Medial or medio-lateral graft tympanoplasty for repair of tympanic membrane perforation

Objective

To describe and evaluate the medio-lateral graft tympanoplasty¹ for the reconstruction of anterior or subtotal tympanic membrane (TM) perforation and medial graft tympanoplasty for posterior TM perforation.

Methods

Retrospective study of 200 patients who underwent medio-lateral graft tympanoplasty (100 cases) and medial graft tympanoplasty (100 cases) at community and tertiary care medical centers from 1995 to 2006. All patients underwent preoperative and postoperative audiograms. In the medial graft tympanoplasty, the graft is placed entirely medial to the remaining TM and malleus. First, margin of TM perforation is denuded removing ring of squamous tissue. Tympanomeatal flap is elevated. Temporalis fascia is harvested, semidried, and grafted medial to the TM perforation and malleus with Gelfoam packing supporting the graft. In the medio-lateral graft technique, posterior tympanomeatal flap is elevated same as in the medial graft tympanoplasty first. Anterior-medial canal skin is elevated down to the annulus. At the annulus only squamous epithelial layer of TM is elevated up to anterior half of the TM perforation. Temporalis fascia is grafted medial to posterior half of the perforation and lateral to anterior half of the de-epithelialized TM perforation up to the annulus. Anterior canal skin is rotated to cover the fascia graft and TM perforation as a second layer closure. Patients were followed for at least six months. Outcome was considered successful if TM is healed and intact.

Results

There were four failures (96% success rate) in medial graft method for posterior TM perforation due to infection and re-perforation. In the medio-lateral graft tympanoplasty, there were three failures (97% success rate) due to a postoperative infection, anterior blunting and recurrent cholesteatoma.

Conclusion

The medial graft tympanoplasty works well for posterior TM perforation. The medio-lateral graft method is an excellent method for the reconstruction of large anterior or subtotal TM perforation. This new method should help otologic surgeons to improve outcome of tympanoplasty for anterior or subtotal TM perforation.     

Loop overlay tympanoplasty for anterior or subtotal perforations

Objective

To report our experience with “loop overlay” tympanoplasty, a modified overlay technique with a superiorly based skin flap, for the reconstruction of anterior, subtotal or total tympanic membrane (TM) perforations.

Methods

Retrospective review of patients undergoing loop overlay tympanoplasty from March 1998 to February 2007 was performed. Four hundred and twenty-nine patients who underwent loop overlay tympanoplasty and then follow-up visits a minimum of 6 months later were included in this study. Hearing test results were reported using a four-frequency (0.5, 1, 2, and 3 kHz) pure tone average air–bone gap. The outcome was considered successful if the TM was intact without lateralization or anterior blunting after the follow-up visit.

Results

There was a 98.8% success rate. There was no graft lateralization, anterior blunting, neocholesteatoma, or sensorineural hearing loss. The mean preoperative to postoperative four-tone air–bone gap improved from 23.5 to 8.1 dB, which is a mean gain of 15 dB; this was statistically significant (p < 0.001, paired sample t-test).

Conclusion

The loop overlay graft method is a safe and effective technique for reconstruction of anterior, subtotal or total TM perforations, with excellent graft take and significant improvement of hearing. It provides a precise replacement of the flap and a preserved healing plane.     

Chronic tympanic membrane perforation in an animal model

Objective

The aim of this study was to revalidate and reproduce a chronic tympanic membrane perforation animal model.

Study design

Prospective, animal study.

Methods

Eight female chinchillas underwent bilateral thermal myringotomy. The edges of the perforation were folded inward using microflaps. The perforations were followed over time to monitor the course of closure.

Results

Two animals were excluded from the study because of ear infection. None of the other tympanic membrane perforations remained open. The closing time varied from 4 to 6 weeks.

Conclusions

Our findings demonstrate that the thermal myringotomy combined with infolding technique is not a reliable and consistent method to create a chronic tympanic membrane perforation. The closing time is shorter than expected and varies among the study subjects.There is a clear need for developing a reliable chronic tympanic membrane perforation model.     

Wyniki strukturalne myringoplastyki metodą podkładania

Introduction

The method of tympanic membrane repairing is called myringoplasty.

Aim of the study

We analysed the reasons of failure of this procedure.

