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PubMed2004

Impact of mastoidectomy on simple tympanic membrane perforation repair.

OBJECTIVES/HYPOTHESIS: Mastoidectomy has long been identified as an effective method of treatment for chronic ear infection. The effect of mastoidectomy on patients without evidence of active infectious disease remains highly debated and unproven. The objective in the study was to examine the impact of mastoidectomy on the repair of uncomplicated tympanic membrane perforations. STUDY DESIGN: Retrospective study of patients at tertiary referral center. METHODS: Four hundred eighty-four patients who underwent surgical repair of simple tympanic membrane perforations were identified and reviewed in a retrospective manner. Simple tympanic membrane perforations were defined as tympanic membrane perforations of any size and location without any of the following confounding variables: 1). active infection (active otorrhea, abnormal middle ear mucosa, or granulations tissue); 2). ossicular abnormalities (ossicular fixation, ossicular discontinuity, ossicular malformation, or ossicular absence); 3). cholesteatoma; or 4). prior attempt at tympanic membrane repair (prior tympanoplasty or mastoidectomy). Surgical outcome and clinical course were assessed to compare results of tympanic membrane perforation repair with and without canal wall up mastoidectomy. RESULTS: Tympanic membrane repair was equally effective in both groups at 91%. Hearing results were comparable. Development of persistent ipsilateral otological disease requiring a subsequent ipsilateral procedure was approximately twice as common in the tympanoplasty group. In the tympanoplasty group, 14.1% of patients underwent subsequent ipsilateral otological procedures, and 6.1% of patients in the tympanoplasty with mastoidectomy intact canal wall group underwent subsequent ipsilateral procedures (P <.05). The most common subsequent ipsilateral procedures were tympanoplasty, tympanostomy tube placement, tympanoplasty with mastoidectomy canal wall up, and tympanoplasty with mastoidectomy canal wall down, in that order. After including untreated tympanic membrane perforations as subsequent procedures, the adjusted rate of subsequent procedures was 15.5% in the tympanoplasty group and 12.2% in the tympanoplasty with mastoidectomy group (P >.05). CONCLUSION: Mastoidectomy was not necessary for successful repair of simple tympanic membrane perforations. However, mastoidectomy impacted the clinical course in patients by reducing the number of patients requiring future procedures and by decreasing disease progression. This suggests that even in the absence of active evidence of infection, mastoidectomy improved the underlying disease process. Combining mastoidectomy with tympanoplasty during repair of simple perforations in patients with no active evidence of infection remains an appropriate option and may be valuable in reducing the need for future surgery.

Adolescent↗
PubMed1978

Tragal perichondrium and cartilage in reconstructive ear surgery.

Two hundred and fifty-five ear operations using tragal perichondrium and cartilage for reconstruction are presented. Of these, 108 were myringoplasties, 137 were tympanoplasties with ossicular reconstruction performed by nine different methods, and 10 were tympanoplasties with reconstruction of posterior canal wall defects left by radical mastoid surgery. The method presented in this study of using the tragal perichondrial graft is well suited for myringoplasty and can be used where the drum remnant is very small or the anulus is missing. The natural angle of the tragal perichondrium can take the place of the missing anulus anteriorly, inferiorly or posteriorly. Myringoplasty graft survival at one year follow-up was 92%, and 76% had hearing within 10 db of bone conduction. In tympanoplasty, the tragal perichondrium was used en bloc with its cartilage for reconstruction of the ossicular chain where suited. The malleus was used to reconstruct the ossicular chain in different variations. Other methods used are fully described. At one year follow-up the rate of grafting success for tympanoplasties was 91%, and 78% had hearing within 10 db of bone conduction. A method for reconstruction of the posterior canal wall and tympanoplasty after radical mastoidectomy is presented. It uses tragal cartilage and perichondrium en bloc. At one year follow-up, eight of ten cases operated on by this method had an intact drum and posterior canal wall, one had an intact drum but the posterior canal collapsed into the mastoid, and one had an intact canal wall but the eardrum re-perforated. Nine had postoperative hearing within 10 db of bone conduction. A randomly selected group of 100 tympanoplasties was examined for postoperative gain in hearing according to the speech reception threshold, a more practical criterion of surgical success than 10 db air-bone gap. Although the total number showing improvement was similar to the number gaining hearing within 10 db of pure tone bone conduction (76% vs. 78%), when changes of 5 db were discounted, only 56% were improved (and 33% had a significant gain in hearing).

Adult↗
PubMed1996

Long-term results using ossicular grafts.

