Drum Membrane Research Articles

Stapedectomy and Tympanoplasty: PART II: TYMPANOPLASTY

<h3>Introduction</h3> In the tympanoplastic reconstruction of the ear drum the skin of the external auditory canal and vein or fascia grafts have proven to be the best available tissues. The canal skin and vein may be used either singly or in combination. If the perforation involves less than one-half of the tympanic membrane, either the canal skin or the vein are used singly. In the small perforations, most otologists prefer the vein alone. When the perforation involves more than one-half of the tympanic membrane, I prefer to use the sliding canal graft combined with vein or fascia. The sliding canal graft may be the superior or inferior skin of the external auditory canal. The superior sliding canal graft is essentially a fenestration-type flap with the elevation in continuity of the squamous epithelium from the outer portion of the drum membrane. The endomeatal graft utilizing the skin of the superior anterior

Results of tympanoplasty.

I will occupy myself with the otological results of tympanoplasty as I see them today. In Figure 1, I remind you of the classification which I have suggested. There is a certain mix-up in classifications, and each of us tries to have his own. This makes it very difficult to compare results. In my type, I have tried to classify only according to the physiology of the reconstructed middle ear. There is nothing in my classification about pathology. In Type I, there is just a defect of the drum, and I have only to restore the drum membrane; the ossicular chain is intact. In Type II, there is not only a defect in the drum but a little defect in the chain, where we lose theoretically 2.5 db., owing to disturbance of the leverage. The same loss theoretically occurs in Type III. In Types II and III there is very

THE EXPERIMENTAL STUDIES ABOUT THE INFLUENCE OF THE NEGATIVE AIR PRESSURE IN THE MIDDLE EAR CAVITY UPON THE COCHLEAR ELECTRIC RESPONSE.

The experiments were performed on several living cats, in whose middle ear cavities the negative air pressure was caused by means of drawing the air directly out, pressing it into the external auditory meatus, or simultaneously giving the equal negative pressure into the external auditory meatus and the middle ear cavity.The results were as follows:(1) The decreasement of the air pressure in the middle ear cavity caused by drawing the air directly out as well as pressing it into the external auditory meatus reduced evidently the cochlear electric response, and generally low tones showed clearer effects than high tones.(2) On these experiments, some enhancement of the response was recognized at 2000, 4000, and 8000cps by certain valus of the negative pressure.(3) There was no distinct difference between the effects of the negative air pressure in the middle ear cavity and that caused by the positive air pressure in the external auditory meatus.(4) At the negative pressure of 4cm height of mercury given simultaneously in the external auditory meatus and the middle ear cavity, the decreasement of the cochlear electric response was generally about 2db.(5) Therefore the influence of the negative pressure in the middle ear cavity upon the hearing ability is considered mainly on the transmission system of the drum membrane and the ossicular chain.

Standard controls of the middle ear in tympanoplasty.

The author pursued the causes of failure in tympanoplasty by performing revision operations in 65 failed cases of tympanoplasty, and on these an attempt was made to clarify the operative controls necessary to avoid the failure in tympanoplasty. Thus, he suggests that the following controls be adopted as standards in all cases of tympanoplastic surgery: 1. The antrum and mastoid control, 2. The perilabyrinth control, 3. The ossicular chain control, 4. The epitympanum control, 5. The oval window control, 6. The round window control, 7. The tympanic sinus control, 8. The meso-tympanum control, 9. The hypotympanum control, 10. The tube control, 11. The drum membrane control. By adopting these 11 controls of the middle ear we can perform tympanoplasty with the object of satisfying both elimination of infection in the middle ear and restoration of hearing.

Calcification and Cicatrix of Drum Membrane (Part 1)

Calcification and Cicatrix of Drum Membrane (Part 1)

The surgical treatment of chronic suppurative otitis media.

