Marginal Perforations Research Articles

Influence of coexisting myringosclerosis on myringoplasty outcomes in children

To obtain information on the success rate of tympanoplasty with concomitant myringosclerosis. The medical records of 40 children with myringosclerosis (23 girls, 17 boys; age range six to 16 years, mean age 9.85 years) who had undergone primary tympanoplasty were retrospectively studied. Surgical success was defined as the perforation remaining closed 12 months post-operatively. Sclerotic plaques occupied whole remnant eardrums in 17 patients, and were located in various parts of the eardrum in 23. Tympanosclerosis associated with myringosclerosis was present in six patients. The success rate of primary tympanoplasty was 92.5 per cent. All three surgical failures were observed in girls with marginal perforations. These children underwent successful revision procedures for their residual perforations, variously at four, eight and 10 months after the initial surgery. Appropriate freshening of the perforation edges, with removal of sclerotic plaques, can result in a high rate of successful closure of perforated tympanic membrane with coexisting myringosclerosis.

The posterosuperior quadrant of the tympanic membrane

Objective To document the anatomic relationship of the posterosuperior segment of the tympanic membrane. Study Design Point-prevalence study of postmortem material. Subjects and Materials One hundred seventy temporal bones from adults without history of otologic pathology were studied. The anatomic details of the tympanic membrane were observed, histology was documented on 30 sectioned bones, and, with the use of the scanning electron microscope, lamina propria was studied in 40 bones. Results We established that the posterosuperior quadrant was the largest, representing 28.7 percent of the total area of the eardrum. This feature implies that this quadrant is more likely than are the other quadrants to exhibit changes prompted by pressure challenges. We also verified that the posterosuperior part of tympanic sulcus, above the chorda tympanic nerve, lost its depth in an unexpected way in 60 percent of the cases. In association, we established that at this level there was a decrease in annulus caliber. In 25 percent of cases, by the absence of the circular fibers of lamina propria, the posterosuperior quadrant had only the radial fiber layer. Conclusions Anatomic and morphologic details in posterosuperior quadrant were newly described and may explain the greater incidence of retraction pockets and marginal perforations that provide origin for the cholesteatoma.

S221 – The Postero‐superior Quadrant of the Tympanic Membrane

Objectives The purpose of this study was to document the anatomic relationship of the postero-superior segment of the tympanic membrane and its clinical implications. Methods 100 temporal bones from adults without history of otologic pathology were studied. The morphological and anatomical details of the tympanic membrane were observed in 70 bones, which implied the use of macroscopic sections of the bones. The histological results were documented in 30 serially sectioned bones, stained previously with hematoxylin-eosin. Results We established that the postero-superior quadrant was the largest in size, with a mean dimension of 21.05 mm2, which represents 28.7% of the total area of the tympanic membrane. This feature implies that this quadrant is more exposed to pressure changes. We also verified that the posterosuperior part of the tympanic sulcus, above the chorda tympanic nerve, lost its depth in an unexpected way (60%) or that it gradually diminished from 0.9 to 0.5 mm until it disappeared near the posterior tympanic spine. In association, we established that at this level there was a decrease in the annulus caliber. Additionally, in 25% of cases, given the absence of the circular fibers of lamina propria, the postero-superior quadrant had only the radial fiber layer. Conclusions Anatomic and morphologic details in the postero-superior quadrant were newly described and may explain the greater incidence of retraction pockets and marginal perforations that provide the origin of cholestheatoma.

“Window Shade” Tympanoplasty for Anterior Marginal Perforations

Anterior marginal perforations of the tympanic membrane often present a reconstructive challenge to the otolaryngologist. Poor surgical outcomes are often due to inadequate exposure, a lack of residual tympanic membrane, impaired vascular supply, and delayed healing. This study reports on the success of the "window shade" technique, combining aspects of both the traditional underlay and overlay tympanoplasty techniques, for the management of anterior marginal tympanic membrane perforations. Retrospective review of patients undergoing window shade tympanoplasty from July 1, 1994, to July 1, 2003, at a tertiary care referral center. Only patients found to have anterior tympanic membrane perforations and who underwent a window shade tympanoplasty were included in the study. Tympanoplasty success rate was studied by examining postoperative complications of recurrent perforation, tympanic membrane lateralization, or anterior blunting. The authors identified 164 patients who underwent window shade tympanoplasty during the study period. The overall success rate for tympanic membrane repair was 94.5%. There were no cases of tympanic membrane lateralization or significant blunting. The average healing time was 4 weeks. The surgical technique is described in detail. The window shade tympanoplasty is an excellent surgical option for repair of anterior marginal perforations of the tympanic membrane.

