Tympanoplasty--indications and techniques: myringoplasty, tympanoplasty and mastoidectomy.
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Ear Diseases↗
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Evaluation of inlay butterfly cartilage tympanoplasty: a randomized clinical trial.
OBJECTIVES/HYPOTHESIS: In 1998 Eavey described a new inlay technique for tympanoplasty in the pediatric age group using a cartilage graft through a transcanal approach. This technique was found to be effective and comfortable (no external canal incisions or ear packing). This study evaluated the efficacy of modified-inlay cartilage tympanoplasty compared with the conventional underlay tympanoplasty. STUDY DESIGN: Randomized clinical trial. METHODS: Patients were enrolled from December 1998 to March 2000. Seventy tympanoplasties were done in adults with medium-sized tympanic membrane (TM) perforations: 34 inlay tympanoplasties and 36 underlay tympanoplasties (control group). The main outcome measures were the "take rate" on the 30th postoperative day and the audiometric result at the second postoperative month. Secondary outcome measures include subjective postoperative hearing, postoperative pain, duration of surgery, and cost of the procedures. RESULTS: The "take rate" did not differ between groups on the 30th postoperative day (88.2% in the inlay tympanoplasty group vs 86.1% in the underlay tympanoplasty group; P =.8). After a mean follow-up of 7.5 +/- 3.8 months (range, 3-16 mo), the "take rate" was 85.3% in the inlay tympanoplasty group and 83.3% in the underlay tympanoplasty group (P =.8). In the inlay tympanoplasty group there was closure of the air-bone gap (ABG) to within 10 dB in 64.7% and to within 20 dB in 94.1%. The corresponding numbers to underlay tympanoplasty were 75% and 97.2%. In only 2 cases (5.9%) in the inlay tympanoplasty group and in 1 case (2.8%) in the underlay tympanoplasty group the ABG was greater than 20 dB. No audiometric difference was observed between groups (P =.6). Most patients in the inlay tympanoplasty group reported immediate improvement in their hearing (P <.0001). Pain was reported by 10 patients in the inlay tympanoplasty group and by 30 patients in the underlay tympanoplasty group on the first postoperative day (P <.0001). The duration of the surgery (mean +/- standard deviation) was 33.6 +/- 7.8 minutes for the inlay tympanoplasty group and 62.9 +/- 12.7 minutes for the underlay tympanoplasty group (P <.0001). The estimated charge for inlay tympanoplasty at our institution was 65% less expensive than underlay tympanoplasty. CONCLUSION: The "take rate" and audiometric results following inlay cartilage tympanoplasty or underlay tympanoplasty were similar. Inlay butterfly cartilage tympanoplasty did not require general anesthesia, was less expensive, and more comfortable to the patient.
Adolescent↗
Lateral graft type 1 tympanoplasty using AlloDerm for tympanic membrane reconstruction in children.
OBJECTIVES: To describe the lateral graft type 1 tympanoplasty technique using AlloDerm for tympanic membrane reconstruction in children and to compare its surgical and audiometric outcomes with the traditional underlay type 1 tympanoplasty. METHODS: The records of 34 consecutive children undergoing type 1 tympanoplasty between 2004 and 2005 were reviewed; 18 received lateral graft tympanoplasty with AlloDerm and 16 received underlay tympanoplasty (8 AlloDerm and 8 temporalis fascia). Pre- and post-surgical audiograms, speech reception threshold, closure rate and complication rate were evaluated using one-way and repeated measures ANOVAs. RESULTS: Children who underwent lateral graft type 1 tympanoplasty pre-operatively had larger tympanic membrane perforations, worse pure tone averages, air bone gaps and speech reception thresholds as compared with children undergoing underlay type 1 tympanoplasty (P<0.001). Pure tone averages and air bone gaps improved significantly with surgery in both lateral and underlay type 1 tympanoplasty groups (P<0.05), with both groups achieving comparable postoperative audiometric outcomes (P>0.01). The lateral graft group demonstrated a higher perforation closure rate (94%) as compared with both underlay groups (88%). Complication rates were virtually non-existent. CONCLUSIONS: Despite larger perforations and worse pre-operative audiometric scores, children who underwent lateral graft type 1 tympanoplasty achieved comparable postoperative audiometric results and perforation closure rates as compared with children who underwent underlay type 1 tympanoplasty. Results suggest that lateral graft type 1 tympanoplasty using AlloDerm is effective for tympanic membrane reconstruction in children and should be used when temporalis fascia is not available or the extent of the perforation limits its use.