Although suppurative otitis media has been one of the oldest problems of otology, uncertainty still continues not only as to how to handle a given patient but also as to what constitutes the disorder. Diamant 1 considered it impossible to give a definition that would cover both the clinical and pathologic aspects of the condition known as chronic suppurative otitis media. Attempts to define it as a perforation of the drum membrane with intermittent or discharge resulted in such advice as that of Sir Charles Ballance, 2 who suggested that radical mastoidectomy with skin grafting should be done in any case of suppurative otitis media for the safety of the patient. He based this advice on an analogy to osteomyelitis of other bones and asked what surgeon would advise that a suppurating sinus tract be neglected. He was obviously lumping several distinct clinical and pathologic types

Experiences with Transossicular Mobilization of the Stapes

This is a further report on a method of mobilizing the stapes for the improvement of hearing in otosclerosis which does not require an incision and opening into the middle ear cavity. It has proved successful in 58% of selected cases. Recorded attempts to improve hearing date back to the works of Celsus.2It can be said that surgical measures to overcome deafness began in 1801, when Sir Astley Cooper3advocated perforating the ear drum membrane for deafness owing to obstruction of the Eustachian tube. He reported the results in 20 cases. Thereafter for many years the tympanic membranes were opened or removed in the hope of improving hearing. Subsequently, the ossicles, one or all, were removed. In 1876, Kessel6attempted to mobilize the fixed stapes footplate. His ideas were followed by many others; notable among them were Miot,8Blake,1and Jack.5 Probably because

Functional Recovery and Structural Repair Following Acoustic Overstimulation of the Guinea Pig Ear

Two series of guinea pigs were used in this study in order to investigate the nature of repair or further deterioration of the structures of the Scala Media following acoustic overstimulation. Each animal was first tested for sensitivity by determining the pressure level of sound necessary at each of 12 frequencies to produce 1 micro-volt of electrical response as recorded by a platinum foil electrode at the round window, and for linear range of the ear's response by recording the level at which the recorded potentials began to become nonlinear. Following this the ear of the animal was stimulated with a uniform spectrum of noise: the first series at 150 db above 0.0002 dyne/cm2 and the second at 138 db, measured at the drum membrane by a probe-microphone calibration system. Sensitivity and linear range were again measured, the operative wound closed, and the animal allowed to recover for 56 days, at which time it was reoperated and the above measures made again. The animal was then sacrificed by intra-vital perfusion of Maximow's fixative and the temporal bones removed for histologic processing. All specimens were eventually cut and mounted serially so that graphic reconstructions could be made for comparison of the anatomical condition of the structures of the Scala Media with the functional changes as measured electrically. It appears that individual susceptibility to damage is more a function of the ear's ability to recover than it is of structural weakness. One cannot predict on the basis of initial loss alone, regardless of level of stimulation, whether the ear will, with time, recover some sensitivity or lose it. The determining factors do not show up histologically in a normal ear because they are probably related to the nutrition of the sensory cell. These conclusions and others will be discussed in the light of the experimental evidence.

The effect of ointment prosthesis on fenestrated ears.

The fact that prosthetic devices applied within the ear often produce noticeable improvement in the hearing is well known. Artificial drums, 1 patches over perforations of the tympanic membrane, 2 and tamponades properly inserted into the middleear cavity 3,4 have all proved effective in selected cases. Substantial evidence has accumulated indicating that (in cases with large tympanic perforations, radical mastoid cavities, etc.) obstructing the pathway to the round window can increase acuity. 5,6 Guild noted that hearing seemed less impaired in the face of marked damage to middle-ear structures when the round-window niche was filled with scar tissue, 7 and Hughson 8 developed a surgical procedure for obstructing the round-window niche with transplanted fascia. Most recently, Kobrak has developed the technique of applying a bland ointment to the round-window niche in cases where there is conductive loss with extensive destruction of the drum membrane. 9,10 Kobrak's technique has the advantage

Mobilization of the stapes for otosclerotic deafness; preliminary report on two years' experience.

MOBILIZATION of the ankylosed footplate of the stapes in otosclerotic deafness has been employed for the past two years to restore hearing. The following report of this work is presented at this time to answer two questions which are basic in the evaluation of any surgical technique for the relief of deafness: first, can the operation restore socially useful unaided hearing; and second, will the restored hearing last? In a recent publication one of us (S. R.)¹described a method of palpating the stapes as a means of determining suitability for fenestration. This was done through an ordinary ear speculum in the external auditory canal with the area under local anesthesia. After the lower half of the drum membrane was elevated and the incudostapedial joint exposed, the degree of fixation of the stapes was determined by palpating it with a probe. On April 3, 1952, the above procedure of palpation of the stapes in a case of otosclerotic deafness suddenly resulted in a return of acute hearing. It seemed that while this fixed stapes was being palpated the footplate was accidentally mobilized. This patient had been carefully studied in several audiology centers prior to this incident and had been found to be ideal for the fenestration operation. Hearing tests made shortly after the mobilization of the stapes revealed normal hearing, which has been maintained to the time of this writing. This case (Case 1, E. L.) is described fully in the Report of Cases.

