MMyyringoringoplastyplastyTympanoplastyTympanoplasty

Department of Otorhinolaryngoglogythe 2nd Hospital affliatted to Medical college

Zhejiang UniversityXu Yaping

overviewoverview

DefineDefine termsterms HistoryHistory AnatomyAnatomy Preoperative evaluationPreoperative evaluation TechniquesTechniques ComplicationsComplications ResultsResults

DefinitionDefinition

Myringoplasty and tympanoplasty are Myringoplasty and tympanoplasty are descriptive terms defining descriptive terms defining surgical surgical proceduresprocedures that address pathology of the that address pathology of the tympanic membrane (TM) and middle ear.tympanic membrane (TM) and middle ear.

MyringoplastyMyringoplasty - reconstruction of a perforation - reconstruction of a perforation of the tympanic membrane (TM)of the tympanic membrane (TM) Assumes – normal middle ear (ME) mucosa and Assumes – normal middle ear (ME) mucosa and

ossiclesossicles TM is not elevated from its sulcusTM is not elevated from its sulcus

TympanoplastyTympanoplasty – reconstruction of the TM – reconstruction of the TM Also includes addressing middle ear pathologyAlso includes addressing middle ear pathology

• Cholesteatoma, adhesionsCholesteatoma, adhesions• Ossicular chain problemsOssicular chain problems• Usually involves elevating the TM from its sulcusUsually involves elevating the TM from its sulcus

Classification of TympanoplastyClassification of TympanoplastyWullstein (1956)Wullstein (1956)

Type I: Hearing is achieved via an anatomically and functType I: Hearing is achieved via an anatomically and functionally intact lever mechanism of the ossicular.ionally intact lever mechanism of the ossicular.

an intact ossicular chainan intact ossicular chain Type II: Hearing is achieved via an abnormal but recontrType II: Hearing is achieved via an abnormal but recontr

ucted lever mechanism of the sound-conducting ossiculaucted lever mechanism of the sound-conducting ossicular.r.

Malleus is partially eroded Malleus is partially eroded TM +/- malleus remnant is grafted to the incusTM +/- malleus remnant is grafted to the incus

Type III: Hearing is achieved without a lever mechanism Type III: Hearing is achieved without a lever mechanism but with sound pressure transformation of the tympanic but with sound pressure transformation of the tympanic membrane. membrane.

Malleus and incus are erodedMalleus and incus are eroded TM is grafted to the stapes suprastructureTM is grafted to the stapes suprastructure

Types with sound protectionTypes with sound protection

Type IV: Hearing is achieved by sound protaction of one Type IV: Hearing is achieved by sound protaction of one of the windows ( usually the round window) through the lof the windows ( usually the round window) through the lower aeration pathway.ower aeration pathway.

Stapes suprastructure is eroded but foot plate is mobileStapes suprastructure is eroded but foot plate is mobile

TM is grafted to a mobile foot plateTM is grafted to a mobile foot plate

Type V TympanoplastyType V Tympanoplasty• TM is grafted to a fenestration in the horizontal TM is grafted to a fenestration in the horizontal

semicircular canalsemicircular canal

History of TympanoplastyHistory of Tympanoplasty 1640 – Banzer1640 – Banzer

First attempt at repair of a TM perforationFirst attempt at repair of a TM perforation Used pigs bladder as a lateral graftUsed pigs bladder as a lateral graft

1853 – Toynbee1853 – Toynbee Placed a rubber disk attached to a silver wire over the TMPlaced a rubber disk attached to a silver wire over the TM Reported significant hearing improvementReported significant hearing improvement

1863 – Yearsley 1863 – Yearsley placed a cotton ball over a perforationplaced a cotton ball over a perforation

1877 – Blake1877 – Blake Paper patchPaper patch First reported use of cartilage for reconstruction of the TMFirst reported use of cartilage for reconstruction of the TM

1876 – Roosa1876 – Roosa Treated TM perf. with chemical cauteryTreated TM perf. with chemical cautery

