Tympanoplastic Procedures Research Articles

Erste Erfahrungen mit Prothesen in der Mittelohrchirurgie in der Mongolei

Medical care of the Mongolian population is still far behind the standard of industrialised countries. Also in the field of otorhinolaryngology there are clear deficits in regard to an adequate diagnosis and treatment of difficult cases. Microsurgery of the ear is still in the very beginning due to missing essential equipment and surgical skills of the few ORL-units that exists in the country. The integration of tympanoplastic procedures into surgical routine is the main goal of a support programme that exists between the medical faculties of the universities of Wuerzburg (Germany) and Ulan Bator (Mongolia). The aim of this work is to present the outcome of these operations in Mongolia. As a result of the continuous education and support programme it was possible to perform 90 tympanoplastic procedures between 2005 and 2006 in the local ORL center of Ulan Bator (EMJJ-clinic). The focus of this report is on the postoperative audiological outcome following reconstruction of the ossicular chain either using autologous ossicles or middle ear prostheses. Besides, prostheses made of polyethylene or Teflon (Russian production) as well as titanium prostheses (Kurz Company, Germany) were implanted. The final evaluation of the audiological results was performed 6 month postoperatively. The titanium prostheses provided the most favourable hearing improvement (mean 26 dB) when compared to the other materials (polyethylene 7 dB, Teflon 18 dB), but also compared to the autologous ossicles (8,6 dB). The standard tympanoplastic procedures, which were developed over decades, proved to be highly reliable also in a country with reduced medical care. The hearing results obtained especially with titanium prostheses demonstrated, that this highly biocompatible alloplastic material is the most suitable and reliable for middle ear reconstruction also in a difficult surrounding.

Morphometric Study of the Mastoid Segment of the Facial Nerve

Our study emphasizes the relationship between the temporal bone structures and the mastoid portion of the facial nerve. Thirty-two temporal bones taken from adult cadavers of both sexes subjected to tympanoplastic procedure were used to make reference measures of the mastoid portion of the facial nerve. Appropriate instruments were used for measurement and statistic analysis was subsequently performed. The digastric ridge presented a positive correlation with the stylomastoid foramen in comparison with the sigmoid sinus (P=.03). There was a correlation between the position of the short apophysis of the incus and the position of the facial nerve (P=.001). The distance from the sigmoid sinus to the mastoid portion of the facial nerve presents a positive linear relationship throughout its length (P< .001). The tympanic membrane presented a positional correlation with the distal portion of the facial nerve (P< .008). The mastoid portion of the facial nerve is proportional to reference structures in the temporal bone and this may help us to define measures prior to surgical otologic procedures.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes

To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes. Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears. In all 27 cases, complete healing of the perforation was attained. A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.

A REVIEW OF TYPE 3 TYMPANOPLASTY

With the introduction of newer technologies, the advent of antibiotics, and improved surgical methods; the past 25 years have seen a great revolution, refinement, and improvement of tympanoplastic procedures. Furthermore, the methods of classification have been modified. The introduction of ossicular reconstruction with biocompatible implants greatly enhanced the success of type 3 tympanoplasty. This article reviews the classification, indications, surgical techniques, biomechanical properties, and expected hearing results of type 3 tympanoplasty.

Composite graft tympanoplasty in the treatment of ears with advanced middle ear pathology.

In ears with advanced pathology, the functional and anatomical results of surgery are compromised by such factors as total perforation, tympanosclerosis, atelectasis, suppuration, or previous surgery. Perichondrium cartilage composite grafts (PCCGs) were used for membrane grafting in 550 such cases over a period of 5 years. In all, 197 tympanoplastic procedures of type I (25% with previous surgery) and 353 of type III (47% with previous surgery) were carried out. The graft was obtained from the tragus and/or the concha. Two slightly different surgical techniques of grafting were used. Closure of the eardrum perforation was successful in 92% of the procedures. An air-bone gap of less than or equal to 30 dB was obtained in 92.4% of tympanoplasty type I procedures and in 79% of tympanoplasty type III procedures. The conclusion drawn from the results is that PCCG is a reliable graft in cases of advanced destruction of the middle ear.

