Surgical treatment of sensorineural hearing loss reviews,sinus pain loose teeth,was kann ich gegen tinnitus tun - Good Point

Is Tonsillectomy a Possible Treatment for IgA Nephropathy from Randomized Controlled Trial (RCT)? An applied understanding of the mechanics of the conductive portion of the auditory periphery and a physiologically directed assessment of the external and middle ear are the cornerstones to optimizing hearing results and minimizing the incidence of complications after surgical reconstruction for conductive hearing loss. Sound, defined in the physical dimension, is vibratory energy produced by an object that possesses inertia and elasticity. The ossicular lever is produced when the incus and the malleus rotate as a unit around an axis extending from the anterior mallear ligament through the incudal ligament.7 The ossicular lever taken alone produces a small mechanical advantage for sound transmission. The hydraulic lever assists the transmission of the sound pressure, which is collected over the larger tympanic membrane and passed on to the much smaller stapedial footplate. In a nondiseased ear, sound is transmitted to the oval window with increased energy and at an earlier phase than to the round window. The pinnae gather sound from an arc of 135 degrees relative to the direction of the head and increase sound pressure by 6 dB. The increased gain in sound pressure level from the impedance matching system of the middle ear and tympanic membrane measures roughly 34 dB. In his 1978 review, Austin1 identified five categories of anatomic defects in the middle ear sound-conducting system and described each within the context of the associated prototypic hearing loss (Table 143-1).
In the second category, tympanic membrane perforation combined with ossicular disruption occurred in approximately 60% of Austin’s patients, and was the most common form of conductive hearing loss requiring surgical therapy. In the third category, total loss of the tympanic membrane and ossicles created a condition wherein sound pressure contacted the oval and round windows simultaneously, resulting in partial phase cancellation of the sound wave in the cochlear fluids. The fourth category included patients with ossicular disruption behind an intact tympanic membrane. The fifth category described various congenital malformations with ossicular disruption and closure of the oval window; also included were cases of obliterative otosclerosis with closure of the oval and round windows behind an intact drum. The use of advanced audiometric testing, laboratory studies, or diagnostic imaging is rarely indicated in patients with isolated conductive hearing loss. Rinne testing using all three fork frequencies can accurately estimate the conductive component of a hearing deficit (Table 143-2).16 The test is performed by activating the tuning fork and by placing it firmly on the skin over the cribriform area of the mastoid bone.
Acoustic immittance testing may be useful in distinguishing between conductive and sensorineural hearing loss. After completing her post-graduation in ENT, she worked in Australia for eight years and gained valuable surgical and research experience.
Scientific paper presentation titled "Stem cell therapy in sensorineural hearing loss" in R A F Cooper Consultant award paper category in 42nd Maharashtra state ENT conference, Solapur December 10-12, 2010.
Poster presentation at Frontiers in Otolaryngology, Noosa Queensland July 30, August 1, 2008. Presented scientific paper on 'Intracranial complications of Chronic Suppurative Otitis Media' in 33rd Maharashtra State ENT Conference, Latur in 2001.
Lecture on " Effect of stem cell transplantation on sensorineural hearing loss" at AOI Thane Branch's monthly meeting 23rd February 2011. Lecture on "Common ENT conditions" at CME for General Practitioners at Fortis Hiranandani Hospital, Vashi, Navi Mumbai October 28, 2010. Audiology: Hearing Evaluation For diagnosis and management of hearing disorders we have Diagnostic Audiological Tests. Otologic surgery aims to eradicate aural disease and restore hearing in the ear, or gain surgical access to the skull base. The tympanic membrane (TM) and the ossicles (malleus, incus, and stapes) collect sound and deliver them to the inner ear (the labyrinth). Cholesteatoma is an absolute indication for surgery, unless the patient is elderly, when regular aural toilet may suffice. The appropriate operative procedure depends on the extent of the disease and the surgeon's estimate of ET function.
Severe-to-profound sensorineural hearing loss is characterised by a loss of clarity of speech, which is not overcome by the amplification of sound with a hearing aide.