Sculpted autologous ossicle and cortical bone grafts were the first materials successfully used to reconstruct the ossicular chain in chronic ear surgery. Over the last 20 years, the use of biocompatible implants has been popularized; as a result, bone grafts have fallen into disfavor with most otologists. To determine if autologous bone grafts remain stable with time, 115 cases in which autologous bone grafts were used between 1971 and 1984 were reviewed. Eighty patients underwent Type III tympanoplasty, stapes arch present. Thirty-five underwent Type IV tympanoplasty, stapes arch absent. Minimum follow-up was 2 years; 30 patients were followed for > or = 10 years. In Type III tympanoplasty, overall the initial air/bone gap was 19.7 dB at 6 months, with 59% of those with improved hearing at 15 dB air/bone gap or better. Hearing remained stable for 10 years with overall hearing of 19.2 dB air/bone gap and 50% with an air/bone gap of < or = 15 dB. In Type IV tympanoplasty, the average air/bone gap was 26 dB at 6 months, with 70% of those having improved hearing with < or = 20 dB air/bone gap. At 10 years, the overall air/bone gap was 29.3 dB, with only 28% maintaining an air/bone gap of < or = 20 dB. Poor eustachian tube function and collapse of the middle ear air space were found to be the primary causes for long-term failure. The initial hearing results using autologous bone are comparable with those achieved with synthetic prosthesis. Hearing results using autologous bone remained stable through 5 years. Beyond 5 years, Type III tympanoplasty remained stable, while there was deterioration in Type IV tympanoplasty due to poor eustachian tube function.

Adolescent↗
PubMed2000

Postoperative results for cholesteatoma in children.

OBJECTIVES: to review the postoperative results for cholesteatoma in children. MATERIALS: 32 ears with acquired cholesteatoma in children operated on by a single surgeon between 1987 and 1995 and followed up more than 2 years. The mean follow-up period was 5.4 years. RESULTS: a one-stage operation was performed in seven ears (21.9%) and preplanned stage operation in 25 ears (78.1%). In the first operation, closed tympanoplasty was performed in 31 ears (96.9%) and open tymapanoplasty in one ear (3.1%). During the second stage operation, residual cholesteatoma was found in 16 ears (64.0%). Recurrent cholesteatoma was detected in 19.4% of ears treated with closed tympanoplasty. The mean postoperative air conduction hearing level was within 20 dB in 12.5%, 30 dB in 40.6% and 40 dB in 78.1%. The hearing results of type III tympanoplasty was better than those of type IV tympanoplasty. CONCLUSIONS: preplanned stage tympanoplasty is safer because of the high risk of recurrent and residual cholesteatoma. Surgical methods should be selected flexibly in individual cases depending upon cavity size, eustachian tube function and hearing level. Cholesteatoma in children should be operated on while stapes is present.

Adolescent↗
PubMed2005

Tympanic membrane perforation repair with acellular porcine submucosa.

OBJECTIVES: To evaluate the efficacy of acellular porcine small intestine submucosa in the repair of chronic tympanic membrane perforations. Although tympanoplasty with autologous temporalis fascia and cartilage is common practice in the repair of chronic tympanic membrane perforations, these materials are associated with increased operative time and have variable availability and quality in individual patients. Recently, new materials for tympanoplasty have been explored, including acellular human dermis. Small intestine submucosa (Surgisis) is an inexpensive and readily available alternative to autologous and cadaveric grafts. In this study, we examined the use of small intestine submucosa in the repair of chronic tympanic membrane perforations in a chinchilla model. STUDY DESIGN: Prospective pilot study using 10 adult chinchillas. METHODS: Chronic tympanic membrane perforations were created in 10 adult chinchillas for a total of 20 perforations. Each animal underwent observation in one ear and repair with either autologous cartilage or small intestine submucosa in the opposite ear with Type I tympanoplasty. RESULTS: A total of 20 chronic membrane perforations were created, with zero healing spontaneously after 8 weeks. In tympanoplasties performed in five chinchillas with small intestine submucosa, five of five (100%) remained healed 6 weeks postoperatively, whereas three of five (60%) remained healed with cartilage repair. Histologic analysis was performed in both successful cartilage and small intestine submucosa repairs. CONCLUSION: These results suggest that small intestine submucosa is a viable alternative to autologous and cadaveric grafts in tympanoplasty. A larger randomized study in humans is indicated to evaluate this material in clinical practice.

Animals↗
PubMedDate not supplied

Sensorineural hearing loss in chronic ear surgery.