結核性中耳炎の１例

A 58-year-old woman with no known previous contact with tuberculosis complained of right otorrhea and hearing loss but no facial nerve paralysis. Her tuberculin test was positive, but her chest X-ray showed no signs of lung tuberculosis. Tympanoplasty was performed, and antituberculous chemotherapy (RFP, INH, EB) was given for nine months.Antituberculous chemotherapy reduce the need for a destructive surgical procedure and allow more conservative tympanoplastic procedures to be carried out.

Diagnosis and Management of Eustachian Tube Malfunction

The eustachian tube is an essential part of the pressure regulating system of the middle ear. The physiologic function of the tube is to equalize the middle ear pressure with that of the atmosphere, and at the same time make the middle ear independent of the nasopharyngeal environment with its loud sounds, extensive respiratory pressure changes, and potentially harmful bacterial flora. Thus, the protective closing action is essential in the normal physiology of the eustachian tube, and lack of protection is central in tubal malfunction. We have come to consider eustachian tube closing failure and the subsequent induction of negative middle ear pressure as an important causative factor in the development of chronic ear disease, for example, persistent middle ear effusion and manifest retraction of the tympanic membrane. Here, the patient's behavior may be of more importance than the simple tubal mechanics. In the presence of tubal closing failure, if the patient sniffs habitually, the middle ear cavity will be evacuated repeatedly. This constitutes a repetitive barotrauma which may have secondary effects. As a result of the negative pressure the tympanic membrane retracts, and increased transudation and secretion of fluid may give rise to effusion. Tubal closing failure also implies reduced protection against ascending infection with increased susceptibility to acute otitis media. Repeated sniff-induced barotrauma and repeated purulent infection may together be responsible for the development of manifest structural lesions seen in chronic ear disease. Is it possible to determine the function of the eustachian tube? This question is crucial since it is difficult or impossible to give normative values for tubal function tests. The variability of tubal responses with time has been found to be considerable. Thus, the result of a test represents only one specific moment in time, having little prognostic value. Tubal function is a continuous and composite variable that cannot be "determined" according to a static scheme. Our knowledge of eustachian tube physiology is still fragmentary, and continued study is necessary in order to learn more. Presently, tubal function tests have little value from the clinical viewpoint. When a tympanoplastic procedure is considered, the need for surgery should be determined by the clinical judgment based on the otomicroscopic findings and the hearing. In the case of a central perforation of the eardrum the prognosis for hearing is good, irrespective of results obtained in tubal function tests.(ABSTRACT TRUNCATED AT 400 WORDS)

The chronic discharging ear in Nigeria.

A study of 386 Nigerian patients with chronic suppurative otitis media is presented. The disease usually starts in early life, even though presentation in hospital may be delayed until adult life. The important aetiological factors were found to be essentially socio-economic. Tubo-tympanic disease dominates the clinical picture and the rarity of the attic retraction type of chronic ear disease would suggest exceptionally good eustachian function in the population studied, but further study is required in this respect. It is suggested that complicated tympano-plastic procedures are in general inappropriate in the chronic ear population of this study.

Erste tierexperimentelle und klinische Erfahrungen mit bioaktiver Glaskeramik in der rekonstruktiven Mittelohrchirurgie

The bioactive glass ceramic material (Ceravital) is fully accepted in osseous areas without formation of surrounding fibrous tissue; it is fixed by direct chemical bond. The use of this material in ENT surgery was tested in animals. In 70 rabbit ears, defects were inflicted on the tympanic membrane, ossicular chain and posterior wall of the external auditory meatus. Using standard tympanoplastic procedures, these defects were reconstructed using glass ceramic implants. The histological examinations of the preparations, which were embedded in Methylmetacrylate were performed using transmission light microscopy and fluorescence microscopy with incident light. The reactions between the implant and the host tissue, e.g., mucous membrane, free transplanted fascia and skin, were examined. In 85 patients Ceravital implants were used to reconstruct the ossicular chain and the posterior meatal wall of the outer ear canal. Functional results were satisfactory. No disturbances in woundhealing were observed.

Malleomyringoplasty and Wireclip Prosthesis

A new tympanoplastic method reestablished an effective sound conducting mechanism in cases in which there was destruction of the tympanic membrane and the handle of the malleus. The tympanic membrane is reconstructed from the two adherent fascial layers covering the temporalis muscle and the handle of the malleus is reproduced by incorporating a shaped and perforated autogenous bone graft between the layers (malleomyringoplasty). Ossicular continuity is restored by utilizing a corrugated wireclip prosthesis to connect the malleus replacement bone to the long process of the incus in type 2 cases and to a stapedial crus in type 3 cases. The results in two cases show that this tympanoplastic procedure is worth pursuing in cases characterized by loss of the handle of the malleus.

