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The goals myringoplasty and tympanoplas- quadrant? Does it only involve the
ty are to achieve a dry, self-cleansing ear posterior quadrant?
while preserving or restoring hearing. • What is the status of the middle ear
mucosa? Is it normal or granular/
Myringoplasty refers to grafting of the polypoidal? Is there airflow through
tympanic membrane without inspection of the perforation with a Valsalva man-
the ossicular chain. oeuvre?
• Is the handle of the malleus media-
Tympanoplasty entails grafting of the tym- lised? This may necessitate an ossicu-
panic membrane with inspection of ossicu- loplasty even in the presence of an
lar chain with/without reconstruction of the intact ossicular chain
middle ear hearing mechanism. • Is an ossiculoplasty required?
• Does the ossiculoplasty need to be
Ossiculoplasty is reconstruction of the staged?
hearing mechanism using either an autolo- • What is the status of the contralateral
gous graft or prosthesis. ear?
Meatoplasty involves enlargement of the Audiometry: This should have been done
lateral cartilaginous portion of the external recently i.e. within the preceding 3months.
auditory canal. A narrow entrance to the Correlate the size of the perforation with
ear canal within the cartilaginous portion the audiogram, particularly the air-bone
of the canal prevents proper ventilation and gap. Lerut, Pfammater & Linder investi-
self-cleaning of the ear canal, and may gated the correlation between air-bone gap
compromise hearing aid fitting. and perforation size. There was a strong
(Meatoplasty video) correlation between air-bone gap and
increasing perforation size; however the
Canalplasty is partial or total widening of location (anterior/posterior) had no impact
the bony portion of the external ear canal. on hearing. The greatest changes in air-
In order to visualise the tympanic annulus, bone gap were at 0.5 and 4kHz, and the
particularly in anterior or subtotal perfora- smallest changes at 2kHz. The audiograms
tions, canalplasty is essential and may be thus revealed a consistent “V”-shaped
an integral part of myringoplasty or tym- pattern with the turning point at
panoplasty. (Canalplasty video) 2kHz. This can be explained by the fact
that 2kHz is the resonance frequency of the
Preoperative assessment middle ear; thus hearing is better preserved
at this frequency. The clinical significance
Otomicroscopy: Both the size and site of is that one can predict the expected air-
the perforation determine the surgical bone gap by looking at the size of the
approach perforation. If the audiogram does not
• Size of perforation: Is the perforation correspond with the expected findings,
limited or subtotal? Microperforations then additional middle ear pathology must
may have a higher failure rate than be expected. If the air-bone gap is greater
larger perforations than 30dB, then an ossiculoplasty may be
• Site of perforation: Does the perfora- required.
tion extend far into the anterosuperior
Tympanometry: Tympanometry provides Surgical Approaches
additional information regarding the pa-
tient’s middle ear function; it can also be Optimal graft take depends on securing the
used to assess eustachian tube dysfunction graft; this in turn depends on having
(see below). The curve is always flat in the sufficient surgical exposure in order to
presence of a tympanic membrane perfora- stabilise the graft. Three different ap-
tion, but the volume measurements are of proaches may be used i.e. transcanal,
interest. endaural or retroauricular.
