Dr. Muhammad Mozammal Haqure

Historical Background

Berthold (1878):

Myringoplastik

Full thickness skin graft

Nylen (1921): Monocular operating

microscope.

Holmgren, teacher of Nylen (1922):

Binocular operating microscope

In 1953, the Zeiss operating microscope:

Commercially available

Historical Background…..

Moritz (1952)

Zollner (1953, 1955) German,

Wullstein (1953,1956) Onlay skin graft

To restore or conserve hearing and promote healing, after excision of disease from the middle ear and mastoid.

Middle Ear Reconstruction

Not only the restoration of the anatomical ormechanical components but also of thephysiology or function of the ear.

Tympanoplasty

Ossiculoplasty

Mastoidectomy:

Open or canal wall-down procedures

Closed or canal wall-up procedures

Tympanoplasty

Definition: Repair of the tympanic membrane

(TM) with inspection of middle ear & possible

ossicular chain reconstruction.

This is different than a myringoplasty

Aims:

Prevent recurrent disease

Improve hearing

Provide a dry ear canal

Enable patient to bathe & swim freely

Tympanoplasty………..

Appropriate candidates: Perforation of TM

Cholesteatoma / other lesion involving TM or tympanic cavity

Resolved otorrhea

Preferably no Eustachian tube dysfunction

Tympanoplasty………..Poor Candidates:

Multiple failed attempts at closure

Poor Eustachian tube function

Smoker

Systemic disease

DM

Steroid use

Actively draining

Tympanoplasty……….. Commonly used materials:

Temporalis fascia

Perichondrium/cartilage

Periosteum

Fat

Vein

Duramater

Techniques Overlay

Underlay

Tympanoplasty………..

Approaches

Transcanal

Post auricular

Endaural

Tympanoplasty………..

Wullstein (1956)

Type I

Type II

Type III

Type IV

Type V

Types of tympanoplasty

Type I—

intact ossicular chain

simple

tympanoplasty

(Myringoplasty)

Types of tympanoplastyType II—

intact incus and

stapes with erosion

of malleus

Graft onto incus

= incudopexy

Graft onto malleus

remnant

Types of tympanoplastyType III—

intact mobile stapes

superstructure

Graft onto head of

stapes

Columella

tympanoplasty

Types of tympanoplastyType IV—

intact stapes footplate

with absent or

eroded stapes

superstructure

Footplate MOBILE

Graft covers RW

(round window baffle)

Footplate exteriorized

Types of tympanoplasty

Type V- fenestration of horizontalsemicircular canal

Immobilefootplate

Underlay v. Overlay

Underlay= medial Overlay= lateral

Underlay technique—selection of patients Posterior central perforations

“Smaller” perforations

Any perforation with intact annulus

Underlay technique—procedure

Overlay technique—selection of patients

Marginal perforations

Total perforations/“larger perforations”

Need for canalplasty

Previously failed tympanoplasties

Overlay technique—procedure

Tympanoplasty--complications Persistent / recurrent perforation

Cholesteatoma (ME, drum, EAC)

Dysguesia

Blunting

Lateralization

SNHL / vertigo

Facial nerve injury

Ossicular disorders Types

Ossiculardiscontinuity

Ossicular fixation

Causes Chronic otitis media

Trauma

Congenital

Tympanosclerosis

Otosclerosis

Common ossicular disorders

Long process of Incus

Stapes superstructure

Handle of the Malleus

Ossiculoplasty (OCR)

Appropriate candidates:

Resolved otorrhea with no middle ear disease

Conductive or mixed hearing loss

No Eustachian tube dysfunction (ideal)

Need enough middle ear space and aeration to allow for prosthesis and function

Previous CWU for second-look

Ossicular grafts and implants

Autologous :

Ossicle grafts: Incus/ Head of the malleus

Cortical bone grafts: Mastoid cortex

Cartilage

Homologous human ossicles

Synthetic ossicular implants:

Porous high-density polyethylene (Plastipore) -FBGCR

Plastic material -microdegradation

Bioactive glasses, aluminum oxide ceramic, carbon,

hydroxylapatite-polyethylene (Hapex)

Ossicular chain defect Austin’s classification

4 Common types: Incus absent in all cases and TM reconstruction

required in all cases.