1878 – Berthold 1878 – Berthold Coined the term myringoplastyCoined the term myringoplasty Placed cork plaster against TM to remove Placed cork plaster against TM to remove

epitheliumepithelium Applied a FTSGApplied a FTSG

AnatomyAnatomy

Preoperative EvaluationPreoperative Evaluation

HistoryHistory Hearing lossHearing loss TinnitusTinnitus VertigoVertigo OtalgiaOtalgia OtorrheaOtorrhea Facial paralysisFacial paralysis Prior otologic proceduresPrior otologic procedures Medical history – DM, heart, lung, kidney, liverMedical history – DM, heart, lung, kidney, liver

Physical exam – complete H/N examPhysical exam – complete H/N exam Facial nerveFacial nerve External earExternal ear Tullio’s PhenomenonTullio’s Phenomenon OtomicroscopyOtomicroscopy

• Ear canalEar canal• TMTM

Perforation – location, sizePerforation – location, size Retraction pockets, granulation tissueRetraction pockets, granulation tissue Status of middle ear through perforationStatus of middle ear through perforation

Audiometry – preferable with a dry earAudiometry – preferable with a dry ear >2 weeks >2 weeks• Air and bone lines, acoustic reflexesAir and bone lines, acoustic reflexes

TympanometryTympanometry: : eustachian tubeeustachian tube +/- CT temporal bone+/- CT temporal bone

Indications for SurgeryIndications for Surgery

Conductive hearing lossConductive hearing loss due to TM perforation due to TM perforation or ossicular dysfunctionor ossicular dysfunction

Chronic or Chronic or recurrent otitis mediarecurrent otitis media secondary to secondary to contamination contamination

Progressive hearing lossProgressive hearing loss due to chronic middle due to chronic middle ear pathologyear pathology

Perforation or hearing lossPerforation or hearing loss persistent > 3 months persistent > 3 months due to trauma, infection, or surgerydue to trauma, infection, or surgery

InabilityInability to bathe or participate in water sports to bathe or participate in water sports safelysafely

Goals of SurgeryGoals of Surgery

Establish an intact TMEstablish an intact TM Eradicate middle ear disease and create Eradicate middle ear disease and create

an air-containing middle ear spacean air-containing middle ear space Restore hearing by building a secure Restore hearing by building a secure

connection between the ear drum and the connection between the ear drum and the cochleacochlea

MMyyringoringoplastyplasty

TechniquesTechniques

Overlay technique (lateral grafting)Overlay technique (lateral grafting) Underlay technique (medial grafting)Underlay technique (medial grafting)

Medial GraftingMedial Grafting

Debride the edges of the perforationsDebride the edges of the perforations

PurposePurpose Separates the Separates the

continuity continuity

of the inner mucosa of the inner mucosa with with

the outer epitheliumthe outer epithelium Disrupts the fistulous Disrupts the fistulous

tracttract

Elevation of the tympanomeatal flapElevation of the tympanomeatal flap

Inspect the Inspect the undersurface of the undersurface of the TM for squamTM for squam

Inspect the middle earInspect the middle ear OssiclesOssicles

• ErosionErosion• mobilitymobility

Round window reflexRound window reflex Eustachian tubeEustachian tube

Pack middle ear with gelfoamPack middle ear with gelfoam

Placing medial fascia graftPlacing medial fascia graft

Replacing the tympanomeatal flapReplacing the tympanomeatal flap

Lateral GraftingLateral Grafting

Tympanic MembraneTympanic Membrane

Oval shape.Oval shape. 8x10 mm.8x10 mm. 55° angle w/ respect to 55° angle w/ respect to

floor of meatus.floor of meatus. 130 µm thick.130 µm thick. 3 layers:3 layers:

• Outer epithelial – Outer epithelial – keratinizing squamouskeratinizing squamous

• Middle fibrous – superficial Middle fibrous – superficial radial, deep circularradial, deep circular

• Inner – mucosaInner – mucosa

Graft MaterialsGraft Materials

FasciaFascia PerichondriumPerichondrium: tragal cartilage: tragal cartilage VeinVein DuraDura SkinSkin CartilageCartilage: : tragal cartilagetragal cartilage

