume 44, Issue 15: 1-C, 2-B, 3-D, 4-C, 5-B, 6-D, 7-A, 8-B, 9-A, 10-C
훿 2011 Audio-Digest Foundation • ISSN 0271-1354 • www.audiodigest.org
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Remarks represent viewpoints of the speakers, not necessarily those of the Audio-Digest Foundation.
Update on Cholesteatoma
Hamid R. Djalilian, MD, Director of Neurotology and
Skull Base Surgery, and Associate Professor of Otolaryngology and Biomedical Engineering, University of California, Irvine, Orange, CA
Classification: external auditory canal; congenital (usually in
middle ear); primary acquired — from retraction pocket;
usually posterosuperior quadrant and pars flaccida; secondary acquired — from perforation; results in keratin-producing epithelium implanted in middle ear
External auditory canal: uncommon; requires treatment if
very deep or patient young; most commonly seen in older
adults; definition — erosion of canal bone and normal squamous epithelium; if superficial, clean and instruct patient to
clean with alcohol and vinegar 2 times per week; treat
older patients at risk from surgery conservatively; completely remove deep cholesteatomas; then obliterate space;
shave bit of mastoid bone with bone pate, cartilage, and
fascia; rotate some normal skin from canal over that area to
ensure good closure
Congenital: most commonly occurs in anterosuperior quadrant; definition — white mass behind normal tympanic
membrane (TM); normal pars flaccida and pars tensa; no
history of otorrhea or perforations; original definition included no history of otitis media; no longer grounds for exclusion; can occur in petrous apex, extradurally in
retrosigmoid region, and in mastoid region
Primary acquired: generally driven by eustachian tube dysfunction; 3 possible causes — anatomy (ie, small eustachian tube); allergic rhinitis; laryngopharyngeal reflux;
must look for and treat reflux; instruct patients with reflux
to take medications before dinner (not before breakfast);
study — nasopharyngeal pH test on patients with eustachian
tube dysfunction; highest acid production occurred at
night; poor middle ear gas exchange another possible issue;
not well understood; inhaled allergens that affect nose also
affect ear; examine pars flaccida in all patients; look for retraction, destruction of scutum, and accumulation of keratin; Tos classification — Tos I, mild retraction of pars
flaccida; Tos II, pars flaccida attached to malleus neck; Tos
III, head of malleus visible due to scutum destruction; Tos
IV, cholesteatoma; Tos 0, normal
Diagnosis: use microscope on every patient with ear problem; look in all areas, especially pars flaccida; remove everything from TM; speaker uses either suction or sharp
hook placed between debris and TM; if in doubt, use blunt
side of hook to gently palpate; if hard, cartilage or tympanosclerosis; if soft, must evaluate
Cholesteatoma spread: generally predictable, depending on
site of origin; most commonly in pars flaccida; posterior epitympanic cholesteatoma — will spread up and back into mastoid; stapes generally spared; on computed tomography (CT),
look for extension anterior to malleus; if present, generally
will require canal-wall-down approach; anterior epitympanic
cholesteatoma — anterior, around ossicles, and comes back;
can affect geniculate ganglion; difficult to completely remove
with canal-wall-up approach; posterosuperior quadrant
cholesteatoma — generally destroys long process of incus; can
destroy stapes; can spread to oval window, sinus tympani, and
facial recess; examine those areas intraoperatively
Patient evaluation: granulation tissue on TM cholesteatoma
until proven otherwise; obtain patient history; obtain operative reports from previous surgery; head and neck examination; examine nasopharynx and larynx for nasopharyngeal
tumor or reflux; microscopy; pneumatic otoscopy to look
for fistula (speaker does not perform; uses microscope with
16X to 25X magnification to look for fluid); audiometry to
look for mixed hearing loss; CT imaging — thin cuts with
axial, coronal, and sagittal views; look for fistula, facial
nerve issues, tegmen problems, sigmoid sinus plate destruction, and long process of incus; always personally review CT images; magnetic resonance imaging (MRI) —
request T1 pre- and postgadolinium, T2, and diffusionweighted images; diffusion-weighted images valuable to
look for recurrence of cholesteatoma; can detect cholesteatoma 5 mm; cholesteatoma appears white; when to obtain
MRI — destruction to tegmen (look for abscess); in case of
facial paralysis, rule out tumor; suspected sigmoid sinus
thrombosis; as postoperative test instead of second look operation in most patients;
Conservative management: for patients with very small mastoid cells and area open into ear canal; possible to reach bottom of retraction to clean out; generally for older patients
Management of congenital cholesteatomas: dictated by extent; if limited to middle ear, postauricular tympanoplasty;
speaker separates TM from malleus to allow for straight-on
look; also avoids excessive manipulation of incus; generally uses laser; puts gelatin sponge (eg, Gel foam) with
dexamethasone in round window to reduce impact of any
sensorineural hearing loss; recommends otoendoscopy during surgery to obtain all-around view; if mastoid involved,
Educational Objectives
Faculty Disclosure
The goal of this program is to improve the management of
cholesteatoma and Meniere disease. After hearing and assimilating this program, the clinician will be better able to:
1. Review the classifications of cholesteatomas.
2. Perform evaluation and diagnosis of patients with cholesteatoma.
3. Choose and perform the appropriate surgical procedure
for a cholesteatoma.
4. Employ conservative treatment methods for patients
with Meniere disease.
5. Utilize invasive therapies for patients with persistent
vestibular dysfunction due to Meniere disease.
In adherence to ACCME Standards for Commercial Support,
Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Djalilian owns
stock in Mind:Set Technologies. Dr. Rauch has received research grant support from Otonomy, Inc. The planning committee reported nothing to disclose. In their lectures, Drs.
Djalilian and Rauch present information that is related to the
off-label or investigational use a therapy, product, or device.