This is a case of chronic middle ear problems in an adult, and it illustrates medical notes and provides CT images of the middle ear.
The medical notes report:
86-year old male complaining of chronic ET dysfunction with multiple episodes of otitis media. The patient says that this started shortly after moving to Florida several years ago and he has undergone BMT a few times. The patient admits to hearing loss and occasional drainage from his ears. He denies any tinnitus, otalgia, aural pressure, vertigo or imbalance. The patient is interested in having a permanent PE tube placed.
- Any idea what ”BMT” means?
Past Medical History: Diabetes, hypertension, hypercholesterolaemia, asthma, hyperthyroidism, and arthritis.
Audiometric Evaluation: SNHL AU
AD: PTA= 65 dB HL, SRT= elevated speech thresholds, WRS= 100% at 90 dB HL, appears to have ME fluid
AS: PTA= 60 dB HL, SRT= elevated speech thresholds, WRS= 96% at 90 dB HL, PE tube in the EAC was removed, possible small perforation that is not readily apparent on microscope exam
Tympanometry: Type B AU, large ECV AS consistent with TM perforation.
OAEs: Absent AU
Patient receiving hearing aids from the VA at the end of the month.
Impression: Chronic otomastoiditis. Mixed hearing loss.
Plan: A CT scan of the temporal bones was ordered and the patient was asked to return after the above to consider his surgical options.
Two weeks later:
Plan: The risks, benefits, alternatives and goals of myringotomy AD and patch myringoplasty AS were discussed with the patient, who agrees with the plan. Under topical anesthesia a myringotomy was performed AD and the serous fluid was removed. The patient noticed improvement in his hearing. A paper patch myringoplasty was performed AS. The patient was instructed in dry ear precautions. He was asked to return in two weeks for a follow up. CT was ordered.
CT Scan of the Temporal Bones-IACs W/O Contrast:
Abnormal though nonspecific CT appearance of the right ME cavity, possibly reflecting underlying chronic otitis media, chronic granulation tissue, ME effusion. An underlying acquired pars flaccid cholesteatoma with no bony erosive changes is not highly suspected at this time, given the findings described above. Opacification of some of the mid to inferior bilateral mastoid air cells, right side greater than the left. This would be consistent with a component of chronic mastoiditis. Lack of pneumatization of the inferior bilateral mastoid air cells difficult to ascertain a component of underlying congenital hypoplasia from the sequel of chronic bilateral mastoiditis; however, no CT evidence of coalescent mastoiditis.
- What is “granulation tissue”?
Two week follow-up:
AD: Patient complains of worsening hearing loss, the TM is retracted and there is fluid behind the TM.
AS: There is a dry perforation in the TM.
Plan: A myringotomy was performed under topical anesthesia with the use of an operating microscope, per the patient’s request. The risks, benefits, alternative and goals of mastoidectomy and tympanoplasty AD were discussed with the patient, who agrees with the plan. Schedule surgery at the patient’s earliest convenience following medical clearance.
One month later report:
The patient was not cleared for surgery by his cardiologist, who said that the patient was at high risk for cardiac complications due to general anesthesia. The patient was informed of this and conservative regimen was offered including PE tube insertion AD. The patient agrees with the plan for PE tube insertion. The patient states that he is able to auto inflate occasionally AD, but continues to have problems including hearing loss on that side. He has no new complaints.
Plan: The risks, benefits, alternative and goals of PE tube insertion AD were discussed with the patient, who agrees with the plan. A PE tube was inserted under topical anesthesia in the anterior inferior quadrant of the TM AD. The patient tolerated the procedure well and noted immediate improvement in his hearing on that side. He was cleared for hearing aids and will return as needed.
Over the next two years, the patient constantly returned to the office for follow up visits to monitor and treat his chronic otomastoiditis and possible cholesteatoma. He often received cerumen removal, ear debridement, dry ear precautions, and prescriptions for the use of Cipro drops.
Two years later:
Audiometric Evaluation: Severe to profound mixed hearing loss
AD: SRT= 80 dB HL, WRS= 44% at 95 dB HL
AS: SRT= 70 dB HL, WRS= 52% at 95 dB HL
Tympanometry: Type B AD
Plan: The patient was advised of the risks of non-treatment including facial paralysis, deafness, and brain abscess. The patient was advised to follow up with his cardiologist again regarding surgical intervention and the risks of non-treatment.
The patient is wearing hearing aids from the VA, which would be a little under powered for the current mixed loss.
CT of the Temporal Bones W/O Contrast:
- Here is the report that we were given, but do the results correlate with the image?
Right-sided probable tympanostomy tube in place. Complete opacification of the right ME cavity with soft tissue density within the right Prussak’s space and with mild blunting of the right-sided scutum without evidence of ossicular or ptotic capsule erosive changes, and this appearance is nonspecific and could represent the presence of granulation tissue, loculated fluid or possibly the presence of early cholesteatoma formation. Near complete opacification of the right mastoid air cells without evidence of definite bony coalescence in keeping with right-sided mastoiditis. Probable tiny amount of cerumen or other foreign body within the left EAC. Normal appearance of left ME cavity and left IE structures. Minimal left inferior mastoid air cell fluid.
Here are the CT images. The first is a coronal scan, and the green arrow points to the concern.
The next scan is in the axial plane. First, here is the “wide image view”. Note that the left and right middle ears are very different in appearance. The left ear is air-filled, which you can see by the black color. The mastoid space also has air in it – again note the black. On the right side, you can see some air behind the middle ear.
6 months later:
AD: SRT= NR, WRS= NR at 95 dB HL
AS: SRT= 80 dB HL, WRS= 44% at 90 dB HL
ARTs: No seal AU
Tympanometry: No seal AD and ECV 3.96 ml AS
He received stronger hearing aids from the VA.
Case donated by Bradford Ress, MD, Ress Ear Institute, and Michelle Bruszer, AuD, then of NSU.