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The most often used skin-flap techniques in one-step and two-steps closed tympanoplasties are discussed. The correct plastic surgery of the meatal skin gave good results. In the ENT Clinic of the Medical Academy in Lódź techniques most often used are two-flaps tympanoplasties with anterior and posterior pedunculated flaps or tympanoplasties with a single pedunculated flap.
The use of the closed tympanoplasty in the treatment of cholesteatoma has been abandoned by many surgeons in the last years. In contrast, as well as other authors we have increasingly limited the use of open techniques. Our attitude towards the closed tympanoplasty is strictly connected with an accurate prevention strategy of recurrent cholesteatoma. The recurrent cholesteatoma takes origin from two following mechanism: 1--the residual cholesteatoma which exteriorizes towards the external auditory canal; 2--the new immigration of the skin into the middle ear through a new perforation or depending on a retraction pocket. The incidence of recurrent cholesteatoma due to the first cause may be considerably reduced by: a--complete eradication of disease during exeresis (complete removal of structures in contact with the cholesteatoma matrix); b--early detection and removal of residual cholesteatoma by an almost planned second look (staged tympanoplasty). In order to prevent new epithelial immigration into the middle ear it is necessary: a--to reconstruct a new barrier between skin and mucous lining [repair of the attic wall, reconstruction of the tympanic membrane by using xenografts (Parmatymp)]; b--to permit the drainage and aeration of the new tympanic cavity at the level of the bony Eustachian tube including the isthmus (performing, if necessary, the tubotomy and/or tuboplasty techniques). The same must be obtained at the level of the tympanic isthmus by enlargement of the epitympanic recesses in order to create a tunnel over the new ossicular chain and by a posterior tympanotomy in order to create a tunnel under the ossicular chain. The use of silastic sheeting is extremely important in order to allow a correct regeneration of the new mucous lining and an efficient drainage-aeration function into the new middle ear cavity (from the mastoid to the tubal isthmus).
In a retrospective study, type III tympanoplasties with stapes elevation on two groups of patients were compared. In group I (101 patients) the stapes elevations, the temporalis fascia grafts for tympanic membrane reconstruction, the grafts of periosteum and cartilage used for repair defects of the posterior bony meatal wall and the Stacke-II plasty replaced in its original position after tympanoplasty were also fixed with fibrin glue (Tissucol). Group II (control group of 102 patients) was operated with fibrin glue. In group I the fascial grafts of the tympanic membrane healed faster, more securely and without fewer complications. The external auditory canal however healed equally well in both groups. Early hearing results of type III tympanoplasty could be improved by fixing the stapes elevations with fibrin glue.
We described our experiences in the use of micro-sliced septal cartilage homografts in tympanoplasty. The cartilage plates (0.1-0.5 mm thick) previously prepared with our method by use of a dermatome were used for the three purposes 1) to reconstruct the attic wall defect, 2) to prevent the retraction of the grafted fascia in myringoplasty, and 3) to prevent the displacement of the columella and the retraction of the grafted fascia in columella-type tympanoplasty. There have been no postoperative infections or extrusions in our 142 cases. These cartilage plates are considered to be very convenient in tympanoplasty.
The use of a homograft tympanic membrane with and without attached ossicles, staging the operation, and the use of sculptured homograft or autograft ossicles have improved the results in tympanoplasty. The indications and techniques of homograft tympanoplasty are described, and the results in 99 primary cases and 11 cases with repair of a mastoid cavity are given. The overall graft success rate was 86 per cent. In patients with an intact ossicular chain, the conductive loss was reduced to less than 20 dB. in 88 per cent. A hearing loss less than 20 dB. was obtained in 68 per cent with an intact stapes, in 77 per cent when the stapes superstructure was absent, and in 79 per cent in stapedectomy done at a second stage. The use of homograft material has provided the means for significantly improving the results in our patients who require tympanoplasty.
OBJECTIVE: To assess the prognostic value of pathologic and technical variables influencing the functional outcome of tympanoplasty. PATIENTS AND STUDY DESIGN: Retrospective review of the records of 544 patients affected by chronic otitis with or without cholesteatoma, operated on by the senior author in a city hospital ENT department. Follow-up was provided systematically by the same institution. INTERVENTIONS: These included tympanoplasty without mastoidectomy in 339 cases, canal wall up technique in 134 cases, and canal wall down in 71 cases. Three hundred twenty-six (60%) were primary, and 218 (40%) were revision procedures. Myringoplasty was performed with autologous temporalis fascia, ossiculoplasty with incus interposition, or partial or total ossicular prostheses. Mean follow-up was 14 months (range, 12-50 months). MAIN OUTCOME MEASURES: Hearing results were defined according to the Committee on Hearing and Equilibrium Guidelines. A one-way analysis of variance was used to determine group differences. Multiple logistic regression analysis was subsequently carried out on the different pathology groups via the hierarchical log linear model. A probability value of p < 0.05 was the level of significance. RESULTS: The status of the mucosal lining, the mastoidectomy, the availability of the malleus handle, and the tympanic membrane perforation were all significantly predictive of the hearing outcome but with differing weight according to the pathologic condition. CONCLUSIONS: Anatomic and technical factors diversely affect the functional outcome of tympanoplasty. A better knowledge of their predictive roles and weights may be useful in both the surgeon's judgment and in the information given to the patient.
