|Year : 2015 | Volume
| Issue : 1 | Page : 57-60
Rehabilitative challenges in the bilateral aural stenosis post chronic suppurative otitis media surgery: A case study
Himanshu Verma, Sneha Uttakalika Sah, Madhumita James
Department of Audiology, Ali Yavar Jung National Institute for the Hearing Handicapped, NRC, New Delhi, India
|Date of Web Publication||10-Mar-2015|
AYJNIHH, NRC, Kasturba NIketan, Lajpat Nagar-II, New Delhi- 24
Source of Support: None, Conflict of Interest: None
Introduction: Chronic suppurative otitis media (CSOM) is an infection characterized by recurrent ear discharge through a persistent tympanic membrane perforation. In cases such as these, an ASLP is concerned with early prevention, assessment and provision of suitable client based rehabilitation options. Case Report: A 3.5yrs old male with bilateral aural stenosis post CSOM surgery reported to clinic with a complaint of reduced hearing sensitivity to soft sounds with delayed in speech and language. A test battery approach for Audiological and Speech and Language evaluation was conducted. Recommendations and referrals were suggested at the end. Discussion: Regardless of all the restrictions, this study highlights the challenges encountered by an ASLP in dealing with post operative aural stenotic case. This case study highlights the occurrence of stenosis post surgery of bilateral CSOM, which is rarely found.
Keywords: Cholesteatoma, Chronic suppurative otitis media, Pure tone audiometry, Stenosis
|How to cite this article:|
Verma H, Sah SU, James M. Rehabilitative challenges in the bilateral aural stenosis post chronic suppurative otitis media surgery: A case study. Indian J Otol 2015;21:57-60
|How to cite this URL:|
Verma H, Sah SU, James M. Rehabilitative challenges in the bilateral aural stenosis post chronic suppurative otitis media surgery: A case study. Indian J Otol [serial online] 2015 [cited 2021 Oct 25];21:57-60. Available from: https://www.indianjotol.org/text.asp?2015/21/1/57/152869
| Introduction|| |
Chronic suppurative otitis media (CSOM) is an infection characterized by recurrent ear discharge through a persistent tympanic membrane perforation. This is a tubotympanic perforation; it is usually safe, while atticoantral perforation is often unsafe. Unsafe CSOM involves cholesteatoma. Cholesteatoma is a nonmalignant but destructive lesion of the skull base.
Cholesteatoma is related to a variety of conditions mainly postoperative, although factors like recurrent inflammation as well as postinflammatory and posttraumatic stenosis or atresia with ear canal obstruction also occur.
Treatments available for unsafe CSOM are systematic antibiotics to control the infection. If no improvement from medication then surgeries such as cortical mastoidectomy, modified radical mastoidectomy or radical mastoidectomy is conducted.
Postcomplications of surgeries can be intratemporal (facial paralysis etc.,) intracranial (meningitis etc.,) sequelae (hearing loss, tympanosclerosis etc.,) or aural stenosis.
In atresia body orifice or passage is abnormally closed or absent. The main cause for atresia is the failure of the external ear canal to develop completely. Other reasons are halted development of ear, bone filling in the ear canal region leading to no external opening or stenotic and markedly narrowed ear canal. 
In rare cases of the ear canal stenosis (narrowing), skin that normally lines the ear canal becomes trapped and cannot self-clean. This trapped skin causes bony remodeling of the surrounding bone and can cause infection termed cholesteatoma.
Atresia repair, split-thickness skin graft (STSG), anteriorly and inferiorly based periosteal flaps (AIPFs) are the recommended surgeries for cases with aural atresia. Although the success rate of such surgery are very less as stated in Jacobsen, Mills, (2006)  where the ear canal remained, unstable and late reoccurrence was observed. Magliulo, (2009)  demonstrated that the surgical procedure, even when performed correctly, did not afford a stable, long-lasting outcome in a cohort of patients.
To improve patient care, to provide comprehensive assessment and management and to understand the complex interrelated factors, which affect the individual, we need a multidisciplinary team approach. The team members for such cases will consist of pediatrician, ENT surgeon, neurologist, audiologist and speech language pathologist (ASLP), psychologist, special educators, social workers, rehabilitative counselors, and family members. 
Every member has an indispensable role in the rehabilitation process, and the role of an ASLP cannot be underrated as well.
In cases such as these, an ASLP is concerned with early prevention, assessment and provision of suitable client based rehabilitation options. Their services are committed to the identification of symptoms, providing personalized hearing health care, progressive speech, and language regime, designing a course of the rehabilitation plan, integration of reliable rehab resources along with increasing public awareness. They use specialized diagnostic tools like audiometers, computers and other testing devices for conducting special tests such as (behavioral observation assessment, pure tone audiometry [PTA], otoacoustic emission, brainstem evoked response audiometry [BERA], immittance audiometry) and various software loaded speech programs. Assimilation and integration of these test results are invaluable contributions by them.  Hence, an ASLP plays a significant role which cannot be underestimated.
Need of the study
In spite of all the modern technologies and rehabilitative options we were confined with due ethical reasons to make a comprehensive approach toward diagnosis and management of this case. Barriers such as cost-effect, success rate, economic status of the client, very limited research reviews in Indian scenario impeded our progress. As there are less established standard treatment norms for such cases, this case was kept on trial and error basis. Regardless of all the restrictions, this study highlights the challenges encountered by an ASLP in dealing with postoperative aural stenotic case.
| Aim and Objective|| |
To discuss and debate the various challenges encountered in the assessment as well as selection of optimum rehabilitation option for a case with bilateral stenosis post CSOM surgery.
| Case Report|| |
Case aged 3.5 years had average intelligence (IQ-85) with all the motor milestones been achieved age appropriately. He had medical history of bilateral CSOM with otitis externa and had undergone right cortical mastoidectomy for the same in a government hospital in Delhi at the age of 2.5 years. 6 months postsurgery soft tissues accumulated in the same ear leading to stenosis of the ear canal [Figure 1] and [Figure 2].