2
1:200 000), using a nasal speculum to
expose the ear canal
• A skin incision is made in the bony
external canal with a #15 blade from
the 12 o’clock position, spiralling
upwards between the cartilages of the
helix of the pinna and tragus (Figure
1). The incision is 1,5cm in length and
extends down to the bone
3
• Two endaural retractors are next placed • The middle ear is entered by elevating
in the ear canal to improve exposure the tympanomeatal flap at the level of
(Figure 5) the posterior tympanic spine (Figure 7)
• The edges of the perforation are fresh-
ened using a sickle knife before eleva-
ting the tympanomeatal flap
Tympanomeatal
flap
Malleoincudal
joint
Long process
of incus
Stapedius tendon
Chorda tympani
5
Temporalis
fascia
Periosteal
flap
• The periosteal flap is elevated from the • Cut with the scalpel in a cephalad
bone with a mastoid raspatory until direction and extend the incision
both the Spine of Henlé and the bony superiorly up to 12 o’clock. It is
external canal up to the 12 o’clock important that the blade remains on the
position, are exposed bone. The first incision now extends
from A - B (Figures 11, 13)
The next step is to raise a meatal skin
flap. The authors favour a spiral flap
technique, which should be practiced in
the temporal bone laboratory and will next
be described (Figure 11). (Spiral flap
video)
7
tically elevates the very fragile meatal
skin (Figures 17, 18)
8
• Using the larger (Iowa) raspatory the underlying tissue but swing the handle
meatal skin lateral to this circumferen- of the Key raspatory anteriorly so that
tial incision is dissected free from the the soft tissue is elevated out of the
bony external canal, leaving it pedicled
bony canal. Using a bigger instrument
inferiorly (Figures 23, 24)
avoid injuring the inferiorly based
pedicle (Figure 22)
9
• Elevate meatal spiral flap
• If there is a tympanic membrane perfo-
ration, gelfoam soaked in Ringer’s
Lactate is placed over the perforation
to avoid bone dust entering the middle
ear
• Starting with a 2,7mm rough diamond
burr, enlarge the ear canal by drilling
away any bony overhang
• Commence drilling posteriorly, then
move inferiorly and finally drill the
Figure 26: Ribbon passed around anterior canal wall
meatal spiral flap • The technique of skeletonisation is
important. With the correct technique
the bluish colour of the temporomandi-
bular joint (TMJ) will show through
the irrigation; this should alert one to
stop drilling before the joint is entered
• It is important to check that burr sizes
are correct by first placing a new burr
in the canal before using it
• Always drill under direct vision and
never behind overhanging edges of
bone. In this way one avoids opening
mastoid air cells or injuring the facial
Figure 27: Ribbon secured to self- nerve posteriorly and TMJ anteriorly
retaining retractor • Use the Fisch microraspatory (with
adrenaline gauze) to elevate the meatal
skin before drilling away bony
Canalplasty (Canalplasty video) overhangs (Figure 28)
10
• When drilling close to meatal skin, a 6 o’clock from medially to laterally to
diamond burr is used so that the meatal create a groove. Continue to drill until
skin is not injured by the burr the white colour of the annulus
• The microraspatory is held perpendi- becomes visible at the level of the
cularly to the bone at the level of the sulcus (Figure 31)
annulus; the tip of the microraspatory
is not visible because of the anterior
bony overhang. Using this technique,
one can determine how much bone
needs to be removed before reaching
the annulus (Figure 29)
11
Figure 33: Meatal skin flap being Figure 35: Ivalon® used to secure the
replaced meatal skin
• The meatal skin is secured with gel-
foam pledgets placed medially over the
graft. Two pieces are cut from an
Ivalon® ear wick and inserted laterally
into the ear canal over the meatal flap
(Figures 34, 35). Ivalon® has a smooth
surface which is placed on the outside
(facing the meatal skin) to allow for
atraumatic removal one week
postoperatively
• The postauricular periosteal flap is
replaced and secured with 3/0 Vicryl Figure 36: Securing the retroauricular
sutures (Figure 36) periosteal flap
12
Antrotomy • If the test is positive, there is no need to
further explore the epitympanum
An antrotomy is performed in conjunction • If the test is negative, then one needs to
with a myringo- or tympanoplasty when explore the epitympanum
eustachian tube function is questionable or • If abnormal mucosa is removed from
in the presence of polypoidal middle ear the epitympanum but the ossicles are
mucosa obstructing the epitympanum left intact, this is defined as an
(Figure 38). epitympanotomy.
