Www.nayyarENT.com1 Principles of tympanoplasty By : Dr. Supreet Singh Nayyar, AFMC For more...

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Principles of tympanoplasty

By : Dr. Supreet Singh Nayyar, AFMC

For more presentations , visit www.nayyarENT.com

Tuesday, July 17, 2012

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Layout History & evolution of middle ear surgery

Definition of tympanoplasty

The transformer mechanism in health and disease

Functional considerations of tympanoplasty

Classification

Principles of tympanoplasty surgery

Basics of ossiculoplasty

Reporting protocols

Pediatric tympanoplasty

Recent advancesTuesday, July 17, 2012

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Evolution of Middle Ear Surgery

Era of Experimentation19th century

Era of OppositionLate 19th & early 20th century

Era of Revival1920’s

Era of Reorientation1940’s - 1960’s

Era of ModernityFrom then on.....


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Acoustic transformer mechanism

Ossicular coupling

Hydraulic lever

Ossicular lever

Catenary lever

Acoustic coupling


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Transformer in Diseased State

Effect on Ossicular coupling Ossicular Discontinuity Ossicular Fixity

Effect on Acoustic coupling Loss of Round Window shielding Effect of Stapes, Cochlear & RW

Impedance

Middle ear aeration / fluidTuesday, July 17, 2012

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Definition of Tympanoplasty

“ Procedure to eradicate disease in the middle ear & to reconstruct the hearing mechanism with/without TM (tympanic membrane) grafting ”*

* 1965- American Academy of Ophthalmology & Otolaryngology Subcommittee on Conservation of Hearing


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Goals of Surgery

To establish intact tympanic membrane

Eradication of middle ear disease & create an air containing middle ear space

Restore hearing by building a secure connection between the tympanic membrane & cochlea


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Techniques

Minimalistic techniques◦ Cauterization & fat plug◦ Cauterization with trichloroacetic acid◦ Sealed tympanostomy tubes

Formal Tympanoplasty


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Classification of Tympanoplasty

1956- Wullstein◦ Type 1◦ Type 2 ◦ Type 3 ◦ Type 4◦ Type 5


Mirko Tos◦ 1 - Intact chain

◦ 2 – Short columella

◦ 3 – Long columella

◦ 4 - Sound protection

◦ 5A - Fenestration of LSCC

◦ 5B - Platinectomy

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Classification of Tympanoplasty



Indications 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 for more than three months due to trauma, infection or surgery

Inability to bathe or participate in water sport activities

(Arun Gadre, Christopher Muller, University of Texas Branch, Texas)Tuesday, July 17, 2012


Contraindications (Glasscock 1976 /

Shambaug)

Absolute Uncontrolled cholesteatoma Malignant tumors Unusual infections Intracranial complications

Relative Eustachian tube dysfunction / OME in other ear Dead ear Only hearing ear Elderly patient Very young children Repeated failures Uncooperative patients



Preoperative Evaluation

Extent & location of perforation

Ossicular status

Counseling ◦ Nature of disease◦ Treatment options◦ Outcomes of surgical options◦ Post op morbidity – restriction of water

activities, hearing deterioration



Approach

Transcanal◦ Posterior moderate sized perforations◦ Favorable EAC anatomy

Endaural◦ Visualisation of annulus & ant sulcus is difficult◦ Limited atticotomy

Postaural◦ All perforation sizes◦ Better angle of visualisation◦ Second look ossiculoplasty



Graft Placement

Lateral / Overlay

Medial / Underlay

Over-Underlay



Contd… Overlay Adv

◦ Exposure of anterior meatal recess

◦ High take up rate◦ Middle ear volume not

reduced

Disadv◦ Precision is required◦ Long healing time◦ Blunting / lateralization

Underlay Adv

◦ Less blunting or lateralization

◦ High graft take up in experienced hands

◦ Simpler technique/less time consuming

Disadv ◦ Limited visualisation

of ant meatal recess◦ Less suitable for large

ant perf◦ Difficult in small EAC

with per meatal approach

◦ Reduction in ME spaceTuesday, July 17, 2012


Results – Underlay / Overlay Technique

Review of Underlay versus Overlay tech *◦ Re-perf rate - 36% Overlay, 14% Underlay◦ Hearing improvement – 62% Underlay, 27% Overlay◦ Complication rate less in Underlay