Adolescent↗
Success of cartilage grafting in revision tympanoplasty without mastoidectomy.
OBJECTIVE: Candidates for revision tympanoplasty have experienced at least one failed attempt at repair of the tympanic membrane and are, therefore, at higher risk for subsequent repair failure. The adjunctive use of mastoidectomy with tympanoplasty in those patients with noncholesteatomatous chronic otitis media is often used to decrease the risk for subsequent failure. However, at this institution, where we use cartilage tympanoplasty, mastoidectomy is rarely performed in the absence of cholesteatoma. Our objective was to assess outcomes in patients undergoing revision tympanoplasty without mastoidectomy using cartilage grafting. STUDY DESIGN: We conducted a retrospective case review. SETTING: Tertiary referral center. PATIENTS: A total of 95 patients (42 female, 53 male; 5-81 yr of age) with a recurrent perforation who were treated surgically with cartilage tympanoplasty without mastoidectomy were included in the chart review. Patients must have undergone at least one previous tympanoplasty without mastoidectomy and had to have complete audiologic and chart follow up. INTERVENTIONS: An underlay tympanoplasty technique using either a tragal cartilage-perichondrium island graft or palisaded concha cymba cartilage was used. Ossiculoplasty was performed as needed. MAIN OUTCOME MEASURE: Main outcome measures were incidence of reperforation of the grafted tympanic membrane, hearing result, and prevalence of other complications. RESULTS: Successful closure without reperforation was obtained in 90 of 95 patients (94.7%). Average postoperative pure-tone average air-bone gap was 12.2 +/-7.3 dB compared with 24.6+/-13.8 dB preoperatively (p <0.001). CONCLUSIONS: Revision tympanoplasty with cartilage provided equivalent results to tympanoplasty with mastoidectomy. Thus, mastoidectomy may not be necessary in revision tympanoplasty in the absence of cholesteatoma if the repair is made with cartilage.
Adolescent↗
Candidate's thesis: Revision tympanoplasty utilizing fossa triangularis cartilage.
OBJECTIVES/HYPOTHESIS: A small percentage of fascia graft tympanoplasties fail. Cartilage tympanoplasty has a reputation for excellent graft healing but potentially sacrifices maximum hearing improvement and creates difficulty in postoperative follow-up resulting from opacity and immobility. We sought to use a tissue thicker than fascia but thinner than tragal cartilage to repair tympanic membranes that had failed previous fascia grafting. Our hypothesis was that use of the thinner cartilage would maintain the excellent healing rate and resistance to chronic negative pressure while improving hearing and mobility. STUDY DESIGN: The study is a retrospective review of all patients who received a total cartilage graft tympanoplasty after experiencing a failed standard fascia graft tympanoplasty. No previous operative series on impedance testing following cartilage grafting was identified in the literature. Standard audiologic and tympanometric parameters were obtained in all patients. METHODS: Tragal and fossa triangularis cartilage were statistically analyzed for thickness and weight. Surgical indications included patients who had chronic otologic disease that resulted in recurrent tympanic membrane perforation, atelectasis, or cholesteatoma. The tympanic membrane and any posterior canal wall defect were completely replaced with cartilage. Preoperative and postoperative audiometric and impedence tympanometry measurements were compared. RESULTS: Triangularis fossa cartilage is thinner and has less mass than tragal cartilage. Complete data were obtained on 83 of 159 patients to make up this study. The success rate for tympanic membrane integrity measured by tympanometry was 100% at a minimum 2-year follow-up in all ears included in the study. Hearing results are reported collectively and include all types of ossiculoplasty. The largest closure of air-bone gap was at 1000 Hz, followed by 2000, 500, and 4000 Hz. The patient's best hearing level was most frequently at 2000 Hz. Impedence testing showed a large shift in tympanogram configuration from B to C, indicating that cartilage grafts heal with integrity and measurable mobility although stiffened compared with normal. CONCLUSIONS: Fossa triangularis cartilage is thinner and has less mass than tragal cartilage. This creates a relatively mobile neotympanic membrane that can be monitored postoperatively by standard tympanometry, and allows for excellent hearing results. Recurrent tympanic membrane perforation or atelectasis with or without bony canal erosion that has failed standard fascia graft tympanoplasty can be successfully repaired with fossa triangularis cartilage graft tympanoplasty. Primary surgical use of cartilage graft tympanoplasty should be considered in patients with high-risk otologic disease, since fossa triangularis cartilage is thick enough to resist prolonged negative middle ear pressure and the hearing results with fossa triangularis cartilage shield graft tympanoplasty are comparable to those reported with fascia grafting. In patients with type A or C tympanogram results following successful fossa triangularis cartilage grafts, standard impedance testing can be used to clinically evaluate tympanic membrane mobility and help identify the presence of middle ear disease. However primary placement of a tympanostomy tube should be performed in patients with granulation tissue in the middle ear at time of tympanoplasty. Further study is needed to determine the ideal thickness of cartilage for tympanic membrane reconstruction.
