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The clinical history, pathology and results of tympanoplasty in 12 patients with obliterative otitis are described. The condition is characterized by an intact, not retracted, thick drum and a middle ear totally filled with fibrous tissue and small cholesterol granulomas. The tube is anatomically obstructed in most cases. The results are poor and it is concluded that tympanoplasty is not indicated in this disease.
In recent years, closed cavity intact wall tympanomastoidectomy or combined approached tympanoplasty--(CAT)--has been described and recommended by many. The pendulum now appears to be swinging back again to open cavity tympanomastoidectomy. Pertinent literature in this regard is reviewed. In all patients with chronic otitis media and mastoiditis with intractable tissue pathology, the primary objective is total eradication of disease with the achievement of a dry safe ear while a concomitant but secondary objective is hearing retention and restoration utilizing tympanoplasty techniques. Over a three-and-a-half year period we have utilized a one-stage procedure which provides the desirable objectives of both open and closed cavity tympanomastoidectomy called intact bridge tympanomastoidectomy (I.B.M.). The salient features include: (1) good exposure, as in open cavity tympanomastoidectomy; (2) maintaining and widening the middle-ear space by bony bridge retention and facial buttress sculpturing, to enhance grafting and ossiculoplasty such as TORP or PORP, as in canal up tympanomastoidectomy; (3) enhancement of mastoid obliteration for large cavities, by blocking the aditus with bone paté or cartilage and by providing a separation between middle ear and mastoid. Specific methods, techniques and results are presented and discussed. The results have been gratifying to date. In comparison to intact wall tympanomastoidectomy, this one-stage operation avoids the cost and discomfort of a second and sometimes third stage; surgery for recurrent pathology has been avoided and hearing results have been at least comparable if not improved.
Doubt has been raised about the long-term suitability of ossicular implants in tympanoplasty. Twenty-three ossicular implants that had been in the middle ear for a mean duration of 9.6 years were examined histologically by light microscopy. Although there were only two specimens showing subtotal replacement of the dead ossicular implant by new bone, the structural integrity of all implants was maintained and there was no evidence of overt osteoclastic bone resorption. Therefore our findings support the concept of prolonged survival of ossicular implants in the middle ear and we do not see any good reason for abandoning their use in reconstructive tympanoplasty.
Controversy still exists concerning the ultimate fate of transposed or transplanted ossicles in tympanoplasty. Histological studies on autologous and homologous ossicles removed at revision operations, or from animal studies, vary in their conclusions. The viability, of such materials used in the long-term is still uncertain. Whether this has any functional significance is also uncertain. This report contains a histological review of 10 ossicle remnants stored in the 'closed' mastoid cavity for 12 months, following closed cavity mastoidectomy (combined approach tympanoplasty).
Positive surgical indications for an only hearing ear were evaluated in order to improve patients' quality of life. Fifteen cases of surgery involving an only hearing ear over the past eight years were retrospectively reviewed. Of eight perforated chronic otitis media cases, seven underwent type one tympanoplasty and one underwent simple underlay myringoplasty regardless of otorrhoea at the time of surgery. Of six cholesteatoma cases, two received the canal wall up method and four received the canal wall down method. Ossiculoplasty was carefully performed in six cases. Hearing was improved in seven cases, whereas it remained unchanged in seven cases and deteriorated in one case. Of nine patients, two did not need a hearing aid after surgery. Five patients with severe combined hearing loss (>90 dB) were able to communicate with a hearing aid, alleviating their anxiety regarding hearing loss. Only hearing ears with chronic otitis media and cholesteatoma can be successfully treated by tympanoplasty with or without ossiculoplasty.
BACKGROUND: Any type of otosurgical procedure involves the risk of inner ear damage. As middle ear surgery is also performed for functional reasons this risk should be taken into consideration. The aim of this study was to analyse the frequency and the nature of sensorineural hearing loss following chronic ear surgery. PATIENTS: A total of 3989 middle ear cases operated on between 1991 and February 1999 at the Department of Otorhinolaryngology, Head and Neck Surgery, University of Würzburg, Germany were studied retrospectively: 781 type I tympanoplasties, 2408 type III tympanoplasties and 800 cases of stapes surgery. The pre- and the postoperative audiograms in the frequency range between 500 and 8000 Hz were analysed and correlated to the different intraoperative findings. RESULTS: Sensorineural hearing loss occurred in a total of 1.3% of 2224 patients with normal preoperative bone conduction thresholds: 0.2% became deaf, 0.8% acquired a high tone loss at 4 kHz and in 0.3% patients also 2 kHz was affected. None of the documented intraoperative complications such as bleeding, unexpected opening of a semicircular canal, extensive manipulation at the ossicular chain or a gusher phenoma showed a relevant effect on postoperative bone conduction thresholds. The incidence of high tone loss was not increased in cases of extensive drilling of the temporal bone. An unexpected opening of the vestibulum led to a small, but statistically significant change in postoperative bone conduction thresholds. CONCLUSIONS: Our results demonstrated that the risk for sensorineural hearing loss caused by middle ear surgery is low. None of the analysed factors seems to be a relevant prognostic risk factor for postoperative inner ear depression.