Material and methods

The structural results were observed among 36 patients under restricted criteria with diagnosed chronic otitis media. The unsuccessful procedure was one with reperforation. We studied Eustachian tube function and also localisation and size of the perforation.

Results

The failure rate was 25%, which was mainly observed among individuals with incorrect Eustachian tube function – 70% and margin perforations – 50%. The localisation and the size of the perforation did not matter.

Conclusions

The main reasons of myringoplasty failure were incorrect Eustachian tube function and margin perforations of tympanic membrane.     

Analysis of gene expression profiles in tympanic membrane following perforation using PCR Array in rats—Preliminary investigation

Objectives

The goal of this work was to identify genes, known to be involved in the skin wound healing, that express differentially in the healthy and injured tympanic membrane (TM), and designate the molecules potentially beneficial for treatment of TM perforation. The molecular mechanisms controlling the course of TM regeneration are far from being elucidated.

Methods

Twenty rats had their tympanic membranes perforated, while four served as a control. Animals were sacrificed on either days 1, 2, 3, 5 and 10 post injury, and TMs were immediately dissected and frozen in liquid nitrogen. Total TM RNA was isolated and reversely transcribed. qPCR was performed using Rat Wound Healing RT² Profiler PCR Array (QIAGEN) containing primers for 84 genes.

Results

Statistically significant changes in the expression of 42 genes were found in various stages of TM healing. The increased expression of genes taking part in the inflammatory reaction (interleukin 6, granulocyte and macrophage chemotactic proteins) was observed from day 2. The expression of several genes of extracellular matrix components and their remodeling enzymes was also changed. Among growth factor genes: Vegfa, Igf1 and Hbegf showed increased expression at the beginning of the healing process, while Hgf expression was highest on day 3.

Conclusions

Several changes in the expression of genes involved in remodeling of extracellular matrix point to important role of connective tissue in TM healing. The molecules accelerating this process, like HbEGF and HGF, seem to be good candidates for further evaluation of their possible use in clinical treatment.     

Clinical analysis of secondary acquired cholesteatoma

Objective

This study aimed to analyze the clinical features of patients who underwent surgery for secondary acquired cholesteatoma (SAC).

Materials and methods

The subjects were 30 patients who underwent surgery for SAC in 30 ears. We investigated the age distribution, sex, tympanic membrane (TM) findings, temporal bone pneumatization, morphology of TM epidermis invasion, extent of cholesteatoma invasion, ossicular erosion, surgical methods and surgical results.

Results

There were 10 males (33.3%) and 20 females (66.6%), with a mean age 54.9 years. The TM perforation was medium-sized or larger in 27 ears (90%). Temporal bone pneumatization was poor or bad in 90% (18/20) of the evaluated ears. The cholesteatoma invaded from the malleus manubrium to the promontory in 23 ears (76.7%). There were no patients in whom the cholesteatoma invaded the antrum or mastoid. The ossicles were affected in 19 ears (63.3%). Ossiculoplasty with a columella on the stapes was the most frequent procedure, performed for 16 ears (53.3%). There were no hearing results with a postoperative air-bone gap of more than 31 dB.

Conclusions

Although SAC is rare, it is important for the clinician to keep this type of cholesteatoma in mind.     

Proces gojenia perforacji błon bębenkowych u szczurów

Introduction

Tympanic membrane (TM) perforations are commonly seen in clinical practice as a result of trauma or in the course of otitis media. The TM is a unique structure suspended in air which makes its healing processes different than in the skin wounds.The aim of the study was otoscopical and histological evaluation of the rat's TM healing process.

Material and methods

56 male Wistar rats were used for the study. Fifty of them had TMs perforated bilaterally using CO₂ laser, additional 6 served as a controls. The animals were sacrificed on either day 1, 2, 3, 6 and 10 post injury. Process of healing was assessed otoscopicaly, subsequently TM were dissected and processed for histological evaluation.

Results

At day 6 after perforation half and on day 10 all of TM were healed. On the first day, in histological evaluation, focal thickening of the epithelial layer was observed at some distance from the edge of perforation, on the side of annulus. On the following day proliferation of epithelium covering outer surface of TM on the side of the malleus handle and annulus was clearly visible. An eosinophilic mass containing macrophages and granulocytes was seen in front of the migrating epithelium. On day 3–6 migrating epithelium reached the edge of perforation. Proliferation of the connective tissue layer followed the epithelium.