Tic douloureux of the chorda tympani.

HUNT 1 IN 1907 first described what he called neuralgia after his observation of herpes together with sensory changes and pain accompanying peripheral facial paralysis. He stated that the primary disorder was in the ganglion and compared it with the motor and sensory phenomena of Gasserian ganglion neuralgia. He outlined the anatomic area and called it the geniculate zone, a cone-shaped area including the drum membrane, the external auditory canal, the entrance to the canal, and the concha, tragus, antitragus, and antihelix. He stated that the 9th and 10th cranial nerves contribute to sensation in this area. Clark and Taylor, 2 in 1909, reported a case of tic douloureux involving the sensory portion of the seventh cranial nerve (nervus intermedius). His patient, a woman aged 28, had severe tic-like spasms of pain immediately in front of the left ear for two years and a steady pain deep in

Anesthesia of internal ear following application of topical anesthetic to middle ear.

IN THE treatment of patients with a perforated drum membrane, it is customary to apply a moderately caustic solution, such as 10% silver nitrate, by means of a cotton-tipped applicator to the edge of the perforation. It happens occasionally that some patients experience severe pain following this treatment. To render this treatment tolerable to such patients, it has been my custom to apply to the perforation a pledget of cotton moistened with a topical anesthetic prior to the application of silver nitrate. Two of the patients so treated have experienced transitory anesthesia of the internal ear. One experienced deafness; the other, vertigo. The case reports follow: Case1.—J. B. M., a 20-year-old white youth, was under treatment for bilateral otitis externa in July and Aug., 1947. During the course of treatment, the canal and drum of the left 32 Audiogram showing results of application of topical anesthetic to middle ear.

A method of distinguishing conductive deafness from perceptive deafness; preliminary report.

REPORTS have already been made on various methods of distinguishing conductive deafness from perceptive deafness in the hearing test. Especially in recent years, examinations applying Fowler's recruitment phenomenon are being employed for this purpose. In the present article we intend to introduce a new Chart 1.—Mean values of hearing acuity in five normal ears ( A ) before and ( B ) after instillation of glycerin. method that is altogether different from those that now exist for distinguishing between perceptive and conductive deafness. This method is a very simple one that almost any otologist can easily try in his testing room: First an audiogram of the ear to be tested is recorded, and then the same test is carried out on the same ear after the instillation of 8 drops of glycerin into the canal, care being taken to place the head in such way that the ear is up and the drum membrane

Primary cholesteatoma of the mastoid.

A TUMOR which resembled a primary or true cholesteatoma of the mastoid was observed in an elderly man. Roentgenograms suggested a secondary cholesteatoma, but histological examination established the diagnosis of primary cholesteatoma without cholesterol crystals. REPORT OF A CASE M. C., a 72-year-old man, came to the hospital with complaints of a swelling behind his right ear which had lasted for the previous three months and occasional slight dizziness. His past history showed that he had always had excellent health and his condition had been good except for some stomach ulcers which he had had a number of years ago. He had also received some shotgun wounds in his neck and chest about 25 years ago, which were accidentally discovered during the x-ray examination. He never had any ear complaints or discharge, pains, or the like. Examination of his ear revealed perfectly normal drum membranes without any perforation or scars.

Squamous cell carcinoma secondary to cholesteatoma.