BACKGROUND: In myringoplasty or tympanoplasty, fascia of the temporalis muscle and perichondrium or cartilage-perichondrium composite grafts are most commonly used to reconstruct the tympanic membrane (TM). Primary failures or recurrent perforations in the anterior part of the TM frequently occur in cases of eustachian tube dysfunction or total perforations of the TM. The purpose of this paper is to introduce a perichondrium-cartilage composite graft for closure of total perforations of the TM. Twenty-one patients (17 adults, 4 children) were included in this study, all of whom had a total perforation of the TM. METHODS: An oval shaped piece of cartilage with perichondrium on one side was harvested from the cavum conchae. The cartilage was cut in the shape of a U without removing the inner layer of perichondrium. The inner diameter of the cartilage ring should be nearly the same as the diameter of the tympanic ring. This cartilage framework stabilizes and fixes the perichondrium and prevents the perichondrium from subsiding into the middle ear cavity. Shrinking of the perichondrium is also reduced by the cartilage ring. In all patients introduced in this study, the TM was closed and no residual perforation occurred. The hearing results in tympanoplasty were the same as in other techniques with a residual air-bone gap of about 20 dB. CONCLUSIONS: This technique seems to be a valuable method for the closure of total perforations of the TM. Especially in perforations near the anterior anular region the underlay technique with fascia or perichondrium is an uncertain method. The soft material which is only fixed by adhesion can easily be displaced during wound healing. The hearing results are comparable to that achieved in other techniques. Further studies with greater number of patients are necessary to assess long term results.
BACKGROUND: The behavior of transitory evoked otoacoustic emissions (TEOAE) and distortion products (DPOAE) in patients after middle ear surgery is unknown. METHODS: We examined TEOAEs and DPOAEs in 37 ears following stapes surgery, 16 ears following tympanoplasty type I, and nine ears after reconstruction of the ossicular chain. In all patients, the postoperative conductive hearing loss was less than 15 dB HL. In some cases, there was additional sensorineural hearing loss in the high frequencies. RESULTS: Surprisingly, TEOAEs were present only in 10 of 62 ears postoperatively compared to all 22 control subjects. TEOAEs were detected in four of 37 ears after stapes surgery, in six of 16 ears after tympanoplasty type I, and in none of the nine ears who had undergone reconstruction of the ossicular chain. DPOAEs were detected in only four of 31 ears postoperatively compared to all 22 control ears. CONCLUSIONS: These results and their relation to the retrograde OAE transmission in the middle ear are discussed. Changes enhancing the stiffness of the middle ear seem to have a greater effect than those enhancing the mass.
25 cases of tympanic welding spark injuries of the years 1959-1989 are reported. Early results and late sequelae after conservative therapy, immediate and interval operation are described and discussed. Regarding the tendency of tympanic defects to enlarge after thermal injuries despite conservative and early operative therapy, secondary seal by tympanoplasty is recommended. Even then, however, the rate of residual and recurring perforations must be reckoned as being higher than after tympanoplasty in comparable defects of other origin, due to the inferior nutritive supply owing to the extended scar caused by burning. On the other hand, the rate of inner ear traumatisation with 12% directly after welding injury and with 4% remaining impairment of hearing, is low.
OBJECTIVE: This study was designed to identify the external ear resonance characteristics of patients with tympanic membrane perforation and to investigate subsequent changes in external ear resonance, depending on the length of the postoperative period and which of 3 different types of operation was performed: tympanoplasty with canal wall-up mastoidectomy, epitympanoplasty, and canal wall-down mastoidectomy. STUDY DESIGN AND SETTING: A total of 227 ears of 188 patients and 96 control ears comprised the study. We measured the gain and frequency of the first peak of external ear resonance with a real ear analyzer. RESULTS: Gain and frequency of the first peak recorded in the preoperative group did not differ from those of the control group. However, negative peaks appeared around 1 to 1.5 kHz in half of these ears. The gain increased markedly in all 3 postoperative groups. The canal wall-down mastoidectomy and epitympanoplasty groups showed significantly lower frequencies compared with the tympanoplasty with canal wall-up mastoidectomy and control groups, but there was no difference between them. The increased gain diminished over time, but the peak gain did not equalize with that of the controls, even after 15 months. CONCLUSIONS: Additional gain should be considered of around 1 to 1.5 kHz for hearing aid users with tympanic membrane perforation. Postoperative changes in external ear resonance should be expected in patients with chronic otitis media, suggesting that fine readjustments of the hearing aid may be necessary.