The operation for a cochlear implant involves implanting a prosthesis, the ‘receiver-stimulator’, which electrically stimulates the auditory nerve within the cochlea. The most common type of malignant neoplasm of the ear is a squamous cell carcinoma of the pinna or external ear canal, followed in incidence by melanoma. Acute sinusitis is a bacterial infection of the paranasal sinus secondary to obstruction of the sinus ostium. Chronic sinusitis may follow poorly treated acute sinusitis, or will occur in situations of chronic sinus obstruction (e.g. Inverted papillomas, squamous papilloma and juvenile angiofibroma may all result in obstruction, sinusitis and bleeding. Squamous cell carcinoma of the maxillary sinus is the most common paranasal sinus malignancy.
Tonsillitis may become complicated by an abscess formation in the peritonsillar space, which is commonly referred to as quinsy.
Epiglottitis is a peculiar and serious disease often affecting children, and occasionally adults. Vocal nodules are common benign bilateral swellings at the junction of the middle and anterior third of the vocal fold. Benign cysts and polyps are less common conditions and are usually unilateral and require surgical intervention. Reflux commonly causes hoarseness, throat discomfort and a variety of laryngeal conditions resulting from chronic inflammation due to refluxate in the laryngopharynx. Loss of vocal fold movement is caused by loss of function of the recurrent laryngeal nerve. Diagnosis of the palsy is made by indirect mirror examination or flexible fibreoptic laryngoscopy. Cancer of the head and neck is relatively uncommon when compared to the frequency of other, more common tumours such as bowel and breast cancer. Most head and neck squamous cancers will metastasise to cervical lymph nodes and this factor bears the most significance in terms of prognosis. Thorough clinical evaluation is essential to exclude a cancer in a site not readily seen, such as the tongue base or hypopharynx.
Modern CT scanning and MRI are invaluable for the accurate assessment and staging of head and neck cancer disease. A relatively new imaging technique, positron emission tomography (PET) is an imaging technique which looks at the metabolic behaviour of the tumour and images this characteristic rather than an anatomical mass. Guidelines for diagnostic and pre-operative workup of a patient with a suspected head and neck malignancy are given in Diagnostic and pre-operative workup of the patient with head and neck squamous carcinoma. Endoscopic evaluation under anaesthesia for more accurate staging and to exclude a second primary. For cervical node with unknown primary, full endoscopic evaluation and, if no primary found, proceed to open biopsy with frozen section and neck dissection if squamous cell carcinoma is confirmed.
For early disease, particularly in the larynx, cure rates of radiotherapy and surgery are equivalent. Chemotherapy on its own has little role to play in the treatment of squamous cell cancer of the head and neck other than in a palliative sense, but is used as an adjunct to the use of radiotherapy.
The emphasis in treatment is now on organ preservation, particularly with respect to the larynx. The combination of surgery and radiotherapy in advanced disease is superior to single modality therapy.
In planning treatment, it is vital to consider general patient factors such as general health and medical condition, fitness for either surgery or a challenging course of radiation, nutritional status, which is often poor in these patients, and may need attention pretreatment. Endolaryngeal and hypopharyngeal disease is now being successfully treated with endoscopic laser techniques where previously external partial procedures, and even total laryngectomy, may have been considered.
In certain advanced hypopharyngeal and laryngeal cancer, where combined radiotherapy and chemotherapy offers organ preservation and good locoregional control without surgery. For palliation for recurrent disease or advanced disease not suitable for surgery or organ preservation through chemoradiotherapy.
Post-operatively and, less commonly, pre-operatively, in disease where it is felt prudent to use multimodality therapy.
Presentation depends on the anatomical subsite but, unfortunately, tumours are often very advanced at diagnosis. Nasopharyngeal cancer is the commonest tumour seen in certain Asian countries (South China and Southeast Asian countries with Chinese populations). Nasopharyngeal cancer is classified according to the World Health Organisation classification.