Tympanomaxillary shunt. A new method of middle ear ventilation.

INSUFFICIENT ventilation through the eustachian tube is one of the main causes of middle ear pathology and hearing loss. A dysfunction of the tube is always present in chronic serous otitis and very often in chronic otitis, in which case the result of a tympanoplastic procedure may depend on the ventilatory capacity of the tube. Many attempts to improve the patency of the eustachian tube have been reported in the literature, but very few of these have dealt with the problem of a complete or almost complete obstruction. By introducing a plastic tube through a myringotomy opening Armstrong 1 succeeded in creating a simple procedure for ventilation and drainage of the middle ear. The effect of the plastic tube, however, is usually only temporary, as sooner or later it will be extruded and the drum will heal. This risk might be diminished by some device for fixing the tube,

Pathology of the eustachian tube.

WE HAVE STUDIED the eustachian tube areas of 400 human temporal bone specimens to gain some insight into the types of pathological change and the significance of these changes in otologic disease. Tubal dysfunction undoubtedly often leads to chronic middle ear disease and furthermore probably is responsible for many of the failures in tympanoplastic procedures as a consequence of inadequate aeration of the middle ear. The chief function of the eustachian tube is to serve as a channel for the transmission of air from the nasopharynx to the middle ear, maintaining equal air pressure in the middle ear and environment and simultaneously minimizing the risk of contamination from the upper respiratory tract by remaining closed under normal resting conditions (Fig 1). The eustachian tube also serves as a pathway for drainage and in this respect ciliated secretory epithelium is recognized as an important physiological mechanism. From the pathological viewpoint, the

Incus autografts and homografts in rats.

RECONSTRUCTION of the middle-ear chain is an important part of tympanoplastic procedures. As the use of alloplastic prostheses in chronic ear surgery does not always lead to the desired improvement in hearing, and the prosthesis is often extruded, many surgeons prefer bone or cartilage if possible. The fate of cortical bone grafts in middle ear and bulla of experimental animals has been studied extensively, 1,2 and from these studies we know these grafts revitalize. Transposition of the incus between malleus and stapes in dogs 3 and between malleus and footplate in apes and cats, 4 has shown different degrees of remodeling in the incus. In humans this transposition of the incus has been advocated by Hall and Rytzner, 5 Guilford, 6 and House, 7 who obtained good functional results. Histologic examination in one of the reports 5 left doubt about the vitality of the transposed ossicle. Kley and Draf 8

Simple apparatus to measure eustachian tube function.

THE MEASUREMENT of eustachian tube function has become an important part of the preoperative assessment of myringoplasty and tympanoplastic procedures. Most otologists feel that the blockage of the eustachian tube is the chief etiological factor in chronic, suppurative, middle ear disease and that restoration of function is necessary for a successful result. Many methods are presently being used in the evaluation of tubal patency. The most popular of these is the time honored, retrograde, forced-air inflation of Politzer. Perlman 1 has modified the pneumophone of van Dishoeck for clinical use. This apparatus is used to quantitate the pressure necessary to overcome the elasticity of the closed eustachian tube when air is forced, in a retrograde manner, through the tube. More recently, fluorescein solution and radio opaque materials have been put into the tympanum and allowed to pass through the eustachian tube and viewed either in the nasopharynx under ultraviolet light

Preservation of the external ear canal in tympanoplasty

For the purpose of eliminating the troublesome mastoid cavity after tympanoplasty, some surgical procedures have been devised, which consist of preservation of the external ear canal, so that the operative mastoid cavity is primarily closed, with the use of fascia, periost or vein as a tympanic graft. Surgical procedures are as follows : At the first place, mastoidectomy is carried out without sacrifice of bony bridge using Shambaugh's endaural incision. Then, the meatal skin incision is made on the posterior canal skin and on it the window is made to see the drum and to prepare the vascular bed on the undersurface of the drum to receive the graft. Thereafter, the drum is separated from sulcus and elevated, but the anterior superior portion is preserved, which serves for reconstructive pro- cedure of the drum by giving the fixed point. After an adequate tympanoplastic procedure is used in accordance with middle ear condition, the drum is repaired with fascia or other tympanic graft on the undersurface of the drum and recon- structed. Such reconstructive procedures as de- scribed above are easily performed through the meatal window which is made on the early stage in operation. Finally the meatal skin is replaced and the window is closed. With these procedures, it seems that nearly normal ear canal and fully satisfactory results in hearing can he obtained. In Addition, healing process is more rapidly and less postoperative after care is needed than in classical tympanoplasty.