Review of Overlay tech**◦ Graft uptake 97% - Temp fascia, 84% -Canal skin◦ Rate of Ant blunting & Lateralization 1.3%◦ AB gap within 10 dB – 80%

Review of Underlay versus Overlay tech***◦ Graft uptake - 89% Underlay, 96% Overlay◦ Hearing improvement – 85% Underlay, 80% Overlay◦ Complications – 7.8% Underlay, 9% Overlay

* Doyle et al(1972), ** Sheehy et al, *** Rizer (1997)



Graft MaterialsAutografts

◦ Skin Canal skin

Pedicled Free

◦ Heterotopic skin graft◦ Periosteum ◦ Vein ◦ Temporalis fascia ◦ Fatty tissue◦ Tragal perichondrium & cartilage◦ Subcutaneous tissue



Graft Materials Allografts

◦ Historical Amnion Cornea Duramater Peritoneum Pericardium Aorta valves Ear drum

◦ Lyophilised dura ◦ Cartilage◦ Fascia

◦ Risk of HIV, Hepatitis B, Creutzfeldt Jacob disease

Xenografts◦ Historical

Bovine Periostem Drum Jugular vein



Reasons for Graft failure

◦Technical/surgeon errors◦Infectious complications◦Poor tubal function◦Patient factors



Ossicular status Austin / Kartush Classification

Types Ossicular chain status

0 M+I+S+

A M+S+

B M+S-

C M-S+

D M-S-

E Ossicular head fixation

F Stapes fixation



Autografts

Bone Adv

◦ Immediate availability◦ Biocompatibility◦ Low cost◦ Low extrusion rate

Disadv◦ Disease recurrence◦ Fixation to adjacent

structures◦ Skill & time to shape

Cartilage Conchal /Tragal

Cartilage

Materials used in Ossiculoplasty



Homografts

Irradiated Ossicles En Bloc TM with attached Ossicles Risk of disease transmission



Allografts Biocompatible

◦ 1960’s – Polyethylene tubing, Teflon, Proplast◦ 1970’s – HDPS (Plastipore), Thermal fused

HDPS (Polycel)◦ Silastic, Stainless steel, Titanium

Bioinert◦ Al 2O3 Ceramic (Germany & Japan in 1970’s)

Bioactive ◦ Bioactive glass – Bioglass, Ceravital (1970’s)◦ CaPO4 Ceramic - Hydroxyapatite



Configurations of Allografts Total Ossicular Replacement Prosthesis

(TORP) Partial Ossicular Replacement Prosthesis

(PORP) Prosthesis for ossicular discontinuity

restricted to IS joint Combined forms - Hydroxyapatite

platform with Plastipore shaft


Different Types of Prosthesis

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Choice of prosthesis / placement◦ Ossicular status◦ Med – lat distance / vertical position◦ Retracted umbo – severing of tensor tympani

tendon

Ossiculoplasty



Surgical Techniques in case of ossicular fixation Tympanosclerosis

◦ Disease restricted to attic◦ Disease restricted to stapes◦ Combined attic & stapedial disease

Acquired bony fixation◦ Removal of fixation with intact chain◦ Removal of incus/malleus head with interposition

of allograft/autograft



Surgical Techniques for ossicular discontinuity

Ossicular status

◦ Lenticular process missing

◦ Tip of Incus missing

◦ Long process of Incus missing Stapes superstructure +/- Malleus handle +/-



Configurations of Prosthesis



Factors affecting outcomes of ossiculoplasty

Intrinsic factors

◦ Status of ossicular chain – mobility ◦ Severity of disease◦ Eustachian tube function◦ Adequate control of allergy