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Impedance matching of sound pressure delivered to the inner ear through the conductive pathway results from the interaction of the catenary, ossicular, and hydraulic lever systems. Amplification from the pinna and external auditory canal can be up to 15 dB, depending on the azimuth of sound delivery. Baha is also very effective as an alternative to surgical reconstruction in patients with auricular atresia. This chapter summarizes fundamental physical properties of the conductive portion of the auditory system, outlines an appropriate diagnostic evaluation, and proposes a framework for planning surgical treatment of external auditory canal (EAC) and middle ear defects (Box 143-1). The transduction of vibratory energy from the air in the EAC (low impedance) to the cochlear fluids (high impedance) is possible as a result of the impedance matching function of the middle ear. Further studies by Tonndorf and Khanna5 showed the catenary lever was tightly coupled to the ossicular lever because the tympanic membrane is extensively adherent to the malleus handle. For the hydraulic lever to be functional, the stapes should move in a “piston-like” fashion, which has been elegantly described by Guinan and Peake.9 The increased force is proportional to the ratio of the areas of the tympanic membrane to the footplate.
Intensity differences and phase protection cause differential displacement of cochlear fluids, which sets a fluid wave in motion along the tectorial membrane, producing mechanical stimulation of sensory hair cells. The EAC and auricle, primarily the conchal component of the pinna, provide an additional increase of up to 15 dB, depending on the azimuth of sound delivery and functional length of the canal.
In the first category, tympanic membrane perforation with undisturbed ossicular continuity produced a hearing loss that was linearly proportional to the size of the perforation (loss of areal ratio plus loss of catenary lever). Conductive hearing loss was flat across speech frequencies and averaged 50 dB when corrected for the previously described misleading bone levels. The fork is gently struck by the examiner and placed on the forehead or on the vertex of the skull, and the patient states on which side he or she hears the tone more clearly.
The diagnosis of a conductive loss is made in the presence of an air-bone gap on the pure-tone audiogram with speech testing commensurate to the results measured audiometrically (Fig.
Voluntary responses are not required for successful measures of static compliance, tympanometry, and acoustic reflexes, making them an important component of the auditory test battery. Her main areas of interests are Otology, Neurotology, Hearing Research, Pediatric ENT and voice & phonosurgery. The proximity to the brain, major vessels, and the facial nerve demands skill in microsurgery of bone, soft tissues, and nerve. The space behind the TM is in continuity with a system of air cells extending posteriorly into the mastoid, and together these constitute the middle ear cleft.


If disease is confined to the middle ear and ET function is only moderately impaired, then grafting the TM (myringoplasty) may be all that is required. A conductive loss results from an interruption of sound transmission through the TM and the ossicles. Glue ear may be treated by performing a myringotomy and placing a ventilation tube within the TM.
Eventually, amplification ceases to aide communication, and, under these circumstances, a cochlear implant may be of more benefit. Symptoms include otalgia, aural discharge or hearing loss if the external ear canal is occluded. It is most commonly due to vasomotor rhinitis, which in turn is usually secondary to allergy or coryza. The obstruction is usually due to a viral swelling of the nasal mucosa, but may also follow dental infection or dental work, nasal allergy, facial fractures and barotrauma. Diagnosis is made following imaging of the paranasal sinuses (CT or MRI scan) and, unless a juvenile angiofibroma is suspected, a transnasal biopsy. The most common cancer of the ethmoid sinus in Australia is adenocarcinoma, which occurs more commonly in people employed in the hardwood industry.
They belong to a collection of lymphoid tissue calledWaldeyer's ring which also comprises an aggregate of lymphoid tissue at the base of the tongue called the lingual tonsil and lymphoid tissue around the opening of the eustachian tube called the tubal tonsil. This results in severe pain, toxicity and trismus and usually a large unilateral tonsillar swelling.
There is an acute bacterial inflammation of the epiglottis and supraglottic structures with rapid onset and rapid progression such that the airway may be occluded, with death resulting from acute upper airway obstruction.
The lesions are removed with microsurgical techniques via a direct laryngoscopy under general anaesthesia. A thorough search to exclude tumour, including CT scan from skull base to thorax, must be made. Nonetheless, because of the significance of functional impairment and the potential for disfigurement, it is an important management problem. Up to 80% of these cancers can be attributed to a combination of cigarette and alcohol abuse. It is generally accepted that the survival rate of head and neck cancer is halved when a positive neck node is present. In the oral cavity and the oropharynx, for example, common symptoms include a mass or an ulcer with pain and difficulties with speech and swallowing. Thorough endoscopic evaluation and fine-needle aspiration cytology (which has not been found to cause recurrent neck disease) should be used to investigate these lesions before open biopsy or surgical removal.