Immediate repair of the tympanic membrane to prevent persistent perforation after intentional removal of long-lasting tubes

Our purpose was to evaluate efficiency of immediate repair of the tympanic membrane perforation after intentional removal of the long-lasting tubes. This study was done in 36 ears of 27 patients who had either Goode-T or Paparella-II silicone tube insertion due to chronic OME or ROM and tube removal. Only the ears in which tube removal was performed due to no longer need for middle ear ventilation were included to the study. After removal of the tube, the perforation edges were refreshed and Steri-Strip (3M) patch was adhered on the perforation site. Otoscopic, tympanometric and audiologic data were reported. Mean duration of the tube persistence was 49.58+/-11.94 months. It was found that there were two subgroups in the study group: those under regular follow-up (20 ears), and the ears which were out of regular follow-up (16 ears). Mean tube persistence times were 34.10 and 52.11 months in these subgroups, respectively (chi2-test, p=0.056). In six ears (16.67%), persistent perforation (PP) was found. PP rate (PPR) was higher in group-B (25%) than in group-A (10%) (chi2-test, p>0.1). The rest perforation was anteriorly marginal in five of six PP (83.33%). The PPR in the ears in which rest perforation was anteriorly marginal was 35.71% (5/14) while it was 4.54% (1/22) in the ears with central rest perforation (chi2-test, p<0.02). Even immediate repair of the perforation after removal of the long-lasting tubes resulted in a high PPR. The data in this study documented that this high PPR was associated with type and localisation of rest perforation and tube persistence time. Anteriorly, marginal perforations had about eight times higher risk of PP and longer tube persistence caused higher anterior marginal perforations after tube removal.

Spontaneous healing of various tympanic membrane perforations in the rat

Objectives—To investigate the spontaneous healing process of various types of perforation and the location of the epithelial generation center in the tympanic membrane of rats.Material and methods—Various types of perforation were made in the ears of 50 rats and the healing process was observed using light and electron microscopy.Results—Epithelia hyperplasia could not be seen at the edge of the perforations, but occurred in the annulus and handle of malleus regions during the early stage of healing. There was no correlation between the healing time and the size of the perforations. When one ear was perforated, no changes were observed in the intact ear on the other side. The epithelium did not migrate into the tympanic cavity in the posterior marginal perforations. All the perforations healed, although the manubria of the malleus were damaged.Conclusions—The perforations healed by means of epithelial migration. The epithelial generation center was located near the annulus and the handle of the malleus, and therefore protection of these two regions is very important in middle ear surgery.

Type 1 Tympanoplasty in Benin: a 10- year review

A review of type 1 Tympanoplasty operations (myringoplasty) done on thirty (30) ears in the University of Benin Teachinhg Hospital, Benin City, (UBTH) during a ten - year period was carried out. The patients were aged 21 to 69 years, and consisted of 21 males and 9 females. 15 (50% ) of the ears had medium to large sized central perforations whilst 13 (43.3 % ) were subtotal perforations. Two cases (6.6% ) had marginal perforations. The overall success rate in terms of full graft take was 66.6%, whilst 32.3 % had partial take of the graft. Post operative audiograms showed improvement in hearing in 77% of those cases for which records were available. However long term outcome both for graft take and hearing improvement was impossible to establish due to poor follow-up compliance in the majority of patients. Although there are many cases of chronic suppurative otitis media (CSOM) with resultant persistent tympanic (TM) perforation and concomitant hearing defect in the community, the relutance or inability of patients to have reconstructive ear surgery, relative lack of the facilities for the operation in our hospitals and poor follow-up compliance amongst our patients are some of the identificable problems related to this otherwise worthwhile procedure.