Audiometry↗
[Hearing outcome of canal wall reconstruction tympanoplasties for the treatment of cholesteatoma].
While the hearing outcome of patients undergoing a tympanoplasty with canal reconstruction is generally thought to be inferior to that of patients undergoing a canal-up tympanoplasty, a direct comparison of these two procedures, performed by the same operator, has not been reported. Consequently, we compared the hearing outcomes of these two techniques and discussed the postoperative complications that could accompany the procedures. Hearing was evaluated in 52 ears with middle ear cholesteatoma. Using the postsurgical hearing result assessment criteria published by the Japanese Society of Otology in 2000, hearing was then evaluated again at least 6 months after surgery. When the data was analyzed according to the type of operation, the success rates (as determined using the above assessment criteria) were 78.6% for type I, 88.5% for modified type III, and 50.0% for modified type IV. The success rate for the modified type III operations was superior to that of the modified type IV operations, and the incidence of a postoperative air-bone gap in the type IV tympanoplasties was significantly larger than that in other groups. Procedures involving external auditory canal surgery can be particularly problematic for the treatment of cholesteatoma. In this series, the same author (KH) performed all the canal-up tympanoplasty procedures that took place during 1990-1996, and all other tympanoplasties, mainly canal reconstruction procedures, that took place during 1998-2001. The success rate was 68.4% (13/19) for the canal-up tympanoplasties, 100% (8/8) for the atticotomies and 76% (19/25) for the canal wall reconstructions. The postoperative success rate in the atticotomy group was significantly higher than the rates of the other groups. Among the canal reconstructive tympanoplasty procedures, a second exploratory surgery was performed in 15/24 cases, and residual cholesteatoma was observed in 3 cases. The major postoperative complications were epitympanic pocket formation (12/24) and taste disturbances, caused by chordal damage (2/24). These findings indicate that tympanoplasties with canal reconstruction improve the hearing outcome, compared with the outcome of canal-up tympanoplasties. However, epitympanic retraction pocket formation, resulting in recurrent cholesteatoma, is a possible complication of both surgical procedures, and new approaches or techniques should be sought to minimize such postoperative changes.
Adolescent↗
[The application of mastoid cavity plombage in open method tympanoplasty].
OBJECTIVE: The role mastoid cavity plombage played in restoring physiological function of external meatus in open method tympanoplasty was studied. METHOD: 85 cases of cholesteatoma otitis media were performed open method tympanoplasty with the broken bits of their own mastoid process cortex, homological costal cartilage or U shape periosteum connective tissue valve. And plombage was performed at the same time. The reconstruction of ossicular chain (type 0 tympanoplasty): 10 ears did not undergo reconstruction due to increase ment of bone conduction threshold or were in preparation for the second phase operation; 40 ears underwent type III tympanoplasty; 35 ears underwent type IV tympanoplasty. RESULT: The total improvement rate of hearing was 76%, among which 80% were performed type III tympanoplasty and 71.4% underwent type IV tympanoplasty. After operation, the time waited till dry-ears was 19.8 +/- 65.31 days and the dry-ears rate was 97.6% (83/85). Six months after operation, 89.4% (76/85) had smooth external meatus and fine self-cleaning function and no recurrence was found. CONCLUSION: As to cholesteatoma otitis media that could not be performed closed method tympanoplasty, U shape periosteum connective tissue valve and mastoid process cortex were used. Mastoid cavity plombage with homological costal cartilage could effectively overcome the shortcomings of destruction of physiological structure of external meatus caused by open method tympanoplasty, the self-cleaning function of skins of external meatus was remained and the life quality of patients after operation was increased.