It is well demonstrated that they are more sensitive than clinical examination in detecting metastatic neck disease. There has been a shift away from radical surgery, such as total laryngectomy, to the use of protocols involving the use of chemo-radiation for relatively advanced tumours. Reconstructive techniques involving free flaps which bring a better blood supply to the area have allowed better healing in previously irradiated tissues where the blood supply has been diminished by radiation. Whether radiation is used preoperatively or post-operatively is often determined by the accepted practices in individual cancer treatment units.
Radiation affects both normal tissue and cancer tissue, and the salivary glands and oral mucosa are particularly affected.
Secondary neck disease is a significant factor in determining prognosis and, in general, the presence of neck disease lowers the survival by some 50%. It is not unusual to find orbital and anterior cranial fossa involvement on CT and MRI scanning. The prognosis of these cancers is poor, usually because of the advanced state of disease at diagnosis and the proximity of the anterior cranial fossa.
The mucosa is stratified, ciliated, columnar epithelium, with a large aggregate of lymphoid tissue forming part of Waldeyer's ring. Alternating condensation and rarefaction of sound pressure passes through the external ear structures to the tympanic membrane.
This complex system consists of frequency-dependent stiffness and inertia reactances, along with a frequency-independent frictional component. The tympanic membrane, which is rigidly fixed at the periphery and mobile centrally, acts as a catenary lever, exerting its force on the malleus handle in response to pressure changes transmitted through the EAC.5 A twofold gain in sound pressure level is generated at the malleus. Because ear canal resonance occurs at a frequency whose wavelength is four times the canal length, the corresponding resonant frequency is roughly 3500 Hz. The degree of hearing loss, flat across speech frequencies, was not altered by the location of the perforation on the drumhead.
Caution was taken when interpreting audiograms in these patients because underestimation of the magnitude of the conductive loss frequently occurred.
More complete phase cancellation caused increased hearing loss compared with patients with partial perforations. Placement of the tuning fork over the nasal bones or on the teeth may present a stronger stimulus for Weber testing in difficult-to-test patients.13 Lateralization of the tone represents either a conductive loss ipsilateral to the side of localization or a sensorineural loss greater in the contralateral ear. Note the air-bone gap, normal speech discrimination, and normal masked bone conduction in the left ear.
She is well known for her research work on stem cell treatment for sensorineural hearing loss. LXV Annual Meeting of The Clilean Academy of Otolaryngology and Extraordinary Meeting of the German-Spanish Society. Surgical treatment of the hearing apparatus requires a good working knowledge of auditory physiology and pathophysiology. Aeration of the middle ear cleft is maintained by the eustachian tube (ET), which runs from the nasopharynx to the anterior tympanic cavity (Schematic anatomy of the ear. Examination of the TM in noncholesteatomatous COM is associated with a central perforation of the TM, where the edges of the perforation are visible and are bounded by a rim of drum (Chronic otitis media and surgical treatment. If the mastoid is also infected, exenteration of the mastoid air cell system is combined with myringoplasty (a ‘canal wall up’ mastoidectomy; Chronic otitis media and surgical treatment.
Hearing restoration surgery will also be performed with operations for COM as discussed above.
A cochlear implant is also indicated for congenitally deaf children, provided that the operation is performed before the child is 5 years of age.
They usually require surgical excision via an endoscopic approach, with clearance of polyps from the ethmoid sinus being most common, but also from other paranasal sinuses as required. It is usually due to aerobic organisms and manifests as pain, facial swelling and mucopurulent nasal discharge.
Other cancers of the nasal complex include adenoidcystic carcinoma, sinonasal undifferentiated (small cell) carcinoma, transitional carcinoma and malignant melanoma.
The adenoid tissue usually atrophies over the second decade of life and is not a common cause of disease after childhood.