Etiopathogenetic aspects of recurrent cholesteatoma development

The causes of cholesteatoma development have been interpreted in different ways. The object of our study was to present the most frequent causes of recurring cholesteatomas on the basis of our investigations. The prospective study carried out at the Institute for Otorhinolaryngology and Maxillofacial Surgery included 120 patients treated surgically for cholesteatomas. Seventy-five patients were cured after the first operation, while 45 were reoperated after recurrent cholesteatoma.The modified student t test was used to establish the difference between statistically significant groups (small independent sample proportion). The cholesteatoma was often localized in attic (25.3%) and was spreading into antrum (28%). Another group of cholesteatoma was more frequently present in mesotympanum. The small marginal perforations in back quadrants were noted more frequently in the second group (26.7%). Likewise, 40% of the patients from this group had intact chain of auditory ossicles. Destruction of all three auditory ossicles was more often in the first group. Polypoid mucosa was less detected in the first group (18.7%) in relation to the second group (46.7%). Canal wall-up tympanoplasty was used more commonly in the second group of patients.In patients treated surgically for cholesteatoma, the recurrence of the condition may be caused by different factors such as development of cholesteatoma in posterior parts of cavum, polypoid mucosa, localization of cholesteatoma in meso- and retrotympanum and obscured cavity recesses, intact chain of auditory ossicles and the application of close tympanoplasty.

The Relationship between Traumatic Tympanic Membrane Perforations and Pneumatization of the Mastoid

We evaluated the possible relationship between tympanic membrane perforations resulting from blast trauma or slap and pneumatization of the mastoid cells. A total of 25 male patients with tympanic membrane perforations resulting from blast injury (n = 7), slap (n = 17), and football hit (n = 1) and 20 healthy male volunteers without any ear problem had temporal bone computed tomographic scans in the axial plane, parallel to the infraorbitomeatal line, with 2 mm slice thickness and 2-mm intervals using bone algorithm with a ProSpeed Spiral tomography machine. The area of air cells in each slice was measured using trace and area measurement functions of the tomography machine, and by multiplying the resulting area by slice thickness, the volume of each slice was calculated. For each ear, the total of volumes of air cells was calculated by adding the volumes of each slice containing air cells. The calculated volumes of mastoid cells were evaluated by comparing microscopic findings. Both patient and control groups consisted of males, and their ages ranged from 17 to 32 (mean 24.5) years. Microscopic examinations revealed that perforations were frequently located in the lower quadrants and that most of them were less than 3 mm. There were no pars flaccida and marginal perforations. Ossicular chain destruction was noted neither in temporal bone tomographic nor during intraoperative examinations. The mean (± SD) volumes of right and left ear mastoid air cells in patient and control groups were 6.92 ± 2.45 vs. 7.00 ± 2.59 cm³ and 9.04 ± 4.55 vs. 8.95 ± 4.53 cm³, respectively, and the differences were not statistically significant. It was found that the level of mastoid pneumatization has no statistically significant effect on tympanic membrane pathologies due to blast or other injuries.

Tympanoplasty: Factors Influencing Surgical Outcome

We reviewed the records of 183 patients who had undergone myringoplasty during a six year period at the Asir Central Hospital (ACH). This study was limited to cases of repair of uncomplicated perforation of tympanic membrane that did not require ossiculoplasty or mastoidectomy. One hundred and thirty-four (73.2%) were successful myringoplasty and 78 (75.7%) patients had their hearing improved postoperatively. Various factors liable to influence the success rate such as status of middle ear, size and site of perforations, surgical approach and presence of tympanosclerosis were analyzed. Only status of the middle ear and the presence of tympanosclerosis at the time of surgery were found to have a major effect on the final outcome of surgery.

The anterior marginal perforation

The anterior tympanomeatal angle remains the main problem area in anterior marginal perforations with both conventional onlay and underlay techniques. Here we describe a variation of Gerlach's quilting technique to overcome the problem and this modification has proven to be both simple and effective. When the graft is prepared a small tag is fashioned anteriorly and later pulled through a small tunnel under the anterior-superior annulus. This prevents the graft falling away anteriorly without producing the blunting associated with more extensive undermining of the anterior annulus.

Some considerations on middle ear cholesteatoma in 'foreign workers'.