Conclusions

The present results indicate that the squamous epithelium covering the outer surface of TM constitutes the first layer which restores continuity of TM. The proliferation of the connective tissue occurs in the direct vicinity of the proliferating and migrating epithelium.     

A middle ear implant with a titanium canal wall prosthesis for a case of an open mastoid cavity

Objective

Open mastoid cavity rehabilitation should focus on both anatomical and functional aspects. We hereby report the technique and results of a combined strategy to reconstruct the external ear canal using a titanium wall implant and the middle ear using a fully implantable active middle ear device.

Methods

A fully implantable active middle ear implant was used to rehabilitate the mixed hearing loss of a 63-year-old woman, and a titanium posterior canal wall prosthesis was used to reconstruct the external ear canal during the same procedure. The middle ear implant was placed directly on the footplate. The auditory results were compared to the preoperative unaided thresholds and to the amplification of a conventional hearing aid.

Results

Following the procedure, there was an anatomically normal external ear canal with a healed tympanic membrane separating the external from the middle ear spaces. The postoperative auditory gains were on average 31.8 dB on pure-tone audiometry, and 20 dB on speech reception threshold. No complications occurred.

Conclusion

The rehabilitation of the external ear canal in an open mastoid cavity allows for clinical follow-up of the patient, and the implantation of an active middle ear implant provides appropriate auditory gains both in pure tones and in speech reception thresholds.     

James Sheehy鼓膜成形术

目的 应用James Sheehy鼓膜成形术对无残边鼓膜大穿孔行鼓膜成形术并观察其疗效。方法2001年1月至2003年6月，共有60名无残边鼓膜大穿孔的患者接受．James Sheehy鼓膜成形术治疗，男36名，女24名，年龄16～64岁，平均45．23岁。术前气骨导差5—45dB，平均28．5dB。其中54名患者随访超过6个月。技术关键：①做耳道后壁带血管蒂皮瓣，切除耳道前壁皮肤；②行耳道成形术至一个显微镜视野下能够看到整个鼓环；③必要时探查听骨链；④颞肌筋膜外植修补鼓膜，上方置于残余锤骨柄下方；⑤耳道前壁游离皮肤及耳道后壁带血管蒂皮肤复位。结果52名患者一期愈合，2名患者术后3个月修补鼓膜中心部位出现2处针眼样穿孔，经明胶海绵贴补二期愈合，鼓膜形态如常；6名患者术后出现轻微颞颌关节症状，3天后消失；2名患者出现修补鼓膜外侧愈合。结论．James Sheehy鼓膜成形术为无残边鼓膜大穿孔治疗的可靠技术，鼓膜修补成功率高，术后反应轻微，新生鼓膜形态好。     

External auditory canal stenting utilizing a useful rolled, tapered silastic sheet (RTSS) post middle ear surgery

Objective

To overcome the demerits of conventional postoperative aural packing, we developed a useful protocol for postoperative stenting of the external auditory canal after middle ear surgery which enables transcanal drainage and simultaneously allows for visual inspection and treatment of the canal, as necessary.

Methods

Twenty-four surgeries, 21 patients underwent tympanoplasty with a postaural incision. At the end of all surgical procedures, the external auditory canal was packed with a 0.3 mm thickness rolled, tapered silastic sheet (RTSS) with antibiotic ointment applied to one surface. The inserted RTSSs were removed at 5–10 days postoperatively. We assessed the efficacy and the reliability of the RTSS.

Results

In 23 ear surgeries on 20 patients, we achieved successful postoperative ear packing utilizing our RTSS. With these patients, the tympanic membrane and the external auditory meatus were able to be observed immediately after the completion of the stenting during the surgery and the removal of the gauze over the operated ear at Day 1 to Day 3 postoperatively. During 4 surgeries with ventilation tube insertion to the tympanic membrane, there was secretion through the inserted ventilation tube which was easy to suction. In one surgery, on one patient, additional packing materials were utilized once only during a sandwich graft myringoplasty. No patients showed any harmful effects during the postoperative period.

Conclusions

The useful and reliable RTSS, with antibiotic ointment applied to one surface, has several positive advantages that the conventional packing methods do not.     