The abscess must be drained by an incision in the upper half of the tonsil pillar followed by admission to hospital and intravenous antibiotics for several days. Intubation in an operating theatre environment is the treatment of choice in both adults and children, with the surgeon standing by to perform urgent surgical access to the airway should intubation fail. The condition responds to anti-reflux measures and medication, including proton pump inhibitors. Treatment is required for unilateral palsy if the voice is poor and sufficient time has elapsed (usually 6 months) to exclude spontaneous recovery.
Their effects are believed to be synergistic, resulting in widespread changes in the mucosa and the potential for multiple tumours (estimated at between 15 and 20%). Head and neck cancer surgeons refer to neck nodes in terms of different levels, I through V. Painful swallowing (odinophagia) is a serious symptom which indicates the presence of a cancer until otherwise proven.
CT scanning is beneficial in the detection of bone disease and spread of laryngeal disease beyond the laryngeal framework. Partial laryngectomy, particularly with endoscopic laser surgery, often provides organ sparing and successful outcomes. Modern reconstructive techniques and the use of free flaps have allowed many of these tumours to be successfully resected and reconstructed in a single-stage procedure. It is apparent now that similar regional control of disease can be achieved by a more selective approach.
People with a long history of wood-dust exposure (cabinet makers, sawmill operators) are usually common among patients diagnosed with ethmoid cancer. It frequently invades the base of the skull, causing cranial nerve involvement and palsies.
Conditions that alter ossicular stiffness, such as otosclerosis, produce prominently low-frequency hearing loss. The addition of the conchal component of the pinna increases the EAC length, resulting in a lower resonant frequency, which has been measured at 2700 Hz. Falsely depressed bone-conducted hearing levels (?10 dB in speech frequencies) resulted from impedance variation occurring at the oval window caused by the ossicular discontinuity. The decreased sound pressure also reached the round and oval windows nearly simultaneously, inducing phase cancellation in the labyrinthine fluids. Otomicroscopy is useful to remove foreign bodies and to examine the tympanic membrane and middle ear structures more precisely, and is a prudent step in preoperative evaluation. The 256-Hz tuning fork is the most sensitive of the available frequencies,14 but it can yield an unacceptable number of false-positive results.
A negative or abnormal Rinne result is found when bone conduction is perceived longer than air conduction. The middle ear static compliance is determined by subtracting the compliance at 200 mm H2O from the total compliance when pressure is equal on both sides of the tympanic membrane. The dotted arrows depict the flow of air through the eustachian tube into the middle ear and mastoid.
Although causes of cholesteatoma may vary, most often the invagination is secondary to the negative middle ear pressure accompanying ET dysfunction.
A better hearing ear is a relative contraindication, due to the risk of sensorineural deafness at surgery. Sound transmission through the ossicular chain may be interrupted if the ossicles are no longer in continuity or if the ossicular chain is fixed. However, it is usually not possible to reconstruct the ossicular chain if there is a co-existent TM perforation. When the ossicles are disrupted, reconstruction aims to re-establish a stable link between the TM and the stapes footplate.
Up until this age a child may learn to comprehend speech with the implant, even though he or she has no previous auditory experience. This is usually post-traumatic and may originate from a breach of the cribriform plate, a paranasal sinus (ethmoid, frontal or sphenoid sinus) or from the middle ear space via the ET. In a history of recurrent tonsillitis, this is an indication for a tonsillectomy, usually after the acute abscess has settled down.


After the airway is secure, the problem usually settles rapidly with intravenous antibiotics and, on occasion, steroids.
There is rarely an indication for surgery as almost all cases will improve or resolve completely with voice therapy and re-education of vocal habits.
On the right side, it arises higher in the thorax looping around the right subclavian artery.
Such operations may be medialisation of the vocal fold via laryngeal framework-type surgery or injection of fat lateral to the fold to medialise it. These tumours are best treated via a multidisciplinary surgical approach in departments, which can make the best use of advances in tumour biology, imaging modalities, radiotherapy and chemotherapy and conservation and organ preservation techniques. MRI is particularly useful for investigation of the tongue and soft tissue extension of disease, including involvement of the nerves and brain. It should be remembered, however, that the preservation of a crippled larynx which does not function and aspirates is a poor outcome.
