R E T R A C T I O N P O C K E T S A N D P E R F O R AT I O N S

B P O C , L O N D O N 2 0 1 8

P R O F I A B R U C E M D F R C S PA E D I AT R I C O T O L A R Y N G O L O G I S T, M A N C H E S T E R , U K

P E R F O R AT I O N S

• Sequelae of acute or chronic ear infection, physical trauma, barotrauma or iatrogenic

• Permanent perforation more likely with chronicity of ear disease & ETD

• 5 types of Tympanoplasty described, dependent upon integrity and mobility of the ossicular chain

• Choosing the technique for repair influenced more by perforation and patient factors than success for particular techniques

M Y R I N G O P L A S T Y / T Y P E 1 T Y M PA N O P L A S T Y

• TM repair when middle ear normal- no ossicular surgery

• Success in children varies widely (majority 50-95%), Mean on metanalysis 83.4% Hardman 2015

• Aims of myringoplasty:

Limit infections and impact on QoL

Prevent complications of recurrent ear infections

Improve hearing

Limit developmental consequences of hearing loss (HL)

Avoid behind-the-ear (BTE) HA

Avoid need for waterproofing / allow swimming

FA C T O R S A F F E C T I N G M Y R I N G O P L A S T Y S U C C E S S

• Patient factors

ET function, health of contralateral ear -Hardman 2015, (age)

• Perforation factors

No unequivocal evidence that infection affects outcome - Tan 2016

Size of perforation - Hardman 2015

Site of perforation

• Surgical factors

Surgical technique

Graft material

Adults & children Mean success 86.6% 5.8% higher failure rate in children Cartilage has superior closure rates (2.8% better than fascia) Success 6.1% better for perforations <50% No clear benefit from combined cortical mastoidectomy No superior graft placement technique (underlay etc.)

T I M I N G O F P E R F O R AT I O N R E PA I R

• How old? No current consensus, but trend towards younger ages Hartzell 2010

• How old? ETD commonest in 2-4 year olds…

…Consider in 4 + year olds if contralateral ear normal

155 children with 6 months FU

Success 2-4 yrs 50%, 5-7 yrs 61%, 8-13 yrs 74%

Mean improvement in ABG 9dB

• When? Initially wait for spontaneous closure (approx. 6 months) Duval 2015

• When? Initial conservative approach (waterproofing) allows for assessment of ET function in contralateral ear

Significant variability in success ratesS U R G I C A L T E C H N I Q U E F O R M Y R I N G O P L A S T Y

• Permeatal, post-auricular, endaural or endoscopic

• Choice influenced by surgical training / surgical preference and physical characteristics of the perforation

e.g. post-auricular for anterior, permeatal or endural for posterior Tan 2016

G R A F T M AT E R I A L F O R M Y R I N G O P L A S T Y

• autologous

fat- lobule, temporalis fascia, cartilage- tragus or concha

• xenografts (porcine or bovine)

• scaffolding materials (paper patch, gelatin sponge)

• (basic fibroblast growth factor (b-FGF)- stimulates cell proliferation and angiogenesis)

Autologous Graft Material Ethos Pros Cons Indication

Fat Graft

Promotes Angiogenesis And Neovascularisation

(Gun 2014)

Low Morbidity Harvest Rapid Surgery

Low-Invasiveness

Tends To Be Considered Only For Small

Perforations Avoid In Infected Ears

Central Perforation <25%

Grommet Removal

Temporalis Fascia Graft

ScaffoldStrong

Resistant To Infection

Low Morbidity Harvest

Retract Or Re-Perforate If Poor Eustachian Tube

Function

Any Size Perforation

Cartilage-

Underlay (Alone Or

Composite)

Reinforce Neotympanum

Very Strong High Success Rate

Resistant To Infection

Unable To Visualise Middle Ear

Larger Cartilage = Poorer Hearing Result

Any Size Perforation Younger Children

Revision Cases

Cartilage- Inlay (Butterfly)

Graft Anchored To Edges Of Perforation

No Need For

Tympanomeatal Flap (Avoid Flap When Extensive

Tympanosclerosis)

? Central Perforation 25 - 50%

Perforation History Relevance To Management & Decision Making

Age No Consensus 4+ Years If Ear Infections Have Significant Consequences On Development & Wellbeing

Symptoms Duration & Severity Of Symptoms Influence Decision To Operate Wait Approx. 6 Months For Spontaneous Closure

AetiologyEar Infection, Trauma, Iatrogenic Ear Infections May Lead To Adhesions. Trauma May Be Associated With Snhl

HearingIncreasing Understanding Of Impact From Unilateral Hearing Loss Perforation In An Only Hearing Ear Is Not Absolute Contra-Indication To Repair

Tinnitus / Vertigo Association With Hearing Loss And Inner Ear Involvement In Disease Process