Contd…

Extrinsic Factors

◦ Surgical technique◦ Design of prosthesis◦ Composition of prosthesis



Advantages of Titanium Prosthesis

◦ Low wt (<4mg), high rigidity◦ Open head plate design- better visualisation

during placement◦ Medial end has claw like design- better fit on

stapes head◦ Unlike hydroxyapatite they are not top heavy,

stay upright




Poor Eustachian Tube Function Cartilage Tympanoplasty

◦ Prevent recurrence of retraction pockets◦ May reduce extrusion rates◦ Mainly with Temporalis Fascia grafts

Posterosuperior TM/post Pars Flaccida* Entire TM** Composite cartilage perichondrium graft Cartilage Palisade technique***

( * Poe & Gadre :1993; ** Dornhoffer :1997; *** Heerman )



Poor ET Function (contd…)

Tympanostomy ◦ Rarely at the time of TM grafting◦ Maybe during follow up if effusion or

retraction develops



Middle Ear Stents

Teflon / Silicone pieces Silastic sheet Biodegradable materials

◦ Gelfoam ◦ Gelfilm


Reporting protocols

“ Fiction & fact need untangling, otherwise,

surgeons are little better than gossips ”

:Gordon Smyth


Reporting Protocols

Tympanoplasty Reporting Protocol based on AB gap (Kartush)

AB gap Result0 – 10 dB Excellent10 – 20 dB Good20 – 30 dB Fair>30 dB Poor



Reporting Protocols For Disease*

◦ Type & location of perforation◦ Ossicular status◦ Status of mucosa◦ Status of eustachian tube

For Results*◦ Control of pathology◦ Anatomic status◦ Improvement in hearing◦ Post-op complications(*American Academy of Ophthalmology &

Otolaryngology Subcommittee on Conservation of

Hearing )Tuesday, July 17, 2012


Middle ear risk index

◦MERI 0 Normal

◦MERI 1-3 Mild disease

◦MERI 4-6 Moderate disease

◦MERI 7-12 Severe disease



Tympanoplasty Reporting Protocol



Reporting Protocols (contd…)

Pure Tone Averages◦ Frequencies : 500 Hz, 1 KHz, 2 KHz, 3 KHz *◦ Most commonly affected frequencies by

Conductive Hearing Loss

Glasgow Benefit Plot **

• * Recommendation of The American Academy of Otolaryngology – Head & Neck Surgery

• ** Browning et al : Glasgow Benefit Plot : A new method for reporting results of middle ear surgery; 1991, Laryngoscope101 : 180-185


Hearing Evaluation

◦ Belfast Rule Of Thumb *

Post operative air conduction mean threshold over speech frequencies <30 dB

Inter aural air conduction mean threshold <15dB

*Smyth & Peterson, 1985



Paediatric Tympanoplasty

Controversy - Mgt of pts with TM perforation(+/-otorrhea)

Factors affecting decision of surgery◦ Poor tubal function( perforation acts as

natural grommet)◦ Frequent episodes of URTI◦ Negative middle ear pressure in contralateral

ear


◦ Extraction of ankylosed transposed ossicles in revision cases

◦ Potassium Titanyl Phosphate LASER for amputation of malleus & incus & at the same time maintaining chain integrity *

◦ LASER Soldering tech ( Solid State Diode LASER )**

* Nishizaki K et al; Nov 2001 vol 22 issue 6 Pg 424-427, Head & Neck Medicine & Surgery

** Study on cadaveric human temporal bones


Recent Advances – Uses of Laser



Conclusion

Rich history Antibiotics & binocular microscope major

role brought turnaround Better & better results with

tympanoplasty Newer materials for ossiculoplasty Scope of further research e.g. in area of

cartilage & pediatric tympanoplasty



References Text book of Otolaryngology – Head & Neck

Surgery : Charles W Cummings, 4th ed , vol 4, 3058 – 74

Manual of Middle Ear Surgery : Mirko Tos, vol 1 The Otolaryngologic Clinics of North America :

Aug 1994; Ossiculoplasty, vol 27, No 4 Surgery of the Ear : Glasscock – Shambough, 5th

ed Scott Brown otolaryngology 7th edition Internet Journal articles


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