This has allowed a more rapid transition to post-operative radiotherapy, which is essential if all the benefits of multimodality therapy are to be achieved. The mandible is commonly devascularised following radiotherapy and very prone to osteomyelitis and necrosis, secondary to dental sepsis.
These modified or selective neck dissections remove node levels which are most likely to contain metastatic disease from the associated primary.
Genetic markers have also been investigated because of the ethnic predilection of the tumour.
It is one of the few cancers of the head and neck with a predilection to distant metastases with the bone, lung and liver, the preferred sites. Changes in the mass of the middle ear structures, classically described as producing high-frequency deficits, actually result in hearing losses that vary according to where the mass change occurs on the tympanic membrane or ossicular chain.3 Tympanosclerosis, which affects the mass and the stiffness of the ossicular chain, results in a flat hearing loss recorded at high and low frequencies.
Correction of the ossicular problem typically increased bone levels, reflecting the re-establishment of impedance matching at the oval window. The use of 256-Hz, 512-Hz, and 1024-Hz tuning forks assists in the localization of the side of greatest auditory deficit and verifies audiometric findings. The dotted arrows depict the flow of air through the eustachian tube into the middle ear and mastoid.).
The invaginated skin continues to desquamate, but the squames become trapped in the retracted pocket of skin.
A marginal perforation is the hallmark of cholesteatoma, where a perforation extends beyond the edge of the drum and ‘disappears’ behind the posterosuperior wall of the ear canal (Chronic otitis media and surgical treatment. A better approach is to repair the drum first, and perform an ossicular chain reconstruction as a staged procedure. It communicates via a radiofrequency link with an external device called the speech processor. The corrective procedure, septoplasty, involves elevating mucosal flaps and removal of the deviated segment of cartilage or bone. Drainage and aeration of the sinus is of paramount importance; hence, most cases of chronic sinusitis require endoscopic sinus surgery to achieve this.
In childhood, tonsils and adenoids may become large enough to interfere with the airway and can cause significant obstruction with the interference and intermittent cessation of breathing overnight (obstructive sleep apnoea). Both travel in the tracheo-oesophageal groove superiorly to the larynx, where they supply the intrinsic muscles that move the vocal folds.
A recent advance in endoscopic laser surgical techniques has also seen an improvement in outcomes and organ preservation for laryngeal and hypopharyngeal cancers. Levels II, III and IV correspond to the upper, middle and lower cervical lymph nodes respectively and Level V represents the nodes in the posterior triangle. Vocal fold cancers frequently present with hoarseness which does not resolve with adequate treatment after 2 or 3 weeks. Consequently, laser surgery is tending to replace radiotherapy for these lesions as the outcomes are similar and the treatment involves only a 1- or 2-day stay in hospital. Dental consultation and management of the teeth are therefore essential if the jaw is to be involved in the radiotherapy field.
These are multiple levels of nodes involved or spread of tumour beyond the capsule of the lymph node on pathology assessment.
Consequently, fewer than the 5 levels of nodes are removed and, inherent in this approach, is the preservation of various non-lymphatic tissues, including the spinal accessory nerve, internal jugular vein and sternomastoid muscle. An increased incidence is seen in patients with certain major histocompatibility complex profiles (HLA). MRI scan is the investigation of choice and, universally, radiotherapy with concomitant chemotherapy is the treatment of choice. Tuning fork testing should be carried out in any patient before surgery for a conductive anomaly to verify audiometric results and to establish a baseline for comparison for postoperative assessment. Tympanometry, a graphic representation of the compliance of the middle ear during dynamic pressure conditions, tests tympanic membrane integrity and ossicular mobility.
Inadequate aeration of the middle ear leads to negative pressure with respect to the atmosphere behind the ear drum.
