Immunohistochemical investigations were carried out to determine the pattern of cytokeratin (CK) expression in middle ear cholesteatoma and related epithelia. Using monoclonal antibodies specific for CK chains and the indirect immunoperoxidase technique, we examined 10 CK polypeptides for expression. The external stratified squamous epithelium of the tympanic membrane generally expressed CKs 5, 10, and 14. In addition, basal keratinocytes in the annular region of the pars tensa expressed CK 19 (a simple epithelium marker), while suprabasally the hyperproliferative marker CK 16 was expressed. These data reflect the unusual proliferative nature of this region. The unexpected appearance of CK 16 (known to have a limited distribution in healthy epidermis) clearly relates to its expression in the neighboring deep meatus. The medial simple epithelium of the eardrum revealed mucosal CKs 7, 8, 14, 18, and 19. Acquired cholesteatoma lesions, besides CKs 5, 10, and 14, consistently expressed CK 16 in suprabasal layers. These results constitute the first direct molecular evidence for the hyperproliferative nature of the cholesteatoma matrix. Overall, our CK data suggest that aural cholesteatoma lesions and epidermal tissue in this area are related. However, they do not explain the mechanism(s) by which the eardrum or meatal epithelia might invade the middle ear cavity. Congenital cholesteatomas expressed CKs 5, 10, 14, and 16 equally. These CK data do not support the idea of a metaplastic origin from middle ear mucosa; instead, they suggest activation of an ectodermal rest in the middle ear cavity.

In order to overcome the disadvantages of the classic epi- or perineural nerve suture techniques, attempts have been made to secure nerve endings by a variety of measures, as exemplified by the use of artificial and biological glues. The use of a fibrinogen-thrombin adhesive to seal nerve endings is an easy, time-saving method at surgery and provides excellent coaptation of the severed nerve fascicles with minimal iatrogenic trauma. However, the problem remains of excessive connective tissue proliferation at the junction site or of premature loss of tensile strength before proper nerve healing occurs. The combination of the biological glue with the tubulization technique, associated with a fascicular and/or interfascicular nerve junction, may overcome the disadvantages associated with previous nerve repairs.

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