Stapedectomy and tympanoplasty. III. Mastoidectomy, musculoplasty, and tegmental fascia grafts.

The reduction in the size of the mastoidectomy cavity has been a significant contribution in the current renaissance in otological surgery. The cavity may be reduced in size or completely ablated with the temporal fascia graft or flap, the posterior pedicle musculoplasty, the elongated conchal canal flap, the preservation of the bony canal, the use of bone or cartilage chips, and the now classical musculoplasty of Rambo. The classical musculoplasty and ablation of the mastoid cavity is indicated primarily in unilateral ears which require complete radical mastoidectomy. Rather than employ the closed mastoidectomy techniques, I am more frequently inclined to preserve an ear canal and attempt some type of tympanoplastic procedure, either as a primary or as a secondary operation. Fig. 1.—The deep endaural incision is preferred in the small diseased mastoid cavity, for it provides direct access to the antrum, attic, and middle ear, and the healed cavity is

Reconstruction of ear canal in surgery for chronic ear.

Tympanoplastic procedures have now been practiced for more than 10 years, and most of the surgical methods are already well standardized. Excellent descriptions of different alternatives are given in textbooks on ear surgery by Shambaugh¹and by Portmann, Portmann, and Claverie.²In evaluating the results, the Wullstein classification into 5 different types is generally used. The experience in our clinic with these procedures has been reported for 2 periods, 1950-1952 (Palva and siirala, 1954.³) and 1953-1958 (Palva and Pulkkinen, 1960^4-5). During the first period, myringoplasty and columellization were the standard procedures. The cavum minor technique with a full thickness graft (fourth type) was not yet being attempted. If the Thiersch graft did not result in a viable membrane, a prosthetic covering of the round window was utilized. During the latter period, in the absence of the stapes, "sound shadowing" of the round window with full thickness

Manipulation of the labyrinth windows and their surroundings in tympanoplasty.

Introduction Tympanoplasty consists of a series of operative procedures, which not only eliminate chronic infections of the middle ear completely but also improve hearing. The purposes of tympanoplastic procedures are the elimination of inflammatory processes and postinflammatory changes in the middle ear in order to diminish ear discharge and to obtain dry ear and the reconstruction of the damaged sound-conduction mechanism in order to facilitate sound conduction to the inner ear and restore the hearing. In our experience there are cases where tympanoplasty failed to eliminate the inflammatory processes or to restore hearing in chronic otitis media. I have, therefore, clinically observed these cases of failure in order to clarify manipulation of the labyrinth windows and their surroundings and assure accomplishment of both aims of tympanoplasty. Material I examined 242 tympanoplasty cases operated on by us for chronic middle ear suppuration from October, 1957, to November, 1958. The cases included

Prosthetics in the Middle Ear: Preliminary Report on the Use of Prosthetics to Reestablish Continuity of the Sound Pressure Transformer of the Middle Ear

The advent of stapes mobilization and tympanoplastic procedures has introduced the problem of restoring the continuity of the middle ear sound-conducting apparatus when this has been interrupted by disease, congenital malformation, or stapedial fracture. This preliminary report describes methods for reestablishing ossicular continuity using polyethylene tubing or tantalum wire alone or in combination. Rationale It is remarkable that the two essential requisites for normal functioning of the middle ear, namely sound protection for the round window and sound pressure transformation for the oval window, were not clearly appreciated by clinicians until a scant decade ago. Eighty years before this, Helmholtz1defined the purpose of the ossicular chain linking large tympanic membrane to small oval window as a mechanism to transform air-borne sound vibrations of large amplitude but small force into fluid-borne vibrations of small amplitude but large force. Recent investigations by Bekesy2confirm the essential concepts of Helmholtz,