Contralateral Ear Indicator Of Eustachian Tube Function

Previous Ear Surgery Revision Surgery = Lower Success, Revision Surgery Influences Choice Of Graft Material, Previous Ear Surgery - ? Cholesteatoma

Co-Morbidities Relevant To Perforation

Craniofacial Abnormalities Associated With Poor Eustachian Tube Function (Cleft Palate, Achondroplasia, Craniosynostosis)

Co-Morbidities Relevant To Impact

Hearing Loss In Children With Syndromes Or Cognitive Impairment Ear Infection & Sepsis In Diabetes And Immune Deficiencies

Fitness For General Anaesthesia

Influences Decision To Operate

Water Precautions Adequacy Important If Too Young Or Preference To Manage Conservatively

Perforation Exam Description Relevance To Management & Outcome

Contralateral EarGlue Ear, Retraction, (Bilateral Perforation)

Indicators Of Eustachian Tube Function Poor Function = Lower Success

Oral Cavity/ OropharynxCleft Palate Repair, Bifid Uvula

Possible Poor Eustachian Tube Function Poor Function = Lower Success

Nasal Cavity RhinitisAssociation With Eustachian Tube Function Optimise Nasal Health

Ear- Perforation Size %Size Influences Surgical Technique Larger Size = Lower Success

Ear- Perforation SiteQuadrants + Attic Influences Surgical Approach, Technical Difficulty &

Success

Ear- Relation To AnnulusCentral / Marginal Marginal Granulations

No Such Thing As ‘Safe’ Perforation Marginal Granulations - ?Cholesteatoma

Ear- Middle Ear Otorrhoea, GranulationsDry Ear Preferred, But Not Mandatory Influence Surgical Technique

Ear- Atelectasis/Tympanosclerosis

Grade Retraction, Extent Of Tympanosclerosis

Indicators Of Eustachian Tube Function Influence Decision To Operate & Technical Difficulty

Ear- CholesteatomaPerforation At Base Of Retraction

Determines Extent Of Surgery

Howtoassessaperforation

PS

PI

AS

AI

Pars Flaccida

Pars Tensa

Howtoassessaperforation

Size

20%40%

PS

PI

AS

AI

Pars Flaccida

Pars Tensa

Howtoassessaperforation

Relation toAnnulus

CentralMarginal

PS

PI

AS

AI

Size

20%40%

Pars Flaccida

Pars Tensa

Howtoassessaperforation Size

20%40%

Relation toAnnulus

CentralMarginal

PhysicalCharacteristics

Tympanosclerosis

PS

PI

AS

AI

Pars Flaccida

Pars Tensa

Middle Ear Health

Otorrhoea +Granulations

Howtoassessaperforation Size

20%40%

Relation toAnnulus

CentralMarginal

PhysicalCharacteristics

Tympanosclerosis

PS

PI

AS

AIMiddle Ear Health

Otorrhoea +Granulations

Pars Flaccida

Pars Tensa

R E T R A C T I O N S

• Ultimate aim to prevent atelectasis and/or cholesteatoma

• Need to manage the retraction and associated hearing loss

• No management strategy unequivocally proven to prevent progression to cholesteatoma

• Strategies include (or combination):

Watchful Waiting with surveillance for progression

Ventilate the middle ear whilst waiting for maturation in Eustachian Tube function

Resect the retraction

Reinforce the retracted segment with cartilage

Grade Sade Tos

1 Retraction Over Annulus Retraction Towards Malleus

2Retraction Onto Long

Process Of IncusRetraction Onto Malleus

3Retraction Touches

PromontoryErosion Of Outer Attic Wall

4Retraction Adherent To

PromontoryUnable To Fully Visualise

Extent Of Deep Retraction

Is watchful waiting the best strategy for retractions adherent to the incus?

Retraction Exam Description Relevance To Management & Outcome

Contralateral EarGlue Ear, Retraction, Perforation

Indicators Of Eustachian Tube Function

Oral Cavity/ Oropharynx

Cleft Palate Repair, Bifid Uvula

Possible Poor Eustachian Tube Function

Nasal Cavity RhinitisAssociation With Eustachian Tube Function Optimise Nasal Health

Ear- Infection/Inflammation/ Glue Ear

Granulations In Retraction- ? Cholesteatoma Indication Of Eustachian Tube Function

Ear- Extent Of Retraction

Grading System Or Narrative Description

Fixation To Middle Ear Structures Risks Iatrogenic Cholesteatoma If Attempt To Elevate And Resect Retraction Role Of Ventilation Tubes In Early Progressive Retractions

Erosion Of Ossicular Chain

Ear- Extent Of Tympanosclerosis

Extent Of TympanosclerosisInfluence On Technical Difficulty To Elevate Increases Size Of Perforation If Resect

Ear- CholesteatomaCholesteatoma In Retraction Pocket

Determines Extent Of Surgery

iain.bruce@mft.nhs.uk

ORCHID http://orcid.org/0000-0003-0831-4760

@Prof_IainBruce

www.manchesterchildrensent.com