TYMPANOPLASTY THAT WORKS BEST

Timothy T.K. Jung1,2

1Department of Otolaryngology-Head and Neck Surgery, Loma Linda University, Loma Linda, CA and Jerry L. Pettis Veterans Medical Center, Loma Linda, CA, USA; 2Inland Ear, Head & Neck Clinic, Riverside, CA, USA

Introduction

One of the common sequelae of chronic otitis media is tympanic membrane (TM) perforation, which can cause hearing loss and otorrhea. The two traditional methods for reconstruction of TM perforation have been medial (underlay) or lateral (overlay) graft techniques. In the underlay technique, the graft is placed entirely medial to the remaining TM and annulus. This is perhaps the most common and easiest technique. It is typically used for posterior or central TM perforations. In the overlay technique, the graft is placed lateral to the annulus, and any remaining fibrous middle layer after the squamous layer has been carefully removed. The anterior canal wall is widened with a drill to minimize blunting, and the graft is placed lateral to the remaining TM but medial to the manubrium of malleus to prevent lateralization. The canal skin is placed back as a free graft. Each of these techniques has its advantages and disadvantages.1,2 We have developed a new medio-lateral graft tympanoplasty technique which seems to be superior to the traditional methods for repairing anterior or subtotal TM perforation.3,4

The anterior or subtotal TM perforation is difficult to repair because there is less vascularity than in the posterior tympanic membrane4 and there is an anterior bony overhang that blocks the vision. Because of reduced vascularity in the anterior tympanic membrane, there is a greater risk of necrosis and re-absorption of the fascia graft.5 When the medial graft technique is used to repair anterior or subtotal TM perforation, the anterior portion of the fascia graft may fall away, resulting in re-perforation and obliteration of anterior part of the middle-ear cavity.6 Although the lateral graft technique has a higher success rate for the reconstruction of anterior or subtotal TM perforation, lateralization of graft may occur especially when malleus is absent. These problems have been managed by a variety of surgical techniques, such as the use of Williams’s micro-clip,8 sandwich-graft tympanoplasty,6 over-under tympanoplasty,7 window-shade tympanoplasty,9 and so on.

During the past 17 years, we have developed and used the medio-lateral graft tympanoplasty for repair of anterior or subtotal TM perforation. In the medio-lateral graft technique, the fascia graft is placed medially to the posterior half of the TM perforation and laterally to the anterior half of the perforation.3,4 This method is a hybrid of the medial- and lateral-graft techniques that takes advantage of both methods. The purpose of this instruction course is to describe and instruct how to do the medio-lateral graft tympanoplasty for anterior or subtotal TM perforation and medial-graft tympanoplasty for reconstruction of posterior TM perforation.

Materials and methods

Surgical technique

The procedure is usually performed under general anesthesia. Depending on the anatomy and clinical findings, transcanal, endaural, or postauricular approaches are used. A rim of tissue is removed from the perforation edge to de-epithelialize and encourage migration of the mucosal layer and epithelium. Vertical canal incisions are made at the 12- and 6-o’clock positions. The 6-o’clock incision can be extended right up to the annulus. The 12-o’clock incision is made down to a few millimeters above the annulus close to the short process of malleus to preserve blood supply when anterior canal skin is used as the superiorly based flap. A posterior tympanomeatal flap is elevated, and ossicles are evaluated (Fig. 1A). Mastoidectomy or ossiculoplasty are performed at the appropriate time if needed.

image

Fig.1. Surgical steps of medio-lateral graft tympanoplasty for anterior or subtotal TM perforation. (A) A posterior tympanomeatal flap is elevated and ossicles are evaluated. (B) Antero-medial canal skin is elevated along with epithelial layer of TM up to anterior half of the perforation. (C) The temporalis fascia is placed medially (underlay) posterior half of the perforation and laterally (overlay) anterior half of the perforation up to the annulus. (D) Antero-medial canal skin is rotated as a superiorly based flap to cover perforation and fascia as a second layer. If necessary, posterior canal skin can be rotated and cover posterior part of graft and perforation especially for the subtotal TM perforation.