It is at this stage that the retraction pocket is no longer self-cleaning and is, by definition, a cholesteatoma. The mastoidectomy both removes the disease and reduces the surface area of the middle ear cleft, thus decreasing the work done by a compromised ET. The most common cause of ossicular fixation is otosclerosis, where the bone of the labyrinth is abnormal and the stapes footplate becomes fixed to surrounding labyrinthine bone. For this reason, ossicular chain reconstruction is usually a second-stage procedure following surgery for COM. These procedures do not restore anatomical normality, and this is not required to achieve good hearing. The younger the child at the age of implantation the better the speech and language outcomes, and it is preferable to implant before the child's second birthday. The speech processor translates speech into the pattern of electrical stimulation to be delivered to the auditory nerve. Treatment is initially conservative, with elevation of the head and rest for 2 weeks, but if the leak persists surgical repair will be necessary.
Occasionally, drainage of the sinus via trephination or endoscopic antrostomy may be required.
Causes of unilateral paralysis may be tumours of the thyroid, lung or metastatic deposits within mediastinal lymph nodes.
Bilateral vocal fold paralysis can present an upper-airway emergency that may require tracheotomy. Reconstructive techniques and the use of free flaps is well established and continues to provide better outcomes. On this basis, it is now possible to tailor neck dissection according to the site of primary tumour and the levels of nodes involved.
Cancers in the hypopharynx may be more subtle in presentation and can reach a significant size before the primary tumour presents problems for the patients.
The ingestion of preserved foods, especially salted fish, duck eggs and salted mustard green, have also been implicated in nasopharyngeal cancer.
The tumour is usually radiosensitive and, due to the inaccessibility of the site, surgery with clear margins is usually not possible. Perforation size and the condition of the stapes footplate accounted for variations in this patient group.
There is a tendency for the TM to become retracted and the mucosal lining to exude a serous or mucoid discharge. The desquamated skin within the retraction pocket will usually become infected, with the development of an aural discharge. The surgical principles include the preservation of vital structures, including the facial nerve and inner ear, the eradication of disease and the reconstruction of the TM and hearing.
For cholesteatoma, or failed canal wall up mastoidectomy, a modified radical mastoidectomy is performed. In the long term, endoscopic laser techniques allow the reestablishment of an airway, often with the preservation of good voice. Neck dissections are now almost exclusively of a selective nature rather than the older-style radical neck dissection, which sacrificed the sternomastoid muscle, the internal jugular vein and the accessory nerve. These lesions frequently present with a painless, enlarging, lump in the neck which represents a metastatic node. Infection may ensue if bacteria are present in the middle ear cleft, frequently leading to perforation of the TM. Eradication of disease involves the removal of diseased bone and mucosa, and cholesteatoma if it is present. This involves performing a mastoidectomy, removing the posterior and superior (ear) canal walls, and grafting the TM (a ‘canal wall down’ mastoidectomy; Chronic otitis media and surgical treatment. The most common causes of sensorineural loss are hereditary, meningitis, ototoxic, trauma and progression of unknown aetiology.
The commonest cause of paralysis, however, is idiopathic and the commonest nerve affected is the left, probably because of its greater length. It is rare now to sacrifice the accessory nerve in neck dissection as this often produces significant morbidity with denervation of the trapezius muscle and resulting shoulder droop.
Complications of this disease can be serious and include facial nerve palsy, loss of labyrinthine function and intracranial sepsis. An infected discharge follows, associated with chronic changes to the middle ear mucosa and a low-grade osteitis of the temporal bone. A computed tomography (CT) scan of the temporal bone, at 2-mm slices with bony windows, helps to define the extent of disease. The limits of the mastoid cavity, created by removing the mastoid air cells and taking down the posterior and superior canal walls is indicated by the thick, solid line.). The differentiation of the primary cancer does not appear to have prognostic significance, with the possible exception of the oral tongue.
Following this operation, the mastoid cavity is exteriorised so that it is now part of the external ear and is lined with skin. A common misconception is that the intact vocal cord compensates for the palsy, but this is not true, as the functioning vocal fold can never adduct further than the midline. If both vocal folds are paralysed, the voice is often normal, but the airway can be severely compromised if the vocal folds both lay well towards the midline. Hence the need to assess vocal fold function prior to thyroidectomy to exclude an asymptomatic old palsy and, therefore, exercise diligence in protecting the intact nerve.



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