Tympanoplasty

Manal Al Quaimi

207000989

2011

• Definition • History• Anatomy • Etiology • Types • Techniques• Tympanoplasty in children• Complications• Conclusion• References

Myringoplasty Vs. Tympanoplasty

Myringoplasty - reconstruction of perforated Tympanic

Membrane (TM) Assumes – normal middle ear (ME) mucosa and ossicles TM is not elevated from its sulcus

Tympanoplasty - reconstruction of the Tympanic Membrane and

evaluation of Middle Earo Cholesteatoma, adhesionso Ossicular chain problemso Usually involves elevating the TM from its sulcus

Tympanoplasty can be accompanied with or without mastoidectomy

When was the 1st Tympanoplasty !!

1640 – Banzer

+

TM is oval in shape8 mm X 10 mm55 degrees to the floor of the meatus

3 layers – 130 microns thick

Outer epithelial – keratinizing squamousMiddle fibrous – superficial radial, deep circularInner – mucosaEpithelial migratory pattern

Centrifugal growth for the umbo outward

Anatomy :

7

Consists of three layers:

1. Outer epithelial layer

2. Middle fibrous layer

3. Inner mucosal layer

The drum direction is oblique so that the anterior and inferior walls of the External Auditory Meatus are longer than the roof and the posterior walls

• Blood supply– Inner surface

• Ant. Tymp a.

– Outer surface• Deep

auricular a.

Tympanic membrane perforation : • Infection is the principal cause of tympanic membrane

perforation (TMP).• Trauma :

1. Blunt

2. Penetrating

3. Thermal

patients usually complain of hearing loss

Tympanoplasty

Tympanoplasty - reconstruction of the Tympanic Membrane and

evaluation of Middle Ear

• The surgeon takes a graft from the tissues under the skin around the ear and uses it to reconstruct the eardrum.

• One of the most common graft sites is from the tragus.

• It is done under local or general anesthesia.

• It is done on an outpatient basis and is successful 85-90% of the time.

Indication of surgery :

• Conductive hearing loss due to TM perforation or ossicular dysfunction.

• Chronic or recurrent otitis media Progressive hearing loss due to chronic middle ear pathology .

• Perforation or hearing loss persistent > 3 months due to trauma, infection, or surgery

• Inability to bath or participate in water sports safely

Goals of Surgery :

• Establish an intact TM• Eradicate middle ear disease and create an air-

containing middle ear space• Restore hearing by building a secure connection

between the ear drum and the cochlea

Classification of Tympanoplasty :• Wullstein (1956)

• Type I tympanoplasty ( myringoplasty )

• TM is grafted to an intact ossicular chain

• Type II tympanoplasty • Malleus is partially eroded • TM +/- malleus remnant is grafted to

the incus

• Type III tympanoplasty • Malleus and incus are eroded• TM is grafted to the stapes suprastructure

• Type IV tympanoplasty• Stapes suprastructure is eroded but foot

plate is mobile• TM is grafted to a mobile foot plate

• Type V: Used when the footplate the stapes is fixed.

Techniques

- Overlay technique (lateral grafting)

- Underlay technique (medial grafting)

Overlay Technique :1. Temporal fascia or perichondrial graft is harvested.2. Endaural or postaural incision2. Incision is made in the meatus as shown and meatal skin raised along with all epithelium from the outer surface of tympanic membrane remnant.3. Graft placed on the outer surface of TM. A slit is made in the graft to tuck it under the handle of malleus. 4. Meatal skin removed earlier is now replaced, covering the periphery of the graft. Ear canal packed with gelfoamand then with a small antibiotic pack. A modification of the overlay technique is to placethe anterior edge of fascia graft under the annulus after removing the epithelium. This prevents blunting of anterior canal which is seen as a complication of overlay technique .5. Closure of endaural or postaural incision.

Tympanic Membrane grafts: 1. Cartilage2. Fool’s fascia(loose areolar fascia over temporalis fascia)3. Temporalis fascia

• Underlay Technique• 1. Harvesting the graft of temporalis fascia or peri- chondrium from

the tragus.• 2. Preparing the T.M. for grafting. An incision is made along the

edge of perforation and the ring of epithelium removed. Remove also a strip of mucosal layer from the inner side of perforation.

• 3. Inspecting the middle ear. A stapes-type incision is made and the tympanomeatal flap raised to see the integrity and mobility of the ossicular chain and to ensure that no squamous epithelium has grown into the middle ear.

• 4. Placing the graft. Middle ear is packed with gelfoam soaked with an antibiotic. A proper sized graft is placed so that its edges extend under the margins of perforation all round and a small part also extends over the posterior canal wall. Tympanomeatal flap is replaced. An underlay technique has the advantage that the squamous epithelium is not buried in the middle ear.