The purpose of this study is to evaluate the influence of the age factor on the prognosis for tympanoplasty type I. One hundred subjects (41 males, 59 females, 16-65 years old, mean age 37.9 years old) who accepted tympanoplasty type I during a four-year period were reviewed. The success rate of the surgery was analyzed using the three criteria suggested by the Japan Clinical Otology Committee. In addition, linear regression was used to analyze the correlations between age and pre-operative hearing, post-operative hearing and hearing gain. Using the proportion of patients with a postoperative hearing threshold within 40 dB as the criterion, the 16-25 year-old group had the best results (80%) and the 56-65 year-old group had the worst results (66.7%). Using hearing gain exceeding 15 dB as the criterion, the best result was for the 36-45 year-old group (60.9%), and the worst result was for the 56-65 year-old group (26.7%). Using post-operative air-bone gap within 20 dB as the criterion, the best result was for the 16-25 year-old group (70%), and the worst result was for the 56-65 year-old group (40%). The best total success rate was for the 16-25 year-old group (80%) and the worst was for the 56-65 year-old group (66.7%). The total average success rate was 74%. Linear regression analysis showed that the postoperative hearing thresholds increased significantly with advancing age. But there was no statistically significant difference in hearing gain between the various age groups and the preoperative hearing thresholds also increased with advancing age. In conclusion, although tympanoplasty type I offered the patients a similar hearing gain among the different age groups, from the point of view of social function, it offered younger people a better chance of social hearing than the elderly and a higher surgical success rate. The poor postoperative hearing of the elderly was a result of their poor preoperative hearing condition.
Considerable controversy surrounds the subject of tympanoplasty in children. Conflicting opinions about the indications, patient selection, timing, and technique of surgery are supported by various published series of cases. The records of 64 consecutive tympanoplasty procedures performed at the Boston (Mass) Children's Hospital over a recent 6-year period were reviewed. The study was limited to cases of repair of uncomplicated perforation of pars tensa that did not require ossiculoplasty or mastoidectomy. Surgery was successful in 73% of cases. A number of factors that are postulated to affect the outcome of surgery have been analyzed to assess their utility in selecting successful surgical candidates. Only patient age at the time of surgery was found to have statistical significance. We conclude that tympanoplasty for repair of perforation is warranted for children 8 years of age and older.
We investigated the feasibility of using laser tissue welding techniques to perform transcanal underlay tympanoplasty. We used 10 temporal bones obtained from human cadavers. After creating a subtotal tympanic membrane perforation, we introduced harvested periosteum through the perforation and used laser tissue welding to secure the periosteum graft in place in an underlay fashion. The procedure was performed via a transcanal approach and did not require middle ear packing. Immediately after the graft had been placed, we qualitatively tested its integrity with a blunt probe. The graft was as strong as the native cadaver tympanic membrane in all 10 cases. We conclude that laser transcanal underlay tympanoplasty is a feasible and effective method of repairing a tympanic membrane. The ultimate goal is to develop a technique that will allow physicians to routinely perform underlay tympanoplasty on moderately sized perforations in an office setting.
Permanent restoration of hearing is the goal of functional reconstruction in tympanoplasty. Nonbiologic prostheses have been abandoned for otic grafts. This is a long-term study of a group of 32 patients with type II tympanoplasties in which homografts of septal cartilage are used to reconstruct the sound conduction system. The good audiologic results obtained, with absence of immune reactions, allow recommendation of this technique in middle ear surgery.
Tympanoplasty can cause a sensorineural hearing loss by a mechanism of acoustic trauma. Although this lesion appears to be relatively infrequent in clinical practice, we believe that its low apparent incidence is caused when clinicians fail to assess the auditory frequencies above 8000 Hz. Twenty-four patients with normal bone-conduction audiometric thresholds scheduled for tympanoplasty were assessed with an electro-stimulation, bone-conduction high-frequency audiometer which can measure hearing frequencies up to 20 kHz before and after surgery. A measurable hearing loss was found in the upper limits of the audible frequencies in 9 patients (37.5%), and was considered important in 4 of them (16.7%). This hearing loss was recorded above the upper frequency limit of conventional audiometers. The findings in this study indicate that drilling of the temporal bone can impair the hearing level in the high frequencies in a significant number of patients. High-frequency audiometry is a very sensitive tool to assess any damage caused to the inner ear by surgical procedures carried out in the middle ear and temporal bone.