Planer orientation of the bilateral semicircular canals in dizzy patients

Objective

Recent development of 3-dimensional analysis of eye movement enabled to detect the eye rotation axis, which is used to determine the responsible semicircular canal(s) in dizzy patients. Therefore, the knowledge of anatomical orientation of bilateral semicircular canals is essential, as all 6 canals influence the eye movements.

Subjects and methods

Employing the new head coordinate system suitable for MR imaging, we calculated the angles of semicircular canal planes of both ears in 11 dizzy patients who had normal caloric response in both ears.

Results

The angles between adjacent canal pairs were nearly perpendicular in both ears. The angle between the posterior canal planes and head sagittal plane was 51° and significantly larger the angle between the anterior canal planes and head sagittal plane, which was 35°. The angle between the horizontal canal plane and head sagittal plane was almost orthogonal. Pairs of contralateral synergistic canal planes were not parallel, forming 10° between right and left horizontal canal planes, 17° between right anterior and left posterior canal planes and 19° between the right posterior and left anterior canal planes.

Conclusion

Our measurement of the angles of adjacent canal pairs and the angle between each semicircular canal and head sagittal plane coincided with those of previous reports obtained from CT images and skull specimens. However, the angles between contralateral synergistic canal planes were more parallel than those of previous reports.     

Topical platelet rich plasma versus hyaluronic acid during fat graft myringoplasty

Objectives

To evaluate the effect of adding platelet rich plasma (PRP) or Hyaluronic acid (HA) to fat graft myringoplasty (FGM) for medium sized central tympanic membrane (TM) perforations.

Modified fronto-lateral laryngectomy in treatment of glottic T1(a-b) cancer with anterior commissure involvement

Objective

Evaluation of clinical and oncological safety of the modified fronto-lateral laryngectomy in the treatment of T1a-b glottic cancer.

Methods

Retrospective review of charts of patients managed with classical fronto-lateral laryngectomy or with our modified technique using a cervical fascia flap and a false cord flap to reconstruct the defect.

Results

No recurrence of cancer was observed in the present series and slight dysphonia was present in all cases. The patients managed with classical technique required a revision surgery for granulations or anterior synechia in 4 cases; those managed with modified technique did not need a second intervention.

Conclusion

The fronto-lateral laryngectomy should be present in the head-neck surgeon armamentarium. In T1a-b glottic cancer this technique gives a good oncological resection, but the postoperative period requires an intensive rehabilitation process. The modification of the classical technique reduces the incidence of a second intervention.     

When should retained Paparella type I tympanostomy tubes be removed in asymptomatic children?

Objectives

Tympanostomy tubes are routinely used for the treatment of otitis media with effusion (OME). There is no definite consensus on the optimal length of the intubation period and the timing of tube removal. This study was designed to determine the appropriate time for tympanostomy tube removal in asymptomatic patients of preschool age.

Methods

A retrospective study was conducted in 336 patients (478 ears) under the age of 7 years old who underwent tympanostomy tube insertion or removal from January 2006 to September 2010 at our institution. The information gathered from chart review included patients’ age at the time of tube insertion, duration of intubation, and the presence of complications, such as tube site infection and persistent tympanic membrane perforation. Logistic regression, chi-square test and Fisher's exact test were used to determine the statistical significance of observations.

Results

The spontaneous extrusion rate of tympanostomy tubes was about 90% at 18 months and showed a plateau after 18 months. The OME recurrence rate decreased after 12 months of intubation, and complications such as tube site infection and persistent tympanic membrane perforation increased after 15 months of intubation.

Conclusion

Tympanostomy tubes removed before 12 months showed a high possibility of recurrence. Removal after 15 months showed an increased possibility of complications. Spontaneous extrusion seldom occurred after 18 months. From these findings, we concluded that asymptomatically retained tympanostomy tubes are recommended to remove when a tube is retained for more than 18 months.     

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review

Purpose

In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort.

Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale

Background

A recently validated image-based grading scale for acute otitis media (OMGRADE) can be used to assess tympanic membrane (TM) status. The aim of this study was to evaluate the validity and reliability of this scale for remote assessments of TM status using video-otoscopy recordings in an unselected pediatric population.