Type A: M+, S+

Loss of part of incus or total loss of incus.

Type B: M+, S-

Loss of incus & stapes superstructure but the malleus handle still

present.

Type C: M-, S+

Loss of incus & malleus but the stapes superstructure still present.

Type D: M-, S-

Loss of incus, malleus & superstructure of stapes, but mobile

footplate still present.

Type A1: Bone pate-glue/ prosthesis

Type A2: Autograft or homograft bone (Incus

interposition) / Prosthesis

Type B: Autograft or homograft bone/ Prosthesis

Type C: PORP/ Autograft or homograft bone

Partial Ossicular Replacement Prosthesis Intact superstructure

Stapes superstructure TM

PORP - Types

Type D: TORP/ Autograft or homograft bone

Total OssicularReconstruction Prosthesis

Footplate TM

Oval window (with graft)TM

TORP

All OCRs are held in place by tension. When placing a TORP, Gantz will frequently put a second

piece of cartilage to support the prosthesis.

Ossicular chain defect…….

Rare ossicular chain defects

1)Isolated loss of the malleus handle: 2%

2) Isolated loss of the stapes superstructure: 1.7%

Continue….Fixed stapes

1) Malleus handle presnt stapes fixed

2) Malleus handle absent stapes fixed

Defining Success 1995 guidelines of the AAO

Pre and postoperative air-conduction and bone-

conduction thresholds are measured at 4 designated

frequencies (0.5, 1, 2, and 3 kHz), then averaged

Success is defined as a mean postoperative air-

bone gap of less than 20 dB and is the main

outcome considered for this talk

Prognostic Factors It is clear that optimal results depend not only on

the qualities of the prosthesis, but also on the

environment in which it is placed and the

surgical techniques used.

Prognostic Factors Austin (1972) defined four groups in which the incus

had been partially or completely eroded:

Type A, malleus handle present, stapes

superstructure present (60% occurrence)

Type B, malleus handle present, stapes

superstructure absent (23%)

Type C, malleus handle absent, stapes

superstructure present (8%)

Type D, malleus handle absent, stapes

superstructure absent (8%)

Prognostic Factors Kartush (1994) proposed a scoring system called

the middle ear risk index (MERI) to form an index score to determine the probability of success in hearing restoration surgery.

MERI is used to describe the preoperative middle ear environment at the time of ossiculoplasty

Prognostic Factors

All studies of prognostic factors identify middle ear

mucosal status and presence of malleus handle

as important predictors of successful hearing

restoration

Result of ossicular reconstruction Incus/stapes assembly - air-bone gap closure with 10 dB

in 50% cases & under 20 dB in 70-80% cases.

Malleus/stapes assembly –

0-10 dB 50% cases

0-20 dB in 80% cases

Malleus/footplate assembly-

20 dB in 35- 60% cases.

Use of PORP – air-bone gap closure < 20 dB in 77% cases.

Use of TORP – air-bone gap closure < 20dB in 52% cases.

expert surgeon

Complications Persistent CHL

Recurrent CHL

• Displaced ORP

• Extruded ORP

SNHL

Vertigo

Facial nerve injury

Mastoid surgery

Canal wall down/open cavity mastoidectomy

Canal wall up/intact canal wall/closed cavity

mastoidectomy:

Mastoid Surgery…….

Aims:1) Eradication of disease

2) An epithelialized, self cleaning ear.

3) Hearing improvement.

Canal wall down/open cavity mastoidectomy

A. Obliteration techniques

B. Posterior canal wall and outer attic wall

reconstruction.

A. Obliteration techniquesTo line & reduce the size of the mastoid cavity

or

Obliterate it completely

Obliteration techniques…………..

Autologous cancellous iliac crest bone graft (Schiller & Singer, 1960)

Allogenic femoral cortical bone chips

(Shea, Gardner and Simpson, 1972)

Bone chips/ dust

Autogenous cartilage (chondral part of pinna)

Hydroxylapatite ceramic powders &

particles.