OBJECTIVE: The study goal was to analyze long-term hearing results and factors likely to affect outcome after ossicular reconstruction in patients with tympanosclerosis, particularly tympanosclerotic stapes fixation. METHODS: We conducted a retrospective chart review of the past 10 years. The short- and long-term (up to 9(1/2) years) hearing results of first-stage and second-stage operations for middle ear tympanosclerosis in 203 consecutive patients, performed in a tertiary referral otologic private practice, are presented. There were 160 tympanoplasties and 43 tympanoplasties with mastoidectomy performed, with ossicular fixation secondary to tympanosclerosis in 135 cases. Of these 203, 42.9% were primary cases, with the majority being planned second-stage or revision procedures. RESULTS: The average preoperative air-bone gap (ABG) was 30.9 dB. The average short-term postoperative ABG was 17.4 dB with closure of the ABG within 20 dB in 64.6%. The success rate (ABG < or = 20 dB) for patients with ossicular fixation was 65.3%. Partial sensorineural hearing loss occurred in 1.0% of the patients, and none experienced profound sensorineural hearing loss (dead ears). There was no statistically significant change from short-term to long-term follow-up in either ABG or air PTA, with mean differences of only 0.3 and 2.0 dB, respectively. The mean time to the last follow-up was 1.6 years. CONCLUSION: Ossicular reconstruction in individuals with tympanosclerosis can yield satisfactory, lasting hearing results with a low incidence of complications and no dead ears.
The purpose of this paper is to investigate whether a magnetic resonance imaging (MRI) examination of the petrous bones could replace the conventional second look surgical procedure when a canal wall up tympanoplasty procedure has been performed during the first look surgery. Eighteen patients were examined with MRI prior to a second look surgical procedure. MRI was performed on a 1.5 T superconducting system. T2 weighted images before contrast and T1 weighted images after contrast (gadopentate dimeglumine) were obtained. Imaging results were compared with surgical findings. The poor radiosurgical correlation (50% and 61% after re-evaluation) suggests that, at the present time, MRI is not a valid alternative to a second look surgical intervention in the case of cholesteatoma treated by canal wall up tympanoplasty. In our study, MRI was not capable of differentiating small pearls of residual cholesteatoma from surrounding scar tissue.
OBJECTIVES/HYPOTHESIS: It appears that autologous free fascia grafts (fascia lata and temporal fascia) change their dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations. There has been no study regarding this dimensional instability. STUDY DESIGN: Prospectively dimensional instability of the free fascia grafts studied in 14 mongrel dogs. METHODS: Fourteen healthy Mongrel dogs were operated on twice. During the first surgery, fascia lata and temporal fascia grafts of measured dimensions (length, breadth, and thickness) were implanted in the subcutaneous pockets on the thoraco-abdominal wall of the same dog (autograft). Five dogs were operated on again after 2 days, and 7 dogs were operated on again after 5 days to harvest the implanted grafts. The dimensions of the harvested grafts were noted. Changes with respect to their implant dimensions after 2 days and after 5 days were calculated. RESULTS: It was found that free fascia lata exhibits significantly superior dimensional stability when compared with free temporal fascia during the early healing phase, before graft integration has occurred. Shrinking and thickening of temporal fascia are greater and are also most unpredictable. CONCLUSIONS: Poor dimensional stability of temporal fascia may compromise a well-sealed perforation at the time of surgery, and it may reopen by the 5th day. This must be one of the causes of failure of tympanoplasty, which needs to be studied further.