Method

Children 2–16 years attending a South African primary health clinic were offered an ear examination by an otologist using otomicroscopy. An ear and hearing telehealth facilitator then made video-otoscopy recordings (9–33 s) of the ears and uptakes were uploaded to a secure server for remote assessments in Sweden by an otologist and general practitioner at four- and eight-weeks post onsite assessment. TM appearance was judged according to the OMGRADE scale. Concordance between onsite otomicroscopy and asynchronous assessments of video-otoscopy recordings was calculated together with intra- and inter-rater agreements.

Results

One hundred and eighty ears were included. Concordance of TM classifications using the OMGRADE scale was found to be substantial (weighted kappa range 0.66–0.79). Intra- and inter-rater agreement (test–retest) was found to be substantial to almost perfect (weighted kappa range 0.85–0.88 and 0.69–0.72, respectively).

Conclusion

The OMGRADE scale can be used to accurately assess the normal TM and secretory otitis media (SOM) remotely using video-otoscopy recordings in an unselected pediatric population.     

A technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy

Objective

To present a simple technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy, and to assess the efficacy and the surgical results of this technique.

Methods

Retrospective clinical study of a consecutive series of procedures from 2004 to 2008. One hundred thirteen patients undergone canal wall down mastoidectomy with tympanoplasty and concurrent procedure of mastoid obliteration and meatoplasty that uses an anteriorly based musculoperiosteal flap and a horizontal skin incision on the concha were included. Preoperative diagnoses were classified into cholesteatoma, adhesive otitis media, and chronic suppurative otitis media. The mean duration of follow-up was 38 months, with a range of 12–75 months. We analyzed control of suppuration and creation of a dry mastoid cavity according to the Merchant's grading system for evaluation of the efficacy of this technique, and hearing outcome. We evaluated postoperative complications including development of recurrent or residual cholesteatomas and duration of the mastoid cavity achieving a complete healing.

Results

Seventy-two patients had cholesteatoma, whereas 27 patients had adhesive otitis media and 14 patients had chronic suppurative otitis media. Eighty-three percent of all patients, in 86% of patients with cholesteatoma, in 78% of patients with adhesive otitis media, and in 78% of patients with chronic suppurative otitis media were achieved a dry and self-cleaning mastoid and complete control of infection. Duration of the mastoid cavity achieving a dry and self-cleaning mastoid ranged from 4 weeks to 24 weeks and the mean time of the complete epithelialization was 11.1 ± 4.6 weeks. The average ABGs were 32.4 ± 13.8 dB preoperatively and 23 ± 13.2 dB postoperatively. There were 5 patients with failure of control of infection postoperatively and 3 patients of recidivistic cholesteatoma.

Conclusion

The efficacy of our technique to make a dry and healthy mastoid cavity after a canal wall down mastoidectomy is satisfactory, and the rate of complication is acceptably low. We believe that our technique could be a convenient method to prevent cavity problems after canal wall down mastoidectomy.     

Rate of tympanic membrane perforation after intratympanic steroid injection

Purpose

To determine the rate of persistent tympanic membrane perforation after intratympanic steroid injection. To determine which comorbid conditions and risk factors are associated with prolonged time to perforation closure following intratympanic steroid injection.

Keratinic amyloidosis of the external auditory canal

Objective

We present a rare case of keratinic amyloidosis of the external auditory canal. This is only the seventh case reported of localized cutaneous amyloidosis of the external auditory canal with no systemic symptoms.

Patient

A 62-year-old man, who had complained of an itchy external auditory canal and left-side hearing loss, was referred to our hospital because of a bilateral external auditory canal mass.

Intervention

Biopsy of the external auditory canal mass suggested a diagnosis of amyloidosis. However, total systemic examination failed to identify any disease due to systemic amyloidosis. This led us to diagnose him with localized cutaneous amyloidosis of the external auditory canal.

Main outcome measure

We follow up periodically with systemic examination and local observation.

Results

Thirty months after the initial diagnosis, he remains in follow-up and has not shown any significant aggravation of the disease.

Conclusion

In previous cases, the chief complaints were itching sensations and pain in the external auditory canal as well as a sense of discomfort when wearing a hearing aid. This suggests that chronic stimulation and inflammation of the skin lining the external auditory canal induced amyloidosis.