Adolescent↗
Tympanoplasty type I in children--an evaluative study.
OBJECTIVE: A considerable controversy surrounds the subject of paediatric tympanoplasty type I. Conflicting views regarding timing of surgery and various other factors like Eustachian tube, status of contralateral ear, site and type of perforation etc. are presented by various published case series in medical literature. However, very few prospective studies address the issue. Thus, a prospective study was planned to evaluate the success rate of paediatric tympanoplasty type I and analyse the factors suggested to influence the outcome of the said surgery. METHOD: A cohort study with control was carried out in 40 patients of chronic suppurative otitis media-mucosal disease in a tertiary care teaching hospital. Patients were divided into two groups of 20 cases each, one comprising of paediatric patients (8-14 years) and other comprising of adult patients (more than 14 years of age). All the patients underwent tympanoplasty type I by post auricular inlay technique. An intact graft at the end of 6th month was considered a success and a minimum hearing improvement of 10 db in two consecutive frequencies was regarded as an audiological success. Results were tabulated and statistically analysed using chi2-test (with Yates correction). RESULTS: A success rate of 80% in terms of graft uptake and hearing improvement of 61% was seen in paediatric cases, compared to 85% graft uptake and 65% hearing improvement in adult cases. Statistically, on applying chi2-test, the value of P is >0.05 which is insignificant was obtained, indicating that age does not influence paediatric tympanoplasty type I. Also, the data for evaluating the correlation between Eustachian tube and paediatric tympanoplasty type I showed no statistical significance. In addition, no association between site and type of perforation and paediatric tympanoplasty type I was observed when results were compared to adult patients. However, anteriorly placed perforations were found to give poor results in both adult and paediatric group. CONCLUSIONS: The results of this cohort study mitigates against delaying tympanoplasty type I in paediatric population. This study also elucidates that Eustachian tube, contralateral ear pathology, site and type of perforation do not influence the outcome of the said surgery. However, anteriorly placed perforations require vigilance while repair in view of high failure rate. We recommend the age of 8 years for the paediatric tympanoplasty type I, but in view of redundancy of eustachian tube factor, the criteria for delineating minimum age for success of the said surgery is open to debate. More prospective studies are required in this direction.
Adolescent↗
Inlay butterfly cartilage tympanoplasty in children.
OBJECTIVE: To assess the results of inlay butterfly cartilage tympanoplasty in children. STUDY DESIGN: Before-and-after trial; follow-up duration, 26.6 +/- 19.9 months (mean +/- standard deviation). SETTING: Tertiary referral center. PATIENTS: Fifty-nine pediatric cases of tympanic membrane perforation. INTERVENTION: Inlay butterfly cartilage tympanoplasty was performed under general anesthesia according to the technique originally described by Eavey and modified by Lubianca-Neto (i.e., without any associated split-thickness skin graft). MAIN OUTCOME MEASURES: Percentage of perforation closures, surgical complications, preoperative and postoperative puretone hearing thresholds; the results of inlay butterfly cartilage tympanoplasty were compared with those obtained in a retrospective series of 29 underlay fascia temporalis myringoplasties. RESULTS: The 71% "take rate" of inlay butterfly cartilage tympanoplasty was not significantly different from the 83% take rate obtained with underlay fascia temporalis tympanoplasty (p = 0.23, chi test). The anatomic results were improved when the graft diameter was at least 2 mm larger than the size of the perforation (81% take rate) (p = 0.009, chi test). No iatrogenic cholesteatoma was observed. Pure-tone hearing thresholds were improved at 0.5, 1, and 2 kHz, and stable at 4 kHz. Hearing levels were not different from those obtained with underlay fascia temporalis tympanoplasty. CONCLUSION: Inlay butterfly cartilage tympanoplasty is a safe, efficient, time-saving, and easy technique of tympanoplasty in children. Anatomic results may be improved by associating a split-thickness skin graft and/or by trimming a tragal graft much larger than the size of the perforation.