Medial graft for posterior TM perforation

In posterior TM perforation, the temporalis fascia is grafted as a medial graft under the tympanic membrane perforation. As shown in Fig. 2, to ensure closure of TM perforation, graft is inserted between manubrium of malleus and TM. To do this the temporalis fascia is harvested, pressed and semi-dried and a slit cut is made. The TM over the manubrium is elevated and one part of the graft is placed between TM and manubrium, and the other part under the TM. The middle ear cavity is packed with Gelfoam soaked in non-ototoxic antibiotic (usually fluoroquinolone) otic drops. The packing is placed as described below.

Medio-lateral graft for anterior or subtotal TM perforation

For anterior or subtotal TM perforation, medio-lateral graft was used. In medio-lateral tympanoplasty, after the tympanomeatal flap is elevated similar to the medial graft technique, a horizontal incision is made in the anterior canal skin with a curved round knife. The distance of the anterior-horizontal canal incision from the anterior annulus should be about the same as or slightly longer than the diameter of the perforation. After the incision, the anterior canal skin is elevated (Fig. 1B), then canalplasty is performed by drilling the anterior bony overhang with diamond burrs and suction irrigator until a full view of the anterior annulus is possible. The antero-medial canal skin flap is elevated up to the annulus or margin of the TM. At the annulus, only the squamous epithelial layer of the TM is carefully elevated to the anterior half of the perforation edge, leaving the anterior annulus intact. The middle ear cavity is packed with Gelfoam soaked in non-ototoxic antibiotic (usually fluoroquinolone) otic drops. Unlike in the case of usual medial graft technique, the middle-ear packing does not have to be tight because the graft is supported by the intact annulus. In medial-graft tympanoplasty, since the temporalis fascia is grafted medially in relationship to the manubrium of malleus and under the TM perforation and annulus, packing in the middle ear has to be tight to support the graft and to prevent fascia fall-away. In medio-lateral tympanoplasty the temporalis fascia is grafted medially for the posterior half of the perforation and is grafted laterally over the remnant de-epithelialized TM and annulus for the anterior half of the perforation (Fig. 1C). To avoid anterior blunting, the fascia graft is brought only to the anterior sulcus on the annulus, not passing beyond the anterior annular sulcus. As a second layer of closure, antero-medial canal skin is rotated to cover perforation and fascia as a superiorly based flap (Fig. 1D). Antero-lateral canal skin is replaced, and packings are placed. Traditional rosebud packing is inserted by using otosilk strips with a small to medium-sized cotton ball inside, soaked in the antibiotic otic drops. The rest of the ear canal is packed with a gauze strip soaked in antibiotic ointment or Xerofoam gauze. The incision site is closed in the usual manner.

image

Fig.2. Surgical steps to repair posterior TM perforation with medial graft tympanoplasty. First, the edges of perforation are denuded and the tympanomeatal flap is elevated. From top left, the temporalis fascia is harvested, pressed and semidried and slit cut is made. TM over manubrium is elevated and one part of the graft is placed between TM and manubrium and the other under the TM. Bottom right shows overall scheme of medial (underlay) graft.

Discussion

Over the years, various techniques have been attempted to improve tympanoplasty results. These include overlay tympanoplasty10, underlay tympanoplasty,11 Gelfilm sandwich tympanoplasty,12 Crowncork tympanoplasty,13 swinging-door tympanoplasty,15 sandwich-graft tympanoplasty,7 window-shade tympanoplasty,9 and palisade cartilage technique.16 Among them, underlay and overlay techniques are most commonly used. The advantages of medial (underlay) graft include ease of learning the technique, avoidance of the risk of lateralization and blunting of the anterior sulcus, and high success rate, especially for the posterior perforation. The disadvantages of medial graft are poor visualization of the anterior tympanum, possible anterior graft fall-away when used for anterior perforation, reduction of middle ear space with consequent increased risk of adhesions, and less suitability for reconstruction of anterior TM perforation.1,2 The lateral (overlay) graft provides superior exposure, suitable for all perforations, and minimizes reduction of the middle ear space. This technique has a high success rate and has been particularly effective for large, anterior perforations. The disadvantages of lateral graft include anterior blunting, possible lateralization of graft especially with absent malleus, tendency to create more epithelial pearls, need for malleus manipulation, longer healing time, increased operation time, and complexity for repair of small posterior perforations.