Inlay Butterfly GraftInlay Butterfly Graft

Eavey RD 1998

Placement of Butterfly graftPlacement of Butterfly graft

Postop Inlay Butterfly graftPostop Inlay Butterfly graft

Inlay graft for large perforationInlay graft for large perforation

Tragal Tragal perichondriumperichondrium Harvest Harvest

Cut on medial side of tragusCut on medial side of tragus Leave 2 mm tragal cartilage for Leave 2 mm tragal cartilage for

cosmesiscosmesis Abundance: 15 x 10 mm Abundance: 15 x 10 mm FlatFlat ~ 1 mm thickness~ 1 mm thickness Perichondrium is removedPerichondrium is removed

Dornhoffer 2003

Perichondrium/ Cartilage GraftPerichondrium/ Cartilage Graft

Dornhoffer 2003

Medial GraftingMedial Grafting

Dornhoffer 2003

Postop Perichondrium/ Cartilage Postop Perichondrium/ Cartilage Island GraftIsland Graft

Dornhoffer 2003

Postop carePostop care

2 weeks postop:2 weeks postop: Gelfoam completely Gelfoam completely suctioned from EACsuctioned from EAC

Start topical antibiotics x 2 weeksStart topical antibiotics x 2 weeks Adult: Start valsalva Adult: Start valsalva Children: Otovent TIDChildren: Otovent TID 3-4 months:3-4 months: Audiogram Audiogram

Air bone gapAir bone gap Tympanogram no longer reliable. Type B tymp Tympanogram no longer reliable. Type B tymp

despite normal hearingdespite normal hearing

Cartilage T-plasty with TORPCartilage T-plasty with TORP

Type III tympanoplastyType III tympanoplasty

TORP using cartilage stiffenerTORP using cartilage stiffener

Type IV TympanopastyType IV Tympanopasty

ComplicationsComplications

InfectionInfection Poor aseptic techniquePoor aseptic technique Prior contaminationPrior contamination Graft failure is associated with postop infectionGraft failure is associated with postop infection

Graft failureGraft failure InfectionInfection Inadequate packing (anterior mesotympanum)Inadequate packing (anterior mesotympanum) Inadequate overlay of graft with TM remnant Inadequate overlay of graft with TM remnant

(underlay)(underlay)

ChondritisChondritis Injury to the chorda tympani nerveInjury to the chorda tympani nerve SNHL and vertigoSNHL and vertigo

Excessive manipulation of the ossiclesExcessive manipulation of the ossicles

Increased conductive hearing lossIncreased conductive hearing loss Unrecognized eroded ISJUnrecognized eroded ISJ BluntingBlunting

• Thick graft extending onto the anterior canal wall in lateral Thick graft extending onto the anterior canal wall in lateral graftinggrafting

Lateralization of the TM from the malleus handleLateralization of the TM from the malleus handle

External auditory canal stenosisExternal auditory canal stenosis Lateral grafting Lateral grafting

ConclusionConclusion AA high rate of success in high rate of success in closingclosing tympanic membrane tympanic membrane

perforations and improving perforations and improving hearinghearing

Patients should be chosen carefully based on the Patients should be chosen carefully based on the indications indications fofo

r r a dry ear prior to surgery a dry ear prior to surgery

Patients should be thoroughly counseled preoperatively about Patients should be thoroughly counseled preoperatively about

the the expectations and goalsexpectations and goals of the surgery of the surgery

Tympanoplasty in the pediatric age group is controversialTympanoplasty in the pediatric age group is controversial

((less successful than adultsless successful than adults,h,higher incidence of igher incidence of ETDETD ----

eustachian tube dysfunctioneustachian tube dysfunction and and otitis mediaotitis media))

Both underlay and overlay techniques for grafting are effective, Both underlay and overlay techniques for grafting are effective,

however, the surgeon should do what he/she is most however, the surgeon should do what he/she is most

experienced and successfulexperienced and successful