Adolescent↗
Tympanoplasty after war blast lesions of the eardrum: retrospective study.
AIM: To establish whether hearing loss after eardrum blast injury could be recovered by tympanoplasty performed immediately after injury and what material is the most suitable for eardrum closure. METHODS: Tympanoplasty was performed in 119 (a total of 181 injuries) out of 651 patients examined for blast injury of the ear between 1991 and 2000. The study included a total of 106 patients who underwent tympanoplasty: 51 patients with unilateral and 55 with bilateral blast eardrum rupture (a total of 161 injuries). Three different materials were used for eardrum rupture closure: temporal fascia in 81, perichondrium in 61, and heterograft in 19 cases. Injuries were divided in 4 groups, according to the time elapsed between the injury and tympanoplasty (0-20, 21-60, 61-180, and 181 days and more). Otomicroscopic finding, audiometry, and tympanometry were used for definitive evaluation of tympanoplasty outcome. RESULTS: Eardrum rupture was successfully closed with temporal fascia in 91%, perichondrium in 92%, and heterograft in 89% of the cases (p=0.429). There were no statistically significant differences in either values of postoperative air- bone gap (p=0.210) or in eardrum perforation closure rate (p=0.951) with respect to the time period between the injury and tympanoplasty. Also, there was no correlation between the postoperative air-bone gap and the number of days elapsed between the rupture and tympanoplasty (r=-0.037, p=0.641). CONCLUSION: Small ruptures of the eardrum should be left to heal spontaneously. The patients with subtotal and total rupture and rupture that did not heal spontaneously in three months should undergo tympanoplasty. Temporal fascia, perichondrium from tragus, and heterograft are equally acceptable materials for eardrum closure after blast injury.
Blast Injuries↗
Xenograft versus autograft in tympanoplasty.
This retrospective study compares the tympanoplasty success rate when using a xenograft (Zenoderm) or an autograft (temporalis fascia). Fifty-three ears were operated on over a three-year period. All the tympanoplasty operations were performed by the same surgeon. There were 43 ears in the temporalis fascia autograft group and 10 ears in the Zenoderm xenograft group. Both groups were similar with respect to patient age, type of tympanoplasty, area of tympanic membrane perforation and condition of the contralateral ear. The tympanoplasty success rate in the temporalis fascia autograft group was 95 per cent. The tympanoplasty success rate in the Zenoderm xenograft group was only 40 per cent. All Zenoderm tympanoplasty failures were regrafted with temporalis fascia autograft. There was a 100 per cent success rate with this salvage surgery. In conclusion, we suggest that Zenoderm is not a suitable graft material for tympanoplasty.
Adult↗
[Is surgery of the inner nose indicated before tympanoplasty? Effects of nasal obstruction and reconstruction on the eustachian tube].