• If malleus head and incus need to be
removed to re-establish patency, this is
referred to as an epitympanectomy
• Following the procedure, a groove is
drilled posteriorly into the mastoid
bone to accommodate a transmastoid
drain
• A separate stab incision is made pos-
terior to the retroauricular skin incision
and the drain is fixed to the skin using
a silk suture
• The patient may perform Valsalva
manoeuvres from the 2nd day following
Figure 38: Antrotomy defect surgery
• The mastoid drain is usually removed
The detailed surgical steps for antrotomy after 2-4 days
are presented in the chapter on Mastoidec-
tomy and epitympanectomy
Grafting tympanic membrane
Epitympanic patency is determined by perforations
means of the water test: Ringer’s solution
is irrigated into the antrum to test whether Choice of graft material
there is free communication between the
antrum and the middle ear (Figure 39)
• Temporalis fascia is widely used to
reconstruct the tympanic membrane. It
is easily accessible and long-term
results are comparable to that of carti-
lage tympanoplasty. An advantage of
temporalis fascia is that recurrent or
residual cholesteatoma can easily be
identified behind the reconstructed
tympanic membrane
• Tragal perichondrium
• Cartilage is preferred in certain instan-
ces due to its resilience: it may be used
to reinforce an atrophic tympanic
membrane; it is used in addition to
Figure 39: Antrum irrigated with Ringer’s
fascia in a closed mastoidoepitympa-
solution
nectomy to reconstruct the posterior
13
canal wall; and certain middle ear
prostheses require reinforcement of the
overlying tympanic membrane to
prevent extrusion through tympanic
membrane
14
cartilage with a microraspatory. The
perichondrium may also be left attach-
ed to the tragal cartilage when recon-
structing the posterosuperior canal wall
• To thin cartilage, hold it with Hudson
Brown forceps and section the cartilage
with a new #10 blade
Grafting Techniques
Figure 43: Incision to accommodate The authors use the terms “underlay” and
tensor tympani tendon “overlay” to refer to position of the graft
relative to the bony (annular) sulcus. (In
• When doing revision surgery, it is pos- other texts it may refer to the position of
sible to extend the postauricular inci- the graft in relation to the tympanic
sion superiorly in order to find addi- membrane)
tional temporalis fascia (Figure 44) • With underlay technique the graft is
placed medial to the remnant of the
tympanic membrane and anterior tym-
panic sulcus
• With overlay technique the graft is
placed lateral to the tympanic sulcus
15
These surgical steps are discussed in detail
under endaural approach
Figure 49
16
• Retroauricular approach is used
• Canalplasty is done
• Elevate and divide the tympanomeatal
flap posteriorly (Figure 47)
• Scrape the undersurface of the tympa-
nic membrane remnant with a 1,5mm,
45° hook
• Fixing the graft anteriorly requires
special anterior support
• Detach the tympanic annulus between
1 and 2 o’clock (right ear) using a mic- Figure 51: Use a microsuction tube to
roraspatory to create a “buttonhole” suck and pull “tongue” of temporalis
anteriorly between annular ligament fascia through “buttonhole”
and bone (Figure 50)
17
Management of severely retracted
malleus with chronic otitis media with
Ossiculoplasty
Acknowledgments
Figure 57: Two tongues overlap in
middle ear beneath malleus handle This surgical guide is based on the text by
Professor Ugo Fisch (Tympanoplasty,
Mastoidectomy, and Stapes Surgery) and
Reconstruction with open mastoidoepi- the personal experience of Professor
tympanectomy Linder, as well as course material for the
temporal and advanced temporal bone
See the Mastoidectomy and epitympanec- courses conducted annually by Professors
tomy chapter for a description of recon- Fisch and Linder at the Department of
struction at the time of primary surgery Anatomy, University of Zurich,
• A circumferential tympanic groove is Switzerland.
drilled with a small diamond burr to
form a new tympanic sulcus
• The graft is placed as with repair of a Download meatoplasty video
subtotal perforation https://vula.uct.ac.za/access/content/group/
• If a 2nd stage ossiculoplasty is planned 9c29ba04-b1ee-49b9-8c85-
then it becomes necessary to place
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