The treatment of cholesteatoma in patients without a permanent residence or in medically underdeveloped countries presents a serious problem in middle ear surgery. Methods which erradicate disease safely and reduce the risk of recurrence to a minimum are necessary. We differentiate 3 clinical types of cholesteatoma: 1 Retraction of Shrapnell's membrane or in the postero-superior quadrant with very little cholesteatoma lateral to the ossicles. A transcanal technique is used to evert the cholesteatomatous pocket into the meatus intact, followed by reconstruction of the outer attic wall. 2 Circumscribed cholestatoma lateral and often also medial to the ossicles. Combined approach tympanoplasty is used in such cases. 3 Marginal perforations with large cholesteatomas, situated medial to the ossicular chain. For these ears, classical radical mastoidectomy is the method of choice. (Radical mastoidectomy also has to be performed in all cases of type II, where luxation of the matrix in toto has failed.) No recurrence has been detected in cases where follow-up was possible.

Pathogenesis of attic cholesteatomas.

An attic cholesteatoma is defined as an epidermoid cyst found in the attic. Stratified squamous epithelium may also be present in the middle ear as other clinical or pathological entities, such as metaplastic islands of the mucosa in chronic ears with central perforations or as a collapse of an atelectatic drum. Histological examination of 22 temporal bones with attic cholesteatomas has shown them to reside mainly medial to the ossicular chain. This explains the difficulty they have in self-cleansing, as well as the ensuing secondary infection. When a similar process occurs lateral to the ossicles, a self-cleansing nature's atticotomy may be formed. The aetiology ofan attic epidermoid cyst, i.e. an attic cholesteatoma, is usually considered to be an invasive retraction from the external ear. However, it is difficult to accept invasion ofexternal canal skin into the upper medial attic (often through the scutum). This is especially so in the face ofsucb biological phenomena as epithelial contact inhibition, or the invariable outward migration of stratified squamous epithelium from the edges of retraction pockets as well as from cholesteatoma perforations. Also, large cholesteatomas usually present themselves from the ‘beginning’ simultaneously with their perforations; no documentation of an evolving process from a pre-existing perforation exists at present. Marginal perforations which have later cvolved into attic cholesteatomas have so far not been documented. Therefore, the possibility that an attic cholesteatoma often arises primarily in the attic and presents itself secondarily in the external canal as a ‘perforated’ epidermoid cyst, is to be considered. The possibility that a congenital rest is responsible for the epidermoid cyst has often been put forward, but evidence that such rests actually exist has not yet been presented. The frequency with which cholesteatoma sacs (including the congenital type) show mucosal cells as part of their lining, suggests a metaplastic phenomenon, This means that the epithelial cells in question may have changed from mucosal into keratinizing cells or vice versa. Metaplastic changes of mucosas into keratinizing epithelium occur very frequently in the bronchi, nose, ears and genitourinary system. Epidermoid cysts may, therefore, be seen as an analogous formation to glandular cysts in the attic - the latter being very frequently found in the attic in chronically infected ears. Such ‘organ’ formations (glands or epidermoid cysts) may arise when their respective cells (forming mucus or keratin) grow in the midst ofconnective tissue rather than on the surface. Budding of cells, giving rise to epidermoid cysts, is occasionally found in chronically-infected ears adjacent to cholesteatomas.

Central perforations-safe or unsafe?

An analysis of 227 consecutive tympanomastoldectomies was undertaken to compare the types and degree of middle ear pathologic features that are found behind central perforations as compared with attic or marginal perforations. In this series, little difference was found between the two groups. A great deal of disease occurred behind all types of tympanic membrane perforations. Near-normal audiogram results did not guarantee a normal middle ear. Central perforations are not necessarily safe and should be treated with the same caution as attic or marginal perforations.

Atticotomy: a neglected otosurgical technique.

