Transcript Principles Of Tympanoplasty

By : Dr. Supreet Singh Nayyar, AFMC
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Tuesday, July 17, 2012
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
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 advances
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Era of Experimentation
19th century
Era of Opposition
Late 19th & early 20th century
Era of Revival
1920’s
Era of Reorientation
1940’s - 1960’s
Era of Modernity
From then on.....
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
Ossicular coupling
 Hydraulic lever
 Ossicular lever
 Catenary lever

Acoustic coupling
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
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 / fluid
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“ 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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


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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
Minimalistic techniques
◦ Cauterization & fat plug
◦ Cauterization with trichloroacetic acid
◦ Sealed tympanostomy tubes

Formal Tympanoplasty
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
1956◦
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Type
Type
Type
Type
Type
Wullstein
1
2
3
4
5
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
Mirko Tos
◦ 1 - Intact chain
◦ 2 – Short columella
◦ 3 – Long columella
◦ 4 - Sound protection
◦ 5A - Fenestration
of LSCC
◦ 5B - Platinectomy
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
Conductive hearing loss due to TM perforation
or ossicular dysfunction

Chronic or recurrent otitis media
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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)
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Absolute
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Uncontrolled cholesteatoma
Malignant tumors
Unusual infections
Intracranial complications
Relative

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Eustachian tube dysfunction / OME in other ear
Dead ear
Only hearing ear
Elderly patient
Very young children
Repeated failures
Uncooperative patients
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
Extent & location of perforation

Ossicular status

Counseling
◦
◦
◦
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Nature of disease
Treatment options
Outcomes of surgical options
Post op morbidity – restriction of water activities,
hearing deterioration
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
Transcanal

Endaural

Postaural
◦ Posterior moderate sized perforations
◦ Favorable EAC anatomy
◦ Visualisation of annulus & ant sulcus is difficult
◦ Limited atticotomy
◦ All perforation sizes
◦ Better angle of visualisation
◦ Second look ossiculoplasty
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
Lateral / Overlay

Medial / Underlay

Over-Underlay
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Overlay

Adv

Disadv
◦ Exposure of anterior
meatal recess
◦ High take up rate
◦ Middle ear volume not
reduced
◦ Precision is required
◦ Long healing time
◦ Blunting / lateralization

Underlay

Adv

Disadv
◦ Less blunting or
lateralization
◦ High graft take up in
experienced hands
◦ Simpler technique/less
time consuming
◦ Limited visualisation of
ant meatal recess
◦ Less suitable for large
ant perf
◦ Difficult in small EAC
with per meatal
approach
◦ Reduction in ME space
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
Review of Underlay versus Overlay tech *

Review of Overlay tech**

Review of Underlay versus Overlay tech***
◦ Re-perf rate - 36% Overlay, 14% Underlay
◦ Hearing improvement – 62% Underlay, 27% Overlay
◦ Complication rate less in Underlay
◦ Graft uptake 97% - Temp fascia, 84% -Canal skin
◦ Rate of Ant blunting & Lateralization 1.3%
◦ AB gap within 10 dB – 80%
◦ 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)
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 Autografts
◦ Skin
 Canal skin
 Pedicled
 Free
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Heterotopic skin graft
Periosteum
Vein
Temporalis fascia
Fatty tissue
Tragal perichondrium & cartilage
Subcutaneous tissue
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Allografts
◦ Historical

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Amnion
Cornea
Duramater
Peritoneum
Pericardium
Aorta valves
Ear drum

Xenografts
◦ Historical
 Bovine
 Periostem
 Drum
 Jugular vein
◦ Lyophilised dura
◦ Cartilage
◦ Fascia
◦ Risk of HIV, Hepatitis B,
Creutzfeldt Jacob
disease
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◦ Technical/surgeon errors
◦ Infectious complications
◦ Poor tubal function
◦ Patient factors
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
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
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Bone

Adv
◦
◦
◦
◦

Immediate availability
Biocompatibility
Low cost
Low extrusion rate
Cartilage

Conchal /Tragal
Cartilage
Disadv
◦ Disease recurrence
◦ Fixation to adjacent
structures
◦ Skill & time to shape
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
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Irradiated Ossicles
En Bloc TM with attached Ossicles
Risk of disease transmission
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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)
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Bioactive
◦ Bioactive glass – Bioglass, Ceravital (1970’s)
◦ CaPO4 Ceramic - Hydroxyapatite
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


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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
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
Choice of prosthesis / placement
◦ Ossicular status
◦ Med – lat distance / vertical position
◦ Retracted umbo – severing of tensor tympani
tendon
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
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
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
Ossicular status
◦ Lenticular process missing
◦ Tip of Incus missing
◦ Long process of Incus missing
 Stapes superstructure +/ Malleus handle +/-
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
Intrinsic factors
◦
◦
◦
◦
Status of ossicular chain – mobility
Severity of disease
Eustachian tube function
Adequate control of allergy
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
Extrinsic Factors
◦ Surgical technique
◦ Design of prosthesis
◦ Composition of prosthesis
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◦ 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
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
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 )
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
Tympanostomy
◦ Rarely at the time of TM grafting
◦ Maybe during follow up if effusion or
retraction develops
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


Teflon / Silicone pieces
Silastic sheet
Biodegradable materials
◦ Gelfoam
◦ Gelfilm
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“ Fiction & fact need untangling,
otherwise,
surgeons are little better than gossips ”
:Gordon Smyth

Tympanoplasty Reporting Protocol based
on AB gap (Kartush)
AB gap
0 – 10 dB
10 – 20 dB
20 – 30 dB
>30 dB
Result
Excellent
Good
Fair
Poor
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
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 )
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◦ MERI
0
Normal
◦ MERI
1-3
Mild disease
◦ MERI
4-6
Moderate disease
◦ MERI
7-12
Severe disease
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
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
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 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
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

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
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◦ 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
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




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
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
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



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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