PURPOSE: To evaluate the effects on PONV and headache after tympanoplasty of prochlorperazine 0.2 mg.kg-1 i.m., ondansetron 0.06 mg.kg-1 i.v. or placebo (isotonic saline) 0.02 ml.kg-1 i.v. given immediately after induction of anaesthesia prior to tracheal intubation. METHODS: The study was randomised, double blind and prospective. One hundred and forty-eight patients, aged 9-61 yr, received a standardised balanced inhalational anaesthetic with controlled ventilation and induced hypotension. Postoperatively, the frequencies of retching and vomiting in the PACU and of nausea, retching, vomiting, headache, analgesic and antiemetic requirements in the surgical ward for 24 hr were recorded. RESULTS: The four test groups (n = 37 each) were comparable. The incidences of vomiting in the PACU were similar. During the first 24 hr after surgery the antiemetics produced no reductions in the incidence of nausea alone or of vomiting alone. However, the combination of nausea and vomiting was reduced from 53% (placebo) to 16% (P < 0.0005), 19% (P < 0.0005) and 30% (P < 0.05) by i.m. prochlorperazine, i.v. ondansetron and i.v. prochlorperazine, respectively. The frequency of those experiencing no PONV was increased from 27% (placebo) by prochlorperazine i.m. to 57% (P < 0.01), by ondansetron i.v. to 62% (P < 0.005) and by prochlorperazine i.v. to 43% (P = NS). The onset of PONV was delayed in those given prochlorperazine im, and vomiting was less severe in those given ondansetron i.v. Headache occurred with similar frequency in each group. CONCLUSION: Prophylactic prochlorperazine 0.2 mg.kg-1 i.m. and ondansetron 0.06 mg.kg-1 i.v. are similarly efficacious in reducing nausea with vomiting after tympanoplasty, while prochlorperazine 0.1 mg.kg-1 i.v. is less efficacious. Neither drug given as described appeared to reduce the frequency of postoperative nausea alone or vomiting alone.
PURPOSE: To determine whether remifentanil, combined with propofol, could induce controlled hypotension, reduce middle ear blood flow (MEBF) measured by laser-Doppler flowmetry, provide a "dry" operative field, and could be compared with nitroprusside or esmolol combined with alfentanil and propofol. METHODS: Thirty patients undergoing tympanoplasty and anesthetized with 2.5 mg x kg(-1) propofol iv followed by a constant infusion of 120 microg x kg(-1) x min(-1), were randomly assigned in three groups to receive either 1 microg x kg(-1) remifentanil iv followed by a continuous infusion of 0.25 to 0.50 microg x kg(-1) x min(-1), or nitroprusside iv, or esmolol iv combined for the latter two groups with alfentanil iv. RESULTS: Controlled hypotension was achieved at the target pressure of 80 mmHg within 107 +/- 16, 69 +/- 4.4, 53.3 +/- 4.4 sec for remifentanil, nitroprusside and esmolol respectively. MEBF decreased by 24 +/- 0.3, 22 +/- 3.3, 37 +/- 3% and preceded the decrease in SABP, within 30 +/- 6.1, 11.2 +/- 3.1, 15 +/- 2.8 sec for remifentanil, nitroprusside and esmolol respectively. Remifentanil, and nitroprusside decreased MEBF autoregulation less than esmolol (0.36 +/- 0.1, 0.19 +/- 0.2, -0.5 +/- 0.2). Controlled hypotension was sustained in all three groups throughout surgery, and the surgical field rating decreased in a range of 80% in all three groups. Nitroprusside decreased pH and increased PaCO2. There were no postoperative complications in any of the groups. CONCLUSIONS: Remifentanil combined with propofol enabled controlled hypotension, reduced middle ear blood flow and provided good surgical conditions for tympanoplasty with no need for additional use of a potent hypotensive agent.