THE FOLLOWING report is of a case of squamous cell carcinoma found in the mastoid antrum and middle area which had developed secondarily from cholesteatoma of the middle ear. REPORT OF A CASE R. C. C., a 38-yr.-old man, was seen on Jan. 10, 1950, with an exposed cholesteatoma protruding through a fistulous erosion (1 cm. in diameter) which had perforated the outer table of bone and the skin approximately 1 cm. posterior to the antrum area of the left mastoid. His past history was that after a bad fall on his head at the age of 2 yr., his left drum membrane was perforated, and he has had intermittent drainage from the left ear since then. Several weeks before admission he had a complete facial paralysis on the left side which still existed at the time of examination. An aural polyp was discovered during examination of the left external

ENDAURAL RADICAL MASTOIDECTOMY FOR CHRONIC MASTOIDITIS

THE OTOLOGIST who is consulted by a patient with a chronically discharging ear must first make a study of the pathologic condition present. In some cases of continued aural discharge, the pathologic process may be of no danger to the patient's life; whereas in other cases there is found an extremely dangerous situation awaiting only an acute exacerbation, which may lead to serious intracranial complications and threaten the life of the patient. The locations of the perforations in the membrana tympani and the character of the discharge are of significance. Perforations in the anterior inferior quadrant, or so-called tubal perforations with an odorless mucoid type of discharge, are, as a rule, due to nasopharyngeal infections and are not considered serious. Central perforations of the drum membrane with a mucoid type of odorless discharge are usually due to mucosal infections confined to the middle ear itself and may not be dangerous.

RECOVERY IN OTITIC PNEUMOCOCCIC MENINGITIS

A woman aged 55 retained good hearing practically unchanged after removal of the malleus, incus and drum membrane during the course of acute otitis media, mastoiditis and meningitis. She had been examined a month prior to her present illness, when her hearing for the whispered voice was within normal limits but audiometric examination showed moderate decibel loss bilaterally. Subsequent examinations were made with the same audiometer and under the same conditions. The initial cell count of the spinal fluid was 9,000 per cubic millimeter. It is recognized that the higher the count and the older the patient, the less the chance for recovery. The intracranial pathway of extension of the tympanomastoid infection was not demonstrable at the time of operation; it may have been through venous channels. Various routes of intracranial extension, such as via the subarcuate fossa from infected parantral cells, through the dura beneath the gasserian ganglion and

RHABDOMYOSARCOMA OF THE MIDDLE EAR

Although malignant growths of the middle ear do not occur frequently, various types of such tumors have been reported in the world literature. The case presented here is of special interest because no such case was found reported in the available literature. REPORT OF A CASE A Negro girl aged 3 was admitted to Babies Hospital on Jan. 10, 1945, with paralysis of the left side of the face and slight bleeding for five days from a tumor in the left external auditory meatus. The family and past histories were noncontributory. Examination .—The patient was a well developed, thin child weighing 14 Kg. There was complete paralysis of the left side of the face. Cervical nodes were palpable in both the anterior and the posterior region. Examination of the left ear revealed a finger-like mass protruding from the external auditory canal. The drum membrane could not be visualized. The other

THE HEARING AID IN MIXED DEAFNESS

IN THE fitting of a hearing aid the conductive and the perceptive type of deafness offer less difficulty than the mixed type. To simplify matters, some audiologists have subdivided the patients with mixed deafness into conductive-perceptive and perceptive-conductive groups. Most commonly in cases of mixed deafness the otoscopic picture is that of chronic adhesive otitis media. There is frequently a large perforation in the drum membrane with absence of the greater part of the malleus and incus. The inner wall of the middle ear is excessively thickened, and bands of adhesions run from one intratympanic structure to another. The accompanying illustration is the typical audiogram of mixed deafness. There is a profound hearing loss for the high tones, but bone conduction is better than air conduction for the lower frequencies. From a study of 12 patients with mixed deafness, in regard to the selection of a hearing aid, several generalities

ORIGIN OF THE CALORIC REACTION OF THE LABYRINTH

SINCE 1906, when Barany 1 wrote his paper on the caloric reaction of the labyrinth, which made this test one of the most generally employed methods of examining the labyrinth, many theories have been proposed concerning the cause and origin of the vestibular reactions elicited by irrigation with water of a temperature different from that of the body. If these theories are mentioned here, this is done for the present without any comment as to their respective importance. Barany 1 was the first to offer a theory to explain the phenomena of the caloric reaction. In his opinion, the change in temperature at the drum membrane caused by the syringing is conducted toward the semicircular canals by the structures in the temporal bone. The first canal reached is the horizontal one in its most lateral part. When a change of temperature occurs here, the endolymph in this special spot is likewise influenced;