Cartilage graft :

Fascia and perichondrium undergo atrophy

Skin graft: Infection

Cartilage More rigid and resist resorptionGood long-term survivalNourished largely by diffusion

Techniques of cartilage Tympanoplasty• Techniques of cartilage tympanoplasty• Four techniques have been described for cartilage tympanoplasty, namely the inlay butterfly graft, Perichondrium/cartilage

island flap, palisade flap, and cartilage shield tympanoplasty. The choice of technique is dictated by surgeon’s preference, size of the perforation, integrity of the ossicular chain, and the presence of cholesteatoma.

• Inlay butterfly graft• This technique was originally described for small TM perforation myringoplasty. The tragal cartilage graft is harvested with

intact perichondrium on both sides. Using a beaver blade, a 2 mm circumferential incision can be made on the cartilage to create a groove with an appearance similar to the wings of a butterfly. After the perforation rim is freshened, the cartilage graft can then be anchored onto the perforation similar to a tympanostomy tube. A split thickness skin graft can be placed over the graft if the perforation is large. For perforation greater than 1/3 of TM or close to the annulus, the graft can be anchored onto the bony annulus, as described by Ghanem et al in 2006.

• Perichondrium/ cartilage island flap• Tragal cartilage graft is harvested because it is flat, thin (~ 1mm) and abundant. Perichondrium from the side away from the

external auditory canal is removed. A flap of perichondrium is produced posteriorly that will eventually drape over the posterior canal wall. Next, a complete strip of cartilage 2 mm in width is removed vertically from the center of the cartilage to accommodate the entire malleus handle. The entire graft is placed in an underlay fashion, with the malleus fitting in the groove.

• Palisade technique• Cartilage graft can be harvested from either the tragus or concha cymba. The latter is used when a post-auricular incision is

planned, as in the case of mastoidectomy. For conchal cartilage graft, perichondrium is removed from the post-auricular side. Cartilage graft is cut into several slices or strips, which are subsequently pieced together medial to the malleus to reconstruct the TM. This technique is favored when ossicular chain reconstruction is performed because it provides a better visualization of the prosthesis and precise placement of graft onto the prosthesis. In cases of posterior perforation, the anterior half of the TM can be left alone to allow postoperative surveillance and future myringotomy tube placement.

• Cartilage shield technique• A vascular strip incision is made in the ear canal, followed by a post-auricular incision. Areolar tissue overlying temporalis

fascia is harvested. A round piece of conchal cartilage is harvested and perichondrium on both sides is removed. A small wedge of cartilage is removed to accommodate the handle of the malleus. The graft is then placed medial to the malleus and the remnants of the TM. The areolar graft is then placed in between the cartilage graft and the remnants of the TM.

The choice of technique is The choice of technique is dictated by surgeon’s preference, dictated by surgeon’s preference, size of the perforation, integrity size of the perforation, integrity of the ossicular chain, and the of the ossicular chain, and the presence of cholesteatoma.presence of cholesteatoma.

•Postoperative Care- Mastoid dressing removed postoperative day one

- Incisions cleaned bid with H2O2H2O2 and topical abxtopical abx

- Patient instructions Avoid nose blowing Sneeze with mouth open Avoid heavy lifting (>10 lbs) or straining Dry ear precautions

- One week ear drops are started

- Three weeks, gelfoam is removed from the External Auditory Canal

- 2-3 months, postoperative audiogram is performed

Complications

• Infection• Poor aseptic technique• Prior contamination• Graft failure is associated with postop infection

• Graft failure• Infection• Inadequate packing (anterior mesotympanum)• Inadequate overlay of graft with TM remnant

(underlay)

• Chondritis• Injury to the chorda tympani nerve• SNHL and vertigo

• Excessive manipulation of the ossicles• Increased conductive hearing loss

• Unrecognized eroded ISJ• Blunting

• Thick graft extending onto the anterior canal wall in lateral grafting

• Lateralization of the TM from the malleus handle• External auditory canal stenosis

• Lateral grafting

Pediatric patients

Considered less successful than adultsWide range of success rates

35% to 93%

Avoid Tympanoplasty < 3 yearsRepair at age 4If contralateral ear is perforated, perform

adenoidectomy and defer until age 7Cartilage tympanoplasty in the worst ear

Conclusion

Hearing results after cartilage tympanoplasty is comparable to temporalis fascia graft

Tympanoplasty in the pediatric age group is controversial

Both underlay and overlay techniques for grafting are effective, however, the surgeon should do what he is most experienced and successful with.

Choice of techniques depend on surgeon’s preference, status of ossicular chain, Eutstachian tube, presence of cholesteatoma, etc.

Refferances

• http://www.pedsent.com

• http://emedicine.medscape.com/article/858684-overview

• http://orl.zclub.fr/

• Grand Rounds Presentation, UTMB, Dept. of Otolaryngology, January 15, 2003,Christopher Muller, Arun Gadre, M.D.

• Diseases of Ear, Nose and Throat PL Dhingra

• CURRENT Diagnosis and Treatment in Otolaryngology Head and Neck Surgery Second Edition LANGE CURRENT Series

• Tympanoplasty ,Christopher Muller, M.D.Arun Gadre, M.D. University of Texas Medical Branch Galveston, TX