The author's series of 3000 consecutive operations of tympanoplasty from 1960 to 1975 were reviewed in regard to the occurrence of sensorineural hearing loss as a consequence of the surgical procedure. Worsening of bone conduction thresholds by 10 dB through the frequencies 500 to 4000 cps, or a 10% reduction in speech discrimination scores were considered significant. Whereas in transcanal tympanoplasty the incidence of cochlear damage was greater in ears when initially the ossiculare chain was incomplete, by contrast in combined approach tympanoplasty the risk was greater when the chain was intact initially. It was concluded that cochlear trauma was usually due to 1) the hydraulic effect of excessive stapes manipulation during the removal of disease, and 2) the development of a perilymph fistula. The unpredictable predisposing threat of cochlear fragility due to genetic and inflammatory factors was emphasized and the poor results of tympanoplasty in tympanosclerosis were underlined. The current methods of treating sensorineural hearing loss after tympanoplasty were enumerated and discussed. It was concluded that although those aimed at improving labyrinthine circulation had theoretical backing, there is as yet little experimental or clinical evidence to support the claims of their protagonists.

Bone Conduction↗
PubMed2001

[The clinical characteristics of adhesive type cholesteatoma].

OBJECTIVE: To study the clinical characteristics of adhesive type cholesteatoma. METHODS: Fifty-two cases (52 ears) of adhesive type cholesteatomas were reviewed. Of the 52 cases there were 30 males and 22 females; 24 left ears and 28 right ears. The age of the patients ranged from 8 to 70 years. All of the patients were treated by tympanoplasty, and the open and close methods were performed in 37 ears and 10 ears, respectively. Other methods were employed in the remaining 5 cases. Nine ears underwent tympanoplasty type "O" without ossicular re-construction for an increase in the threshold of the bone conduction. Types I, III and IV tympanoplasties were performed in 1, 16 and 26 ears, respectively. RESULTS: The structures of the upper parts of the stapes had disappeared in 25 ears, which was significantly higher in this series than that in the attic type cholesteatoma. The over-all recovery rate of hearing was 69.8%, while 75.9% and 55.6% in the open and closed tympanoplasties, respectively. Postoperative complications of perforations and re-adhesions of the tense part of the tympanic membrane were observed in 3 and 4 ears, respectively. CONCLUSIONS: Adhesive type cholesteatoma is not uncommon. The cause of this disease may be the functional defects in the pharynotympanic tube. A thorough and effective treatment for the secretory otitis media is crucial for the prevention of adhesive type cholesteatomas. The open method tympanoplasty was considered as the first choice for adhesive type cholesteatoma while the closed method must be great careful.

Adolescent↗
PubMed1998

Irradiated rib cartilage graft for reconstruction of the tympanic membrane: preliminary results.

OBJECTIVE: To evaluate the advantages, disadvantages, safety, and results in reconstruction of the tympanic membrane using irradiated rib cartilage. STUDY DESIGN: Retrospective chart review. SETTING: A tertiary referral center. PATIENTS: All patients who had > or =6 months follow-up who underwent tympanoplasty or tympanomastoidectomy using irradiated rib cartilage graft at our institution from January 1, 1993 to December 31, 1996. INTERVENTION: Tympanoplasty or tympanomastoidectomy using homologous irradiated rib cartilage as graft material. MAIN OUTCOME MEASURES: Postoperative speech reception thresholds, speech discrimination scores, and air-bone gap were compared with preoperative levels. Complications directly related to irradiated rib cartilage tympanoplasty were sought. RESULTS: Speech reception threshold did not significantly change. Speech discrimination scores were stable or improved in all patients. Postoperative air-bone gap was < or =10 dB in 43.2% of patients and < or =20 dB in 70.3% of patients. There was a 16% complication rate regarding tympanoplasty in general. No complications unique to irradiated rib cartilage occurred. CONCLUSION: Irradiated rib cartilage is an alternative tympanoplasty material that may save operating time, spares patients an added incision, provides results similar to other grafting material, and is safe.

Adolescent↗
PubMed2001

Tympanic membrane repair with a dermal allograft.