The aim of this retrospective study was to evaluate the long-term hearing results of using costal cartilage prostheses in ossicular chain reconstruction procedures in subjects operated on for a middle ear cholesteatoma with an intact canal wall tympanoplasty. Thirty-six patients (four with bilateral disease) followed up for 10 years who underwent an ossiculoplasty with a cartilage prostheses between January 1987 and December 1989 constituted the population studied. All the subjects underwent a staged intact canal wall tympanoplasty with mastoidectomy. Ossiculoplasty with total or partial chondroprosthesis was performed during the second stage. The long-term outcome was evaluated in terms of hearing according to the guidelines of the Committee on Hearing and Equilibrium (1995), and in terms of complications (anatomical and functional). In 18 patients a partial cartilage ossicular replacement prosthesis (PORP) was used, while in 22 a total cartilage ossicular replacement prosthesis (TORP) was used. In the PORP group the mean preoperative air-bone gap (ABG) was 22.4 dB hearing level (HL); before the second stage the ABG was 37.9 dB HL, at 2 years it was 12.1 dB HL, at 5 years 15.3 dB HL and at 10 years 15.8 dB HL. In the TORP group the mean preoperative ABG was 31.6 dB HL; before the second stage the ABG was 41.1 dB HL, at 2 years it was 14.4 dB HL, at 5 years 17 dB HL and at 10 years 18.5 dB HL. In both groups the number of cases with a postoperative ABG of < 20 dB HL remained stable (P > 0.05) over time. The failure rate was 17.5%, but only in 5% of cases was a functional revision needed. No cases of extrusion of the prostheses were encountered. The use of a chondroprosthesis is associated with functional results similar to those obtained by other authors. The efficacy of the prostheses remains stable over time and is associated with a very low rate of complications and failures. In this series no extrusion occurred and in no case did an infectious disease develop after cartilage transplantation.
OBJECTIVE: The aim of this study is to analyze the clinical features and follow-up of a series of pediatric patients with chronic otitis media undergoing tymponaplasty surgery and to identify the effect of the factors on the course. METHODS: Forty-one children (mean age 15.1+/-2.62 years, range from 8 to 16 years) who had undergone tympanoplasty with or without ossicular reconstruction were evaluated. Age, gender, size and site of perforation, status of operated ear (dry/discharging), status of the contralateral ear, underlying cause of the perforations, surgical technique, preoperative and postoperative hearing levels, average postoperative follow-up time, and postoperative complications were recorded. RESULTS: Myringoplasty in 28 patients (68.3%), incus interposition in 7 patients (17.1%), partial ossicular replacement prostheses in 4 patients (9.7%) and total ossicular replacement prostheses in 2 patients (4.9%) were performed. In the 37 (90.2%) of patients, intact graft was determined during postoperative follow-up. Surgical success including intact graft and postoperative air-bone gap of less than 25 dB were obtained in 34 (82.9%) cases. CONCLUSIONS: The present study suggested that tympanoplasty was a quite successful method in the appropriate pediatric patients between the ages of 8 and 16 years. In the preoperative evaluation for surgery success, some factors, such as dry middle ear, healthy contralateral ear and concordant to postoperative care should be considered.
OBJECTIVE: Because of its rigid quality, cartilage is the grafting material of choice in advanced pathologies, such as adhesive processes or recurrent perforations. However, the use of such a rigid material in tympanic membrane reconstruction causes controversies as to the audiologic aspect. The purpose of this study was to assess overall and frequency-specific hearing results after primary cartilage tympanoplasty with island technique in comparison to the hearing results after primary tympanoplasty with temporalis muscle fascia. STUDY DESIGN AND SETTING: This study was a retrospective review of selected cases between 1999 and 2002. Primary cases with intact ossicular chain, normal middle ear mucosa, and subtotal perforation of the tympanic membrane were included in the study. Fifteen patients were in the cartilage group, whereas 10 patients were in the fascia group. Preoperative and postoperative air-bone gaps at the frequencies of 0.5, 1, 2, and 4 kHz were compared. RESULTS: Both groups were statistically similar on the aspect of the severity of middle ear pathology and the preoperative hearing levels. Mean postoperative gains in air-bone gap were 11.9 dB for the cartilage group and 11.5 dB for the fascia group. There were no statistically significant differences in the postoperative frequency-specific gains in air-bone gap between the 2 groups. CONCLUSIONS: Although cartilage is the ideal grafting material in problem cases, its comparable acoustic properties, especially in the form of cartilage island, to those of fascia will allow a more liberal application in less severe cases, in which functional outcome is more essential.
With the introduction of newer technologies, the advent of antibiotics, and improved surgical methods; the past 25 years have seen a great revolution, refinement, and improvement of tympanoplastic procedures. Furthermore, the methods of classification have been modified. The introduction of ossicular reconstruction with biocompatible implants greatly enhanced the success of type 3 tympanoplasty. This article reviews the classification, indications, surgical techniques, biomechanical properties, and expected hearing results of type 3 tympanoplasty.
The flexible approach to tympanoplasty has been found to be adaptable to various forms of pathologic conditions found in the temporal bone, including inflammation and infection, congenital stenosis, benign and malignant tumors, and traumatic injuries. This approach finds its best indication among all pathologic conditions in the temporal bone, in the surgical treatment of otitis media, and its sequelae. A procedure conceived to treat this dynamic process must be adaptable to new circumstances and new findings and be ready to manage unexpected situations. The flexible tympanoplasty is a step-wise approach designed to explore the contents of the middle ear methodically and in the process disclose, confirm, and often treat disease.