OBJECTIVE/HYPOTHESIS: The pathogenesis of tympanosclerosis is unclear. The study was performed to investigate the role of nitric oxide, free oxygen radicals, and antioxidants in development of tympanosclerosis in patients with chronic otitis media. STUDY DESIGN: A prospective study in patients with nasal polyps. METHODS: Sixty-five patients who underwent tympanoplasty or tympanoplasty together with mastoidectomy were included in the study. Preoperative venous blood samples were drawn, and serum sodium, potassium, calcium, alkaline phosphatase, inorganic phosphorus, parathormone, and calcitonin levels were measured. The patients who had tympanosclerotic plaques on tympanic membrane or middle ear mucosa or near the ossicular chain or mastoid bone were designated as group 1 (n = 34), and the remaining patients as group 2 (n = 31). Intraoperatively, specimens were obtained from the middle ear mucosa and tympanic membrane to measure nitric oxide and malondialdehyde levels. In addition, plasma malondialdehyde levels and erythrocyte superoxide dismutase and catalase activity were determined. RESULTS: All patients had similar demographic features and serum electrolyte and hormone levels. Nitric oxide and malondialdehyde levels of the specimens obtained from the middle ear mucosa (P =.001) and tympanic membrane (P =.01) and, in parallel to this, the plasma malondialdehyde activity level were higher in group 1 than in group 2. Moreover, group 2 had significantly lower erythrocyte catalase activity levels (P =.001) compared with group 1, whereas such a significant difference was not present for superoxide dismutase activity levels (P >.05). CONCLUSION: The study results suggest that nitric oxide, free oxygen radicals, and catalase may have a role in the development of tympanosclerosis in patients with chronic otitis media.
OBJECTIVE: To assess the efficacy of a surgical technique, the temporary attic and posterior canal wall osteoplasty, in preventing cholesteatoma recurrence. DESIGN/PARTICIPANTS: The records of 94 patients submitted to tympanoplasty for cholesteatoma in the ear, nose, and throat department of a main city hospital between 1989 and 1997 were retrospectively reviewed. INTERVENTIONS: Intact canal wall procedure with attic and posterior canal wall temporary removal was performed in 47 cases. A canal wall down operation was performed in the 47 remaining cases. The follow-up ranged from 22 to 84 months. METHODS AND MAIN OUTCOME MEASURES: The patients from one group could be exactly matched for the main prognostic factors (type of cholesteatoma, ossicular status, and preoperative auditory status) with the patients from the other group. Auditory results were defined according to the Committee on Hearing and Equilibrium Guidelines. A 1-way analysis of variance was used to determine group differences. A probability value of p < 0.05 was the level of significance selected. RESULTS: All of the patients in the 2 groups were cholesteatoma free at the last follow-up, and significantly better hearing results were observed in the osteoplasty group. CONCLUSIONS: The osteoplasty with temporary removal of the posterior and attic canal wall is a useful adjunct to tympanoplasty in cholesteatoma cases as far as the hearing results and recurrence rates are concerned. This method combines the functional advantages of canal wall up operations with the safety yielded by canal wall down procedures.
BACKGROUND: Titanium is a well-established implant material, and its use in ossicular chain reconstruction during middle ear surgery is increasing. HYPOTHESIS: Bony fixation of titanium prostheses has to be considered using this material. Contact with bony structures of the middle ear may result in immobilization. In revision procedures, there is a potential risk of damaging or extracting adherent structures such as the stapes. METHODS: This is a case report of an accidentally extracted stapes resulting from bony fixation of a titanium prosthesis in revision tympanoplasty. The surgical specimen was examined by microscopy, histology, and scanning electron microscopy. Energy dispersive x-ray analysis was used to confirm the elemental composition of the extracted stapes and the titanium prosthesis. RESULTS: The prosthesis showed good biocompatibility at the implantation site, with signs of bone resorption of the stapes suprastructure. However, bony fixation of the undersurface of the prosthesis foot to the stapes footplate was confirmed by ultrastructural analysis. CONCLUSION: In revision tympanoplasty, bony fixation of the titanium prosthesis should be considered.
The results of tympanoplasty operations in 55 ears with chronic adhesive otitis media were analysed. In 34% of the ears, the tympanic cavity was found to be aerated on follow-up examination. Hearing improved significantly in only 13 ears (24%). There were severe complications of surgery in two ears (3.6%): one ear became totally deaf and an iatrogenic cholesteatoma developed in the other. Because of these poor results, tympanoplasty is not recommended in the treatment of chronic adhesive otitis media.
Success or failure of tympanoplasty depends on the following factors: (1) the anatomic and functional state of the tympanic membrane and the ossicles; (2) type, extension and activity of chronic otitis media at the time of surgery; (3) permanent restoration and drainage of the middle ear, and (4) surgical technique. In the present long-term study 440 cases of tympanoplasty have been followed up for 2-10 years. The anatomic and functional results were evaluated statistically by a computerized data processing procedure. Thus, multiple correlations between the factors influencing the anatomic and functional results could be investigated.