Journal of Laryngology and Otology

Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings.

Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive ‘proof’ awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesionin vivo.

Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions.

Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.

Meningitis is an important cause of deafness and in some studies has been associated with poorer outcomes in adult patients following cochlear implantation. Of the first 100 adults implanted under the Midland Cochlear Implant Programme, 28 were deafened as a result of meningitis. We compare our experience with these patients with patients with a non-meningitic aetiology.

A degree of cochlear ossification was a more common finding in the meningitic group. In six cases (four meningitics, two non-meningitics) ossification was encountered only during surgery, not being apparent on pre-operative radiology.

The average scores achieved on auditory tests by the meningitic group were similar to those achieved by non-meningitic patients. At nine months, using only the implant, users were able to identify 54 per cent of common environmental sounds, achieved an average score of 30 words per minute on connected discourse tracking and identified an average of 42 per cent of words correctly in BKB sentences.

Poorer outcomes were more commonly associated with cochlear ossification. In patients with cognitive and neurological sequelae, benefits with the implant were not always apparent in the early months, however, with intensive therapy these patients can obtain measurable sustained benefit from their implant.

On the basis of clinical and histologic examination, history and epidemiologic survey of 591 patients with vocal cord polyps, the authors evaluate the morphology of the pathologic substrate, indicate possible pathogenesis and analyse the most frequent factors in the formation of polyps such as vocal abuse and unfavourable microclimate at work. Sex does not play any role in the incidence, and the histologic structure is not related to the time factor.

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.

As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Thirty patients with squamous cell carcinoma of the laryngopharynx were treated with surgery (total laryngectomy and hemithyroidectomy) and radiotherapy. Group 1 (n = 7) patients had surgery only; Group 2 (n = 7) had radiotherapy followed by salvage surgery while Group 3 (n = 16) had surgery followed by radiotherapy.

Parathyroid hormone and calcium levels were measured pre- and post-operatively and pdstradiotherapy. In Group 1 no patients were hypoparathyroid. In Group 2, 29 per cent of patients preoperatively and 57 per cent post-operatively, were hypoparathyroid. In Group 3, no patients were hypoparathyroid pre-operatively, while 25 per cent were hypoparathyroid post-operatively and postradiotherapy. Parathyroid honnone and calcium levels were averaged and compared within and between each group. There was no significant difference within each group, when comparing levels postoperatively and post-radiotherapy from those of pre-operatively. There was no significant difference in levels between each of Groups 1, 2 or 3 (p>0.05).

One hundred and twenty-six patients who underwent tonsillectomy because of recurrent acute tonsillitis, tonsillar hypertrophy or sleep apnoea were evaluated by tonsillar core culturing. The sleep apnoea patients served as controls, since none of them had tonsillar hypertrophy at ENT examination or any history of recurrent acute tonsillitis, and thus their tonsillar core flora could be regarded as normal.

The isolation rate ofH. influenzaewas much lower among sleep apnoea controls (2.7 per cent) than among either the patients with recurrent acute tonsillitis (20.3 per cent) or those with tonsillar hypertrophy (36.7 per cent) (p<0.05), as was that of group A streptococci, 5.4 per centversus16.9 and 20 per cent, respectively (though the latter differences were not statistically significant). The isolation frequencies ofB. catarrhalis, pneumococci, group C and G streptococci did not differ between the three groups.

The high tonsillar core recovery rates ofH. influenzaeand group A streptococci both in patients with recurrent acute tonsillitis and in those with tonsillar hypertrophy, as compared with normal controls, suggests the possible involvement of these bacteria in both conditions.