Obliteration techniques………….. The muscle obliteration techniques:

(more popular)

Local random pattern muscle periosteal transposition & rotation flaps of sternomastoid muscle( Meurmanand Ojala, 1949)

Temporalis muscle (Rambo, 1958)

Postauricular muscle periosteal flaps based on the SCM muscle (Hilger and Hohmann, 1963)

Anteriorly based postauricular muscle-periostealtransposition flaps together with bone pate (Palva, 1963,1982,1993)

Obliteration techniques…………..Local axial pattern flaps:

Temporoparietal fascia flap, based on the

superficial temporal vessels (Byrd, 1980; East,

Brough and Grant, 1991)

The temporalis fascia flap; ‘Hong Kong flap’ ,

(van Hasselt, 1994)

Free grafts: Fascia (temporalis), fascia lata,

abdominal fat, local muscle and periosteal grafts

B: Posterior canal wall and outer attic

reconstruction-

Alternative to cavity obliteration.

Autologous material

> Bone dust & chips

> Cortical bone graft

> Tragal cartilage/Scaphod cartilage

Allogenic

> Bone graft

> Tragal cartilage

Hydroxylapatite

Tympanoplasty with mastoidectomy1) Closed cavity mastoidectomy with tympanoplasty.

2) Open cavity mastoidectomy with tympanoplasty.

3) Obliteration of open mastoid cavity with tympanoplasty.

4) Reconsturction of the outer atlic wall or posterior canal wall of open mastoid cavity with tympanoplasty.

Ossicular chain reconstruction 1) When incus is eroded but malleus handle & stapes

is present.

Malleus/stapes assembly by –

> Autologous & allogenic malleus head or incus body

to fit between the malleus handle & stapes head.

> Artifical prostheses are also available to perform

the same task.

Continue…2) When loss of incus & stapes superstructure but

handle of the malleus present.

Malleus/footplate assembly by-

> Autologous or homologous bone can be used.

> Artifical prostheses are also available.

3) When loss of incus & malleus but stapes

superstructure present.

TM/ stapes head assembly by-

> Autograft or homograft bone can be used .

> Artfical prostheses are also available.

Continue….

4) When loss of incus, malleus & stpaes

superstructure

but mobile footplate.

TM/ footplate assembly by-

> Autograft or homograft bone can be used.

> Artifical prostheses are also available.

SURGICAL APPROACHES

A. Post Aural (William Wilde) Incision: A cured incision is wade in the natural Post aural

gulcus. Starting nt the 12 o’ clock Position sumperorly and terminatiog at the 6 o’clock

position just behing the ear lobule

Used

Myringoplasty & Tympano Pasty ( Comsined At)

Masteidectomy (All)

Cochler Implant

Exposove of CN VII in vertical sac.

B. End aural inusion: i) incision in the canal and icisuratermials

Lempert I: It is semicircular incision made from 12 ‘o clock to 6 o’ clock Position in the

posteromeatul wall at the bony Cartilaginous function.

Lempert II: Starts from the 1st incision at 12 o clock and them pome upwords in a cuvilinear

fashion btween tragus and crus of helix. It pases though the incisura terminals and them

doen not cut hte cartilage. Both masterd and external canal surgery can be done

Indication:

Lage tympanic membrane perforations.

Attic cholesleatonas with limited extension into the andrum.

Excesion of osteona or exostosis of earcanal.

Modified radical mastordectomy where disane is limited to attic, antrum and part of

masted.

C. Permeatal approacho ( tramcanal) (Endomeatal)/

Rosen incision ( Lateral Tympanotomy)

Resn’s incisim in the most commonly used for stapectechomy It comnts of two parts

a) A Small vertical inlision at 12’ o Clock Position near the annulus and

Acarvilinear incirion storting at 6 o’ clock Position to meet the 1st incision in the poster superior region of the canals, 5mm-7mm away from the annulus.

Indication:

Stepes surgery

Myrugplasty

Omicnler chain reconstruction

Exporatory tumpanotomy Examination of omcular chain in congenital conductive defames.

Success rate in achieving tympanoplasty?

Ans: In expert hand armed -95%

Trainee – 74%

Most out patiant methods have a success rate of between 30 and 80 percent depending on pathology technique and operator Patience Minor surgery for small defects can be successful in 80% or More Myringoplasty can be expected to close 90% of Perforndim with a follow up of 12 months in experiorud hands.