A conservative one-stage method of surgically correcting chronic intractable otitis media in children who have failed antibiotic therapy

Abstract

The manifestations of chronic otitis media with an associated dysfunction of the eustachian tube include chronic atelectasis of the middle ear; formation of retraction pockets, cholesteatomas, or cholesterol granulomas; tympanosclerosis; ossicular fixation or erosion; and hearing loss. 1-3 In countries where early medical and surgical intervention are not readily available, life-threatening complications are often observed, including abscesses of the brain or petrous apex, or cholesteatoma that penetrates the cranial vault. However, even early and aggressive antibiotic therapy, in some forms of chronic otitis media, may not prevent the above complications. The necessity for repeated placement of ventilation tubes indicates that the underlying process requires a more assertive treatment than temporarily reventilating the mesotympanum. There are often underlying anatomic variations that can create obstructive sites within the middle ear cleft. These sites can easily be obstructed by adhesions, hypertrophic mucosa, or chronic granulation tissue. Our flexible approach tympanoplasty was developed as a conservative surgical method for systematically identifying (evaluating) and treating these anatomic and pathological factors that contribute to chronic otitis media. The schematic in Fig I depicts sites of obstruction which the surgeon must evaluate in the process of performing the procedure. Figure 1 shows anatomic sites that may, as a result of bony anomalies, be predisposed to narrowing and obstruction. Therefore, indigenous bony obstruction may create a critical mass effect whereby relatively small amounts of mucosal hypertrophy would render a particular anatomic site completely dysfunctional. The development of chronic otitis media can be influenced by sites of obstruction along the middle ear cleft, at the protympanum, mesotympanum (prominent promontory or retraction of the malleus), isthmus, attic, aditus ad antrum, or mastoid air-cells. Obstruction of the eustachian tube can create a generalized pathological environment in the middle ear and mastoid. The combination of a high promontory and a retracted long process of the malleus can be found in many patients with chronic otitis media, leading to an obstructive site in the mesotympanum.