OBJECTIVES: To assess the use of an acellular dermal allograft in the repair of chronic tympanic membrane perforations. Chronic tympanic membrane perforations are a common problem in otolaryngology, and although surgical tympanoplasty using either temporalis fascia or rice paper has proven to be highly successful, these materials are not without their own limitations. The search has continued for a simpler, yet equally effective, means of repairing persistent tympanic membrane perforations in an office setting. In this study we experimentally evaluated the use of an acellular dermis (AlloDerm, (LifeCell Corporation, The Woodlands, TX) as an alternative to traditional tympanoplasty materials. STUDY DESIGN: Prospective study using 28 adult chinchillas. METHODS: Subtotal tympanic membrane perforations were created bilaterally in 28 adult chinchillas. Animals with noninfected, stable perforations that showed no signs of epithelial regeneration after 5 to 8 weeks were used to compare the use of rice paper patch with AlloDerm in patch tympanoplasties. RESULTS: Eighteen of 23 tympanoplasties (78%) that were performed using AlloDerm showed no signs of perforation after 5 to 6 weeks. In those performed using rice paper control, 14 of 21 (66%) showed no signs of perforation after 5 to 6 weeks. In addition, histological evaluation of the healed tympanic membranes demonstrated that the acellular dermis had been incorporated within the middle fibrous layer of the tympanic membrane. CONCLUSIONS: The results and histological studies suggest that acellular dermis may be a suitable alternative to traditional materials currently used for patch tympanoplasty. Future studies to evaluate the efficacy of acellular dermis in humans are warranted.

Animals↗
PubMed1990

[Curietherapy of the Eustachian tube using Ir-192 in chronic otitis of tubal origin].

Failure of chronic otitis surgery, especially tympanoplasty, are mainly related to Eustachian tube dysfunction. A new technique of anti-inflammatory irradiation of the Eustachian tube was designed in 1985 in Créteil to improve the Eustachian tube function. The Eustachian tube is catheterized during the tympanoplasty using a plastic tube, 1.6 mm in diameter; this tube is closed at the external end. The other end of the tube is open and goes through the opposite nasal cavity. The plastic tube is loaded 24 h later with a 4.5 cm long irridium 192 wire to deliver a dose of 3 Gy on the reference isodose, 4 mm in diameter, in approximately 3 h. The tube is then gently withdrawn through the nasal cavity. Seventy-four patients, 16 years old or more, took part in the study. The method was performed successfully in 62 patients. Fifty-six patients were followed up; mean follow-up was more than 20 months. The follow-up assessment included otoscopy, audiometry, impedancemetry and residual Rinne measurement. Otoscopy results were adequate in 86% of patients. Hearing was improved in 44% of patients. Impedancemetry was adequate in 70% of patients and residual Rinne lower than 20 dB in 56%. These results are better if compared with those of a series of 30 tympanoplasties performed without intracavitary irradiation in 1984: the tympanoplasty failure rate then was 73%. In conclusion, this new procedure proved to be safe and simple and led to an improvement of the functional results of complex tympanoplasty.

Adolescent↗
PubMed1978

Biocompatible ossicular implants.

Proplast and Plastipore, two new biocompatible implant materials that encourage tissue ingrowth, were used in 225 tympanoplasties. A 12 to 28-month follow-up shows that in 133 tympanoplasties using a drum-to-footplate or total ossicular replacement prosthesis (TORP), there was an average air conduction gain of 19 dB and 65% closure of the air-bone gap to within 20 dB. In 17 tympanoplasties using a drum-to-stapes or partial ossicular replacement prosthesis (PORP), there was an average air conduction gain of 20 dB and 100% closure of the air-bone gap. In 53 tympanoplasties/mastoidectomies using a TORP, there was an average air conduction gain of 19 dB and 87% closure of the air-bone gap. In 22 tympanoplasties mastoidectomies using a PORP, there was an average air conduction gain of 25 dB and 100% closure of the air-bone gap. Five (2.2%) of the 225 Plastipore prostheses have extruded.

Animals↗
PubMedDate not supplied

The total reconstruction of the tympanic membrane by the "crowncork" technique.

PURPOSE: The "crowncork tympanoplasty" is a technique for the total reconstruction of the tympanic membrane. It is recommended in cases of ear malformation, blunting phenomena, and total deficiency of the membrane caused by chronic otitis media. PATIENTS AND METHODS: The records of 12 patients undergoing "crowncork tympanoplasty" were reviewed. This includes 5 patients who were operated on because of middle ear malformation, 6 cases with a blunting phenomena following prior tympanoplasty, and 1 patient with chronic otitis media. RESULTS: In each case an intact tympanic membrane was achieved. The air bone was reduced to 17, 19, 16, and 11 dB in the frequency 500, 1,000, 2,000, and 4,000 Hz. CONCLUSION: The use of cartilage for tympanoplasty has been useful despite the comparatively worse vibration characteristics of the rigid material. Total reconstruction of selected problem cases using this "crowncork technique" has resulted in good healing with favorable hearing results and should be incorporated into the routine of the skilled otosurgeon.

Adult↗