BACKGROUND: When tympanoplasty is to be done in a patient suffering from chronic otitis media, usually potential interactions between middle ear mucosa, Eustachian tube function, and the nose and nasopharynx are considered. Poor tubal function goes along with a diminished success rate of tympanoplasty. On the other hand, pathological findings in the nose or the nasopharynx are often said to be responsible for inadaequate tubal function. Consequently, many authors feel that surgery of the nose should be performed before tympanoplasty if septal deviation or hypertrophy of the conchae is seen in a patient with chronic otitis media. PATIENTS AND METHODS: In order to better understand interactions between nasal pathology and Eustachian tube function, we utilized a pressure chamber to examine 50 patients undergoing septoplasty and conchotomy. Besides insufflation tests (Toynbee, Valsalva), we performed dynamic tubal examination with the dual-impedance method. Active parameters (positive and negative residual pressure) and passive parameters (tubal opening and tubal closing pressure) were recorded as the chamber pressure was varied. The aim of our investigation was to test if surgery of the nasal septum and the conchae really improves tubal function, thus evaluating indications for septoplasty before tympanoplasty. In addition, we explored the early and the late consequences of nasal surgery on tubal function. This was done to find out the optimal postoperative period during which tympanoplasty could be performed following septoplasty. RESULTS: In many of the patients, insufflation tests were negative and dynamic tubal parameters were outside normal value range before surgery of the nose. One week after surgery, active and passive parameters and insufflation tests even deteriorated in the majority of our patients. Six to 8 weeks after surgery, we observed a tendency towards normalization of tubal parameters. This was significant for tubal closing pressure, but not for the other parameters. Whereas passive tubal parameters showed considerable improvement in many patients, there was no real improvement of active tubal parameters in most patients. This tendency was observed several months after surgery of the nose as well. Despite this improvement of passive tubal function, we did not observe a complete normalization of mean values even after 4 to 6 months. In several patients (who were satisfied with functional results of septoplasty) tubal parameters were even worse some weeks or months after nasal surgery, but this was not subjectively registered by our patients. DISCUSSION: We conclude from our data that dysfunction of the Eustachian tube frequently occurs in patients with deviation of the nasal septum and the conchae. Septoplasty and conchotomy worsen tubal function during the early postoperative period, lasting for at least one week. In a later period, improvement of tubal function may occur but in many patients no effects of nasal surgery on Eustachian tube can be measured. Thus, septoplasty before tympanoplasty cannot be generally recommended in all patients with septal deviation. We suggest that it may be useful in cases with severe nasal pathology or chronic infection of the nose or the nasopharynx, if this is accompanied by poor tubal function. We recommend analysis of Eustachian tube function before deciding on therapeutic management. Individual findings in the specific patient should be the leading criteria in all cases. If septoplasty and conchotomia are done, tympanoplasty should not be performed in the same session or in the early postoperative period, but several months after nasal surgery.
Acoustic Impedance Tests↗
A tympanometric comparison of tympanoplasty with cartilage palisades or fascia after surgery for tensa cholesteatoma in children.
OBJECTIVE: The aim of the present study is to compare the tympanometric and functional findings of cartilage palisade tympanoplasty with those of tympanoplasty with temporalis fascia grafting after one-stage surgery in children with tensa cholesteatoma. STUDY DESIGN: In children aged 5 to 15 years (mean, 9.5 years) with tensa cholesteatoma, cartilage palisade tympanoplasty was performed in 32 ears and fascia tympanoplasty in 29 ears. Tympanometry was performed in 31 ears with cartilage palisade tympanoplasty (the palisade group) and 28 ears with fascia tympanoplasty (the fascia group) at follow-up a median of 48 months after surgical removal of the cholesteatoma (range, 3-75 months). MAIN OUTCOME MEASURES: Postoperative perforations, tympanometric parameters (tympanogram type, compliance, tympanometric width), and hearing. RESULTS: All postoperative re-perforations occurred in the fascia group. However, there was no difference between the palisade group and the fascia group in terms of tympanometric parameters, nor between the two groups when dividing into tensa retraction and sinus cholesteatoma subgroups. When comparing the types of tympanoplasty, the type II group reconstructed with cartilage palisades contained a higher number of ears with a normal compliance (0.2-1.6 mL) but a higher number of ears with a tympanometric width of more than 150 mmH2O. Regarding the number of ears with normal tympanometries, there was no significant difference between the palisade and the fascia group. The late functional hearing results were better in ears reconstructed with cartilage palisades, with functional success in 71%, compared with 54% in the group with fascia grafting. This difference in functional results was particularly pronounced in ears with an abnormal tympanogram (68% vs. 29%). CONCLUSION: Compared to fascia grafting, the present study showed better late functional hearing results after drum reconstruction using cartilage palisades, despite comparable tympanometric findings. Cartilage palisade reconstruction seems to provide better functional results, especially in ears with a poor tubal function, which is the common situation after cholesteatoma surgery.
Acoustic Impedance Tests↗
Eustachian tube patency and function in tympanoplasty with cartilage palisades or fascia after cholesteatoma surgery.