One of the most serious complications of the overlay graft techniques is lateralization of the graft. Later-alization of the TM is a condition in which the visible surface of the TM is located either at the bony annular ring or lateral to it and loses contact with the conducting mechanism of the middle ear. Lateralization of the TM may be associated with considerable morbidity, including hearing loss and cholesteatoma. Surgical repair is often necessary for significant underlying disease, but re-establishment of a normal TM can be challeng-ing.15 Medio-lateral graft tympanoplasty avoids lateralization of the graft by placing the fascia medially to the posterior half of the TM and perforation, as well as the manubrium of the malleus, and laterally to the anterior half of the perforation to prevent lateralization. In our study, there was no lateralization of graft or reconstructed TM.3,4

The medio-lateral graft tympanoplasty is a hybrid between medial and lateral graft methods taking advantages of both methods. It has many advantages over traditional medial or lateral graft: (1) prevention of anterior fall-away of the fascia; (2) stability of the graft, like ‘a button in a button hole’; (3) no need for tight Gelfoam packing to support the graft; (4) prevention of lateralization of the graft; (5) better blood supply and faster healing because the anterior canal skin is rotated as a rotational flap rather than a free graft; (6) easier because the epithelial layer of only the anterior half of the TM remnant is elevated, rather than the entire TM; and (7) less malleus manipulation.

Conclusion

The medial tympanoplasty is best suited for repair of the posterior TM perforation with high success rate. The medio-lateral graft method has been developed and used for reconstruction of the large anterior or subtotal TM perforation. Success rate is high (97%), since it takes advantages of both the medial and lateral grafting methods while avoiding their pitfalls.4 This method should help otologic surgeons to improve the outcome of tympanoplasty for anterior or subtotal TM perforation.

References

1.Rizer F. Overlay versus underlay tympanoplasty. Part I: historical review of the literature; Part II: the study. Laryngoscope 107:1–36, 1997

2.Wehrs R. Grafting techniques. Otolaryngol Clin North Am 32(3):443–455, 1999

3.Jung T, Park S. Mediolateral graft tympanoplasty for anterior or subtotal tympanic membrane perforation. Otolaryngol Head Neck Surg 132:532–536, 2005

4.Jung T, Kim Youhyun, Kim Yoonhwan, Park S, Martin D. Medial or medio-lateral graft tympanoplasty for repair of tympanic membrane perforation. International J Ped Otorhinolaryngo 73:941–943, 2009

5.Applebaum E, Deutsch E. An endoscopic method of tympanic membrane fluorescein angiography. Ann Otol Rhinol Laryngol 95:439–443, 1986

6.Farrior J. Sandwich graft tympanoplasty: experience, results, and complications. Laryngoscope 99:213–217, 1989

7.Weider D. Use of the Williams microclip in various aspects of tymanoplastic surgery. Laryngoscope 91:2106–2125, 1981

8.Kartush J, Michaelides E, Becvarovski Z, LaRouere M. Over-under tympanoplasty. Laryngoscope 112: 802–807, 2002

9.Schraff S, Dash N, Strasnick B. ‘Window shade’ tympanoplasty for anterior marginal perforations. Laryngoscope 115:1655–1659, 2005

10.House W. Myringoplasty. Arch Otolaryngo 71:399–404, 1960

11.Shea J. Vein graft closure of eardrum perforation. J Laryngol Otol 74:3598–362, 1960

12.Karlan M. Gelatin film sandwich in tympanoplasty. Otolaryngol. Head Neck Sur 87:84–86, 1979

13.Harwein J, Leuwer R, Kehrl W. The total reconstruction of the tympanic membrane by the Crowncork technique. Am J Otolaryngo 13:172–175, 1992

14.Schwaber M. Postauricular undersurface tympanic membrane grafting: some modification of the ‘swinging door’ technique. Otolaryngol Head Neck Surg 95:182–187, 1986

15.Sperling N, Kay D. Diagnosis and management of the lateralized tympanic membrane. Larynoscope 110:1987–1993, 2000

16.Neumann A, Schultz-Coulon H, Jahnke K. Type III tympanoplasty applying the palisade cartilage technique: a study of 61 cases. Otol Neurotol 24:33–37, 2003


Address for correspondence: Timothy T.K. Jung, MD, 11790 Pecan Way, Loma Linda, CA 92354, USA. ttkjung@gmail.com or timothy. jung@va.gov

Cholesteatoma and Ear Surgery – An Update, pp. 169–172

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands