Anchored Myringoplasty for TotalPerforation With Malleus Adhesion tothe Promontory
Giovanni Ralli, MD; Jacqueline Crupi, MD; Giuseppe Nola, MD; Marco de Vincentiis, MD
INTRODUCTIONIn the normal ear the distance between the tympanic
membrane at the umbo and the middle ear mucosa at thelevel of the promontory is at least 2.5 mm.1 This distanceinfluences the vibratory properties of the middle ear. Ifthe inferior aspect of the malleus approaches or is fixed tothe promontory, a significant impairment of the conduc-tive mechanism occurs.
Adhesions between the inferior aspect of the malleushandle and the promontory are occasionally present in pa-tients with ear drum perforations. This condition can beisolated or, more commonly, associated with adhesions inother sites of the ossicular chain. Only a few cases have beenreported in the literature2,3 and the overall incidence of thisphenomenon is not known.
According to Schuknecht,4 the adhesions of the malleusto the promontory in the presence of chronic tympanic mem-brane perforation are caused by the unopposed pull of thetensor tympani muscle leading to medial displacement of themanubrium. The fixation of the malleus handle to the prom-ontory can also be the result of a diffuse atrophy and retrac-tion of the tympanic membrane secondary to tubal dysfunc-tion according to the retraction theory.5 Pathologies of themiddle ear, such as adhesions of the umbo to the promon-tory, have been recently classified by Sultan.2
In order to surgically treat such a condition the in-tervention must include the repair of the tympanic mem-brane and its correct relocation in the middle ear cavity. A
variety of myringoplasty techniques have been described inthe past 30 years to repair large tympanic membrane perfo-rations. So far the results documented in these studies arevery promising and the surgical technique continues to beupdated.
Primrose and Kerr6 were able to improve graft ten-sion by using an anterior tunnel created under the annu-lus. Gristwood and Venables7 described an underlay my-ringoplasty creating two anterior tunnels for graftstabilization. Sauvage et al.8 presented a surgical tech-nique that included the creation of a large anterior flap forstabilizing the fascia. In addition, thin Silastic has oftenbeen used to avoid the formation of new adhesions.9
From the University of Rome “La Sapienza,” II E.N.T Division,Department of Otolaryngology (G.R., G.N.), and the University of Rome “LaSapienza” IV E.N.T. Division, Department of Otolaryngology (J.C., M.d.V.),Policlinico Umberto I, Rome, Italy.
Editor’s Note: This Manuscript was accepted for publication January25, 2000.
Send Correspondence to Prof. Giovanni Ralli, MD, Piazza Bologna n.55, Rome 00162, Italy.
Fig. 1. Total perforation of the tympanic membrane after canalincision.
Laryngoscope 110: April 2000 Ralli et al.: Anchored Myringoplasty
674
From 1991 we have been using the technique of un-derlay anchored myringoplasty first described for therepair of total tympanic membrane perforations.10 Thisprocedure utilizes anterior and posterior tunnels toachieve proper tension of the tympanic membrane as wellas lateral traction of the malleus handle. This report ex-pands scope of the underlay anchored myringoplasty toinclude perforations associated with adhesions of the mal-leus to the promontory. The remainder of the ossicularchain must be intact and normally mobile.
MATERIALS AND METHODSFrom 1991 to 1995 76 patients (76 ears) underwent an-
chored myringoplasty for the repair of total tympanic membraneperforations. Twelve patients had associated adhesions of the
malleus handle to the promontory. These 12 subjects are pre-sented separately. Work-up included history, neurotologic exam-ination, audiometric testing, and otomicroscopy (Carl ZeissOPO17). The mean age of the patients was 40.7 years. There weresix men and six women. The mean postoperative follow-up was 54months (range, 1–6 y). Pathology of the drum and middle earalterations were documented using Hopkins telescope 30° opticsconnected to a light source (Karl Storz 482VB) and a videoprinter(Hitachi 900). A total perforation of the tympanic membrane withumbo adhesion at the level of promontory was observed in allcases. Subjects were classified according to age, sex, affected side,number of ears, middle ear conditions, and preoperative air andbone conduction audiometry.
Surgical TechniqueA postauricular incision is made with elevation of the mus-
cle and fascia overlying the mastoid cortex. A canal incision (Fig.1) is followed by the preparation of the spiral flap11 and theelevation of the tympanomeatal flap (Fig. 2). The anterior canalwall overhang is removed for complete visualization of the tym-panic membrane perforation and the annulus. By vertical incisionof the residual external ear canal, two swinging door flaps areelevated12 (Fig. 3). This exposure allows a wide view of the anat-omy of the middle ear. Surgical exploration should assess thestatus and the mobility of the middle ear ossicles. The ear shouldbe examined carefully for fibrous adhesions, tympanosclerosis,otosclerosis, ossicular erosion, or discontinuity.
The perforation is prepared by curetting its margins. Adhe-sions from the umbo to the promontory are sharply divided withscissors. The malleus is then mobilized, taking care to avoid incud-omallear disarticulation. The lateral mobilization of the malleusrestores the normal distance between the umbo and the promontory.
Before anchoring the graft, two tunnels are created in theanterior canal wall. The first tunnel is placed between the fibrousannulus and the bony sulcus superiorly. The second tunnel iscreated between the chorda tympani and the bony sulcus postero-superiorly (Fig. 4). The temporalis fascia graft is designed and cutto include anchoring strips in addition to the radial slit thataccommodates the malleus handle (Fig. 5).
Fig. 2. Incision of the spiral flap.
Fig. 3. The spiral flap is completelyelevated and placed at the inferiorlevel of the canal. The swing doorflaps are incised.
Laryngoscope 110: April 2000 Ralli et al.: Anchored Myringoplasty
675
The graft, with its two sickle-shaped strips, is placed under themalleus handle and the annulus (Fig. 6). The first strip is pulledthrough the tunnel created in the anterosuperior aspect of the an-nulus. This first maneuver anchors and stabilizes the graft anteri-orly. The second strip is put into the posterosuperior tunnel beneaththe chorda tympani. The tension and the stability of the graft maybe easily adjusted by pulling the strips. Gelfoam is placed in themiddle ear space at the anteroinferior level to support the graft.
Once the repair is complete, the tympanic membrane posi-tion is restored by elevation and lateral traction of the malleushandle. The swinging door flaps are positioned in the originallocation covering the posterior aspect of the graft (Fig. 7). Thespiral meatal flap is carefully repositioned to cover the entiresurface of the canal (Figs. 8 and 9). Sylastic is placed at thepromontory level to prevent the reformation of fibrous tissue andthe adhesion of the malleus handle to the promontory. Gelfoamsoaked in physiological solution is used to keep the tympa-
nomeatal flap in place. Patients are started on antibiotic eardrops on the tenth postoperative day. Patients are followedweekly for the first 3 weeks, monthly for 6 months and finallytwice a year with hearing tests and microtoscopy.
RESULTSSurgical results were evaluated according to the an-
atomic status of the drum and hearing results (air bone-conduction thresholds and tympanometry).
Anatomic StatusA healed tympanic membrane was obtained in all but
one patient (11/12 cases; 91.7%). One patient had a per-sistent perforation. One of the 11 healed grafts was foundto have lateralized postoperatively. In all 11 cases theneo-membrane appeared to be intact and well epithelial-ized; however, in one of these patients a lateralization ofthe tympanic membrane with an evident gap between theear drum and the malleus handle was noted. The status ofthe external auditory canal (EAC) was normal in all cases(there was no evidence of inclusional cysts, stenosis, oraltered self-cleaning capacity).
Functional StatusThe mean postoperative pure-tone average (PTA)
was 27 dB compared with 55 dB preoperatively. Thisresult is an improvement of the air-bone gap from 29 dBpreoperatively to 11 dB postoperatively. In seven patients,the air-bone gap was 10 dB or less, and in 4 it was within20 dB. The patient with residual anterior perforation hada residual air-bone gap of 27 dB (preoperative, 37 dB), andthe case with ear drum lateralization presented an air-bone gap of 32 dB. A type A tympanogram was obtained in10 cases (83.3%). While a type B tympanogram was foundin the patient with a lateralization of the graft.
Fig. 4. Elevation of the swing doorflaps and creation of the anteriorand posterior tunnel.
Fig. 5. Temporal fascia graft with two flaps.
Laryngoscope 110: April 2000 Ralli et al.: Anchored Myringoplasty
676
DISCUSSIONConservative myringoplasty is indicated in routine
tympanic membrane perforations. However, repair oftympanic membrane perforations will fail to improvehearing results if fibrous adhesions from the malleus tothe promontory are not identified and removed.
It has been reported that in tympanic membraneperforations associated with adhesions of the umbo to thepromontory, surgery may include a type 1 tympanoplastywith surgical repair of the tympanic membrane, explora-tion of the middle ear structures, and possible removal of
middle ear pathology2 or, a type 2 tympanoplasty3 withsurgical removal of disease and a reconstructive procedureto re-establish ossicular function.9,13
Yabe et al.14 suggest a more aggressive techniquesuch as a type 3 tympanoplasty though, this latter proce-dure (tympanoplasty or tympanomastoidectomy) is usu-ally recommended for total ossicular anchyloses to eradi-cate middle ear disease and to reconstruct the hearingmechanism. Thus in these circumstances a tympanoplastytype 3 could be considered overtreatment for these se-lected patients. The choice of a nonconventional myringo-
Fig. 6. The fascia is anchored un-der the chord tympani and it is po-sitioned medial to both malleus andannulus.
Fig. 7. The fascia is stabilized at theanterior and posterior canal level.
Laryngoscope 110: April 2000 Ralli et al.: Anchored Myringoplasty
677
plasty may be considered a possible alternative to theabove-mentioned procedures.15,16
It is well established that positioning the graft me-dial to the malleus handle helps to avoid the risk of tym-panic membrane lateralization.17,18 Restoration of theumbo to promontory relationship is essential for goodhearing results. The authors believe that the anchoring ofthe graft anteriorly and posteriorly in the surgically cre-ated tunnels results in a lateral force that prevents refor-mation of the adhesions from the umbo to the promontory.Elevation and lateral traction of the malleus handle willresult in stabilization and preservation of the correct an-atomic relationship between the malleus, incus and stapes
in the middle ear cavity. Using the underlay anchoringprocedure that was originally presented for total perfora-tions of the tympanic membrane10 improves sound andhelps maintain an air-containing middle ear space.19
CONCLUSIONThe anchored myringoplasty technique described
here is a useful adjunctive procedure to restore hearingresults in a limited number of cases. Although this condi-tion is uncommon, the results obtained using this tech-nique are promising.
ACKNOWLEDGMENTThe authors thank Dr. Dennis Maceri for his critical
review of the manuscript
BIBLIOGRAPHY1. Beck C. Anatomy of the ear. In: Otorhinolaryngology. New
York: Georg, 1970;3;3:1–49.2. Sultan AA. Chirurgie de l’ oreille moyenne. In: Traite de Tech-
niques Chirurgicales de l’ Oreille. Paris: Maloine, 1988:161–3.3. Tos M. Manual of Middle Ear Surgery. New York: Georg
Thieme, 1993;1:260–264.4. Schuknecht HF, Gulya AJ. Anatomy of the Temporal Bone
With Surgical Implications. Philadelphia: Lea & Febiger,1986:22–25.
5. Tos M. Upon the relationship between secretory otitis inchildhood and chronic otitis and its sequelae in adults.J Laryngol Otol 1981;95:1011–1022.
Fig. 8. The swing door flaps arereturned to the original position.
Fig. 9. The spiral flap is repositioned in place.
Laryngoscope 110: April 2000 Ralli et al.: Anchored Myringoplasty
678
9. Sheehy JL. Surgery for chronic otitis media. Otolaryngology.Philadelphia: JB Lippincott, 1989;20:1–86.
10. Ralli G, Gianfrone G, Tuz M, Pafundi E, Nola G. Myringo-plasty for total perforations. In: Proceedings of the Inter-national Congress of Audiology, Bari, 1996.
11. Fisch U. Tympanoplasty, Mastoidectomy, and Stapes Sur-gery. New York: Georg Thieme, 1994:10–34.
12. Palva T, Palva A. Myringoplasty. Ann Otol Rhinol Laryngol1969;78:1074–80.
13. Wullstein HL, Wullstein SR. Healing and hearing. In: Tym-panoplasty. New York Georg Thieme, 1990:176–177.
14. Yabe T, Moriyama H, Kamide Y, Honda Y. Tympanosclerosis:
clinical and pathological investigation. Nippon JibinkokaGakkai Kaiho1995;98(4):606–612.
15. Fried MP. Recent Advances in Laser Otolaryngology. KeioMed 1993;42:171–173.
16. Lanser M. Effective tympanoplasty. Otolaryngology Update.University of California San Francisco, Nov.3–5, 1994.
17. Sheehy JL, Anderson RG. Myringoplasty. A review of 472cases. Ann Otol Rhinol Laryngol 1980;89:331–333.
18. Glasscock M, Shambaugh. Surgery of the ear. In: Tympano-plasty. Philadelphia: WB Saunders, 1990:344–345.