OBJECTIVE: To compare the Eustachian tube patency and function after tympanoplasty with either cartilage palisades or fascia grafting after one-stage surgery in children with tensa cholesteatoma. STUDY DESIGN: In children operated for tensa cholesteatoma, cartilage palisade tympanoplasty was performed in 32 ears and fascia tympanoplasty in 29 ears. The patency of the Eustachian tube was evaluated by the Valsalva maneuver before the operation, 1 to 3 months after the operation, and at a follow-up examination 46(1/2) months later (median). Eustachian tube function was evaluated by the nine-step inflation/deflation tympanometric test and the Toynbee test at the follow-up examination. Otomicroscopy and hearing evaluation were performed before and after surgery as well as at the follow-up. MAIN OUTCOME MEASURES: Eustachian tube patency and function. Hearing, postoperative eardrum perforation/retraction, and cholesteatoma recurrence. RESULTS: The Valsalva maneuver was positive in 30% of the ears before the operation, in 65% primarily after the operation, and in 78% at the follow-up examination. A poor tubal function was found in 57% at follow-up. Overall, the late functional hearing results were better in ears with a positive Valsalva maneuver. There were no differences in tubal patency or function in relation to graft material, cholesteatoma, and tympanoplasty type. In ears with a poor tubal function, the hearing results were significantly better in the palisade group (63% success), compared with the fascia group (17% success). All of the four perforations, most of the retractions, and a single moist eardrum were found in the fascia group at the reevaluation. We found no correlation between the condition of the eardrum and the Eustachian tube function at the last evaluation. However, in ears with a poor tubal function, a nonretracted, nonperforated drum was found with higher frequency in the palisade group. Decision matrix analysis showed that the last postoperative Valsalva maneuver was the best predictor of the drum condition at the reevaluation. CONCLUSIONS: The Eustachian tube patency frequently improves after tympanoplasty after cholesteatoma surgery in children, regardless of graft material. The patency and function of the Eustachian tube seem to be without relation to graft material, cholesteatoma, or tympanoplasty type. Cartilage palisade tympanoplasty may be a better reconstruction technique after cholesteatoma surgery, especially in ears with a poor tubal function.
Acoustic Impedance Tests↗
Endoscopic transtympanic tympanoplasty in the treatment of conductive hearing loss: early results.
OBJECTIVE: We describe our initial experience with endoscopic transtympanic tympanoplasty and evaluate whether this approach is adequate and minimally invasive in the treatment of conductive hearing loss. STUDY DESIGN: Prospective trial. SETTING: University hospital. PATIENTS: Nine patients underwent endoscopic transtympanic tympanoplasty, with an average follow-up period of 17 months. Presurgical diagnosis was made by transtympanic endoscopy through a perforation made by OtoScan laser-assisted myringotomy in the outpatient clinic. METHODS: With clean endoscopic visualization, ossiculoplasty was performed by inserting a trimmed tragal cartilage through the myringotomy perforation made by laser-assisted myringotomy. Two types of ossiculoplasty were performed: columella reconstruction and interposition. The tympanic membrane was covered with a chitin membrane or sealed with a small piece of perichondrium from the tragal cartilage. MAIN OUTCOME MEASURES: Perioperative and postoperative complications and preoperative and postoperative hearing. RESULTS: Endoscopic transtympanic tympanoplasty with columella and endoscopic transtympanic tympanoplasty with interposition were performed in seven and two patients, respectively. Insertion of the cartilage was performed without conversion to a conventional otomicroscopic technique. The average hearing level before the operation was 59 dB. After the endoscopic transtympanic tympanoplasty, the average improved to the level of 27 dB, with an average air-bone gap of 11 dB. The myringotomy perforation was closed within 2 to 3 weeks. CONCLUSION: As opposed to conventional methods, this procedure does not require surgical exposure such as otosclerosis drilling and skin incision, and avoids the substantial risk of unnecessary injury to the chorda tympani. Endoscopic transtympanic tympanoplasty for a disrupted ossicular chain is an adequate and minimally invasive procedure and should prove to be a useful surgical procedure in future endoscopic tympanoplasty.
Adolescent↗
Eustachian tube function related to the results of tympanoplasty in children.
The results of tympanoplastic surgery to repair a perforation of the tympanic membrane are less satisfactory in children than in adults. This paper reports the results of a propspective study of 45 children (51 ears) which was undertaken to determine which, if any, detectable and controllable pre or intraoperative parameters might predict the outcome of tympanoplasty surgery. A "successful" tympanoplasty was defined as that in which the initial graft took, in which the tympanic membrane remained intact, and which was not associated with high negative middle ear pressure, otitis media with effusion, or cholesteatoma during a follow-up period of one to two years. Assessment of hearing related to the tympanoplastic surgery was not included as an outcome measure. With this criteria, the overall success rate of tympanoplasty in children was 35%. The success of tympanoplasty was not related to graft placement, although the laterally placed grafts had a higher take rate (67%) than grafts placed medially (49%). Preoperative measures, such as the assessment of Eustachian tube function using the modified inflation-deflation test and tympanometric evaluation of the contralateral ear, failed to predict the success of tympanoplasty. Tympanoplasty universally failed in the ears in which an acquired cholesteatoma was present. Children remain uncertain candidates for tympanoplasty surgery since, as a group, their Eustachian tube function is not as good as that of adults.
Adolescent↗
Type III tympanoplasty with cartilage obliteration for cholesteatoma surgery.
BACKGROUND: The main objective of cholesteatoma surgery is complete eradication of the disease. Another goal is to preserve hearing acuity. We reviewed type III tympanoplasty with cartilage obliteration for cholesteatomatous ears. To evaluate the role of ossiculoplasty, the functional results of classic and modified type III tympanoplasties were compared. METHODS: Thirty-six cholesteatomatous ears undergoing type III tympanoplasty with cartilage obliteration were reviewed. The same operator performed these operations from 1984 until 1995. According to the CAO staging system, there were five early, 16 moderate and 15 advanced-stage cases of cholesteatoma. Using the anterior approach, all operations were canal-wall-down type III tympanoplasties with "tailored" open cavity and cartilage obliteration. There were 24 classic and 12 modified type III tympanoplasties. RESULTS: The average follow-up duration was 7.2 years. Neither recidivistic cholesteatoma nor retraction pocket was observed postoperatively. There was an improvement in atelectatic score after surgery. The mean postoperative air-bone gap (ABG) was 15.8 +/- 10.7 dB and the mean closure of the ABG was 4.0 +/- 14.3 dB. After the disease stage and preoperative hearing status were adjusted using regression analysis, there was no significant difference in hearing results between ears that underwent classic or modified type III tympanoplasties. CONCLUSIONS: We performed the canal-wall-down tympanoplasty with cartilage obliteration using the anterior approach for treatment of cholesteatoma. Such surgical techniques eradicate the cholesteatoma, prevent its recurrence and create a clean ear. Hearing reconstruction can also be accomplished in a single-stage procedure offering a serviceable hearing acuity.
Adolescent↗
Closed tympanoplasty in middle ear cholesteatoma surgery.
OBJECTIVE: To determine the effect of closed tympanoplasty surgery for middle ear cholesteatoma and to compare the postoperative results with the outcomes of canal-wall-down mastoidectomy. METHODS: Seventy patients with middle ear cholesteatoma were involved in the study. Pneumo-otoscopy, pure-tone audiometry, anamnestic and clinical data were evaluated before the surgery. Modified radical mastoidectomy was performed for 31 patients. Thirty-nine patients were treated with closed tympanoplasty surgery, including intact canal wall mastoidectomy, endaural atticotomy, lateral attic and aditus wall reconstruction and tympanoplasty. The follow-up examination was carried out 12 months after the surgery. The recurrence of cholesteatoma, otorrhea and hearing level were evaluated postoperatively. RESULTS: Otorrhea was estimated in 4 cases (10.3%) after closed tympanoplasty surgery and in 6 cases (19.4%) after modified radical mastoidectomy. Among the patients who were operated using closed tympanoplasty technique the middle ear cholesteatoma recurrence rate was 12.8% and among those, who underwent modified radical mastoidectomy recurrent disease occurred in 9.7% of the cases. The hearing improvement was found in 15 cases (38.46%) after closed tympanoplasty, while there was no hearing improvement after modified radical mastoidectomy. CONCLUSIONS: We conclude that despite the fact, that cholesteatoma recurrence rate after closed tympanoplasty is relatively high, this surgical method permits to preserve adequate hearing level and releases from postoperative cavity care problems as compared with modified radical mastoidectomy.
Adolescent↗