Transmeatal atticotomy was a popular surgical procedure during the turn of the century. Due to its limited success it was replaced by the modified radical mastoidectomy. An investigation of the indications, technique and results of transmeatal atticotomy done at the University of Iowa Hospitals was undertaken. A review of 82 patients with a 12 month or more follow-up and 61 patients with a 24 month or more follow-up was done. An attempt was made to discuss what factors in the history, physical examination, x-ray and audiological exam, operative findings and operative techniques influenced the patient's eventual outcome. The criteria for a successful result were considered to be: 1) no drainage from eight weeks postoperatively; 2) no tympanic membrane perforation; 3) no retraction pocket out of sight or touch with a Day hook; 4) no residual or recurrent cholesteatoma. The transmeatal atticotomy is primarily used in the extirpation of cholesteatoma confined to the epitympanum. It is occasionally used in the mobilization of ossicles with congenital fixation in the attic. At our institution the indications for atticotomy in patients with cholesteatoma are 1) drainage responsive to medical therapy (aural saline irrigations and antibiotic steroid ear drops); 2) absence of bone erosion on otologic or radiologic examination; 3) minimal hearing loss, e.g., an SRT of 40 dB or better; 4) absence of complication. Of the cases investigated 73.2% had a clean, dry ear without a retraction pocket, perforation or cholesteatoma at two years postoperative follow-up. Of the failures there were 12 cholesteatomas and two marginal perforations that occurred. There was therefore a 17.1% incidence of failure of atticotomy resulting in a dangerous ear. Of these, five required modified radical mastoidectomy for irradication of disease. Examination of the history presented by these patients revealed that those who had a history of drainage had a less chance of a favorable result than those who did not. Those whose drainage responded to conservative management did better than those who did not. If longer than four months of medical therapy was required before the drainage stopped then the surgical outcome was not as good. The presence or absence of scutum erosion had no significant effect on the results. The degree of hearing loss had little effect on the results. Those who still had suppuration at the time of surgery did less well than those who did not. The patients who had a small amount of scutum excised at surgery did less well than those who had greater attic exposure. Those patients who had recurrent cholesteatoma tended to have less scutum excised, and had their ossicles left intact more often. Transmeatal atticotomy should be limited to those patients with disease confined to the epitympanum. This may be indicated by a history of drainage that responds well to conservative medical therapy and in a patient demonstrating no evidence of bone erosion in the antrum. The operation should include wide exposure of cholesteatomatous disease with removal of the head of the malleus and the incus whenever there is doubt of the extent of the lesion.

Current concepts of chronic attic and middle ear disease; new surgical technique to preserve hearing.

• Chronic inflammatory disease in the middle ear sometimes leads to retraction and perforation of the pars flaccida of the tympanum. These attic perforations, marginal in location, are more difficult to remedy than perforations of the pars tensa. The latter are characteristic of acute otitis, generally central in location, and likely to heal spontaneously in a few weeks. Prophylaxis includes follow-up of all cases of acute otitis to make sure that treatment with sulfonamides and antibiotics is continued until the exudate in the middle ear is resolved completely. In cases of incomplete resolution or other longstanding disease resulting in marginal perforations, if there is persistent drainage with symptoms of extension to neighboring structures and evidence of cholesteatoma, surgery must be considered. In four cases of chronic otitis persisting from 3 to 20 years there were marginal perforations. All were successfully treated by modified radical mastoidectomy with special attention to the ossicular chain. Audiograms showed that the severe hearing losses that were almost inevitable with older types of radical mastoid surgery were avoided in these cases.

Chloramphinicol (chloromycetin) in treatment of aural infections.

A RECENT report has indicated that chloramphenicol (Chloromycetin) used locally is of value in the treatment of infected ears. 1 Ears draining because of many causes (acute and chronic external otitis, otitis media with central and marginal perforations of the tympanic membrane, and postoperative mastoid cavities) were treated with a 1.5% solution of chloramphenicol. The primary diluent of the drug was acetyl dimethylamine, secondarily diluted with 70% alcohol. The use of this drug resulted in cessation of drainage in 78% of the ears so treated. Many other drugs have been similarly locally used for relief of drainage in diseased ears. Among these can be mentioned nitrofurazone (Furacin),* dihydrostreptomycin-boric acid powder, 5 a sulfanilimide derivative (Sulfamylon),† streptomycin, 8 Sulfamylon and streptomycin, 9 and polymyxin-bacitracin. 10 Peele 2 refers to over 50 articles on various medications (not all different) used in treating draining ears, including many of those previously noted. It is,