Contrast enhanced computed tomography of the temporal bone revealed soft tissue in the region of bilateral external auditory canal (EAC), obliterating the cartilaginous part of the both EACs. Bilateral inner ears were normal. The soft tissue showed mild enhancement and central mild thickening of the right maxillary sinus. Left osteomeatal complex was found to be blocked. It concludes occlusion of the cartilaginous part of both EAC by soft tissues with bilateral mastoiditis and destruction of left ossicular chain.
High resolution computer tomography (HRCT) of the temporal bone reported soft tissue density in left EAC, middle ear cavity and the mastoid antrum with destruction of trabeculae and middle ear ossicles. Left sided inner ear, facial canal, and tegmen tympani were preserved. As the patient was postoperated right cortical mastoidectomy, right EAC, middle ear and the mastoid antrum showed soft tissue density lesion with destruction of trabeculae. Right sided inner ear and facial canal were preserved. Mucosal thickening was seen in left ethmoid air cells and left maxillary sinus with widening of left maxillary ostia extending into left nasal cavity s/o antrochoanal polyp. Right maxillary and ethmoid air cells were normal. Nasal septum was central. HRCT gave impression of bilateral CSOM involving middle ear mastoid antrum and ossicles with bilateral inner ear and facial canal preserved and left antrochoanal polyp with left ethmoid sinusitis.
Otoscopy showed bilateral stenosis with tympanic membrane intact.
Initially, we encountered various challenges while performing the audiological evaluation. While doing air conduction (AC) PTA and AC BERA the child complained for otalgia because of the headphone placement. Next, we tried for bone conduction (BC) PTA and obtained reliable thresholds. BC BERA though suggested with sedation could not be completed due to high levels of electroencephalogram activity in spite of repeated trials. Hence, the case was given a follow-up appointment.
As we could not get reliable results during the first trial of the test, the case was followed-up, and AC and BC PTA and BERA were successfully done in this trial. The audiometric reports are as given: AC PTA and BC PTA thresholds are marked in given audiogram [Figure 3] and it gives an impression of moderately severe conductive hearing loss in right ear and moderate conductive loss in left ear.
|Figure 3: Audiogram showing air conduction and bone conduction thresholds|
Click here to view
Air conduction and BC BERA testing were done using insert earphones in both ears. Clicks were used as stimuli with a repetition rate of 27.7 m/s using alternating polarity and 3 runs were made for each intensity both for AC and BC BERA.
Air conduction BERA revealed good wave V morphology at 80 dBnHL with latency of 6.57 ms.
Bone conduction BERA revealed wave V present at 20 dBnHL with wave V latency of 7.90 ms.
Brainstem evoked response audiometry gave an overall impression of the child having bilateral moderate conductive hearing loss.
Otoacoustic emission and immittance audiometry was conducted using fitted ear probe.
Behavioral observation assessment was conducted with many trials and a provisional diagnosis of moderate to moderately severe hearing loss was stated. This was followed by a hearing aid trial with BC transducer.
Speech and language evaluation illustrated delay in receptive and expressive speech and language development with receptive and expressive delay of 2½ years.
All the above manifestations threw down the gauntlet on us for its management. The favorable remediation options suggested to the client were surgeries (atresia repair, STSG, AIPFs. Although the success rate of such surgery are very less). 
Client was counseled for the given ways to improve the transmission of sound to the healthy inner ear that include the bone conducting hearing aid, the bone anchored hearing aids system,  bilateral contra lateral routing of signal, implantable middle ear hearing aids, vibrant sound bridge device (semi implantable device).
Intensive speech and language stimulation and regular therapy with preschool education program were recommended.
Owing to the low socioeconomic status, options for surgery and implantable device were not affordable. Hence, a moderate class hearing aid (under assistance to disabled persons scheme) was provided from our center to be used with a BC transducer, which was of benefit to the subject.
| Summary and Conclusion|| |
This case study highlights the occurrence of stenosis postsurgery of bilateral CSOM, which is rarely found. In this case, it happened because of the accumulation of soft tissue in the right ear canal.
This study throws light on the clinical challenges encountered by an ASLP in the assessment and management of such cases.
The future challenge for such cases will be to preclude the reoccurrence of infection and stenosis. Also to prevent the degradation in hearing, improve speech and language and provide preschool education resulting in good prognosis.
| References|| |
Jacobsen N, Mills R. Management of stenosis and acquired atresia of the external auditory meatus. J Laryngol Otol 2006;120:266-71.
Magliulo G, Colicchio MG, Appiani MC. Facial nerve dehiscence and cholesteatoma. Ann Otol Rhinol Laryngol 2011;120:261-7.
Saedi B, Karimi-Yazdi A, Mojtaba F, Hamidreza S. Association between audiometric profile and intraoperative findings in patient with CSOM. Iranian Journal of Otorhinolaryngology 2011;23:37-42.
Adoga A, Nimkur T, Silas O. Chronic suppurative otitis media: Socio-economic implications in a tertiary hospital in Northern Nigeria. Pan Afr Med J 2010;4:3.
Macnamara M, Phillips D, Proops DW. The bone anchored hearing aid (BAHA) in chronic suppurative otitis media (CSOM). The Journal of Laryngology and Otology Supplement 1996;21: 38-40.
[Figure 1], [Figure 2], [Figure 3]