FACTORS INFLUENCING HEARING AFTER TYPE-III TYMPANOPLASTY USING COLUMELLA

Yuji Kanazawa, Yasushi Naito, Keizo Fujiwara, Masahiro Kikuchi, Shogo Shinihara

Department of Otolaryngology, Kobe City Medical Center General Hospital, Kobe, Japan

Introduction

The purpose of tympanoplasty for chronic ear diseases is to cure the disease, preserving/improving hearing. To obtain post-operative hearing, a variety of materials are used for a columella in type-III tympanoplasty, including autografts and prostheses. This surgery is usually performed with canal-wall-up or canal-wall-down mastoidectomy, which influences the post-operative middle ear conditions. Among middle ear conditions, aeration of the tympanic cavity is critical to the success of any type of tympanoplasty.1 Therefore, both choice of the material of the columella and the middle ear aeration are important for successful tympanoplasty. The overall goal of this study is to better understand the keys resulting in good hearing outcomes with type-III tympanoplasty.

Patients and methods

From April 2004 to May 2011, 110 ears of 107 patients underwent type-III tympanoplasty using a columella at Kobe Medical Center General Hospital. All procedures were performed by the senior author (YN). Excluding nine patients of ossicular malformations, 101 ears of 99 patients were enrolled in this study (58 male and 41 female patients; age, 3–78 yr; mean age, 38 yr). Ossiculoplasty’s with the columella on stapes head and on stapes footplate were performed in 74 and 27 ears, respectively. Fifty-one ears (50%) were pars flaccida type cholesteatoma, 25 ears (25%) were pars tensa type, combined, or secondary cholesteatoma, 13 ears (13%) were congenital cholesteatoma, and 13 ears (13%) were adhesive otitis media, tympanosclerosis and others. Seventy-five ears (74%) underwent canal wall down mastoidectomy with soft wall reconstruction.2 Audiometric data obtained at least one year after the surgery were used by calculating the pure-tone average of 0.5, 1, 2, 4 kHz. Post-operative air-bone (A-B) gaps were calculated in each ear and divided into four bins: 0–10, 11–20, 21–30, and greater than 30 dB. We reviewed the relationship between the materials of columella and post-operative A-B gap. In addition, we reviewed the clinical records and the computed tomography (CT) findings of the ears of which postoperative A-B gaps were greater than 21 dB, and determine the cause of poor postoperative hearing.

Results

Hearing outcomes in the 101 ears according to the post-operative A-B gap were as follows (Table 1): 0–10 dB, 21 ears; 11–20 dB, 39 ears; 21–30 dB, nine ears; and greater than 30 dB, five ears in 74 ears undergoing type-III tympanoplasty using columella on stapes head, and 0–10 dB, six ears; 11–20 dB, 11 ears; 21–30 dB, seven ears; and greater than 30 dB, three ears in 27 ears undergoing type-III tympanoplasty using columella on stapes footplate. The relationship between the A-B gap and the materials for columella showed Table 2. There was no significant difference among materials for columella in hearing outcomes. Among the 24 ears (24%) of which post-operative A-B gaps were greater than 21 dB, 18 ears exhibited poor middle ear aeration caused by eardrum retraction, adhesion, inflammation or fibrosis (11 ears), tympanosclerosis and diseased stapes mobility (five ears), Eustachian tube dysfunction due to sniffing habit or cleft palate (two ears). Six ears had problems of columella: displacement (two ears), detachment from the eardrum or stapes head (two ears), ankylosis due to contacting with the bony wall of the tympanic cavity (two ears).

Table 1. Postoperative hearing. Number of the ears divided according to postoperative air-bone gap (average: 500, 1000, 2000, 4000Hz)

Columella on stapes head

Collumella on stapes footplate

0–10dB

21 ears

6 ears

11–20dB

39 ears

11 ears

21–30dB

9 ears

7 ears

31dB

5 ears

3 ears

Total ears

74 ears

27 ears

A-B gap average

13.8dB

18.5dB

[0–43.8]

[0–37.5]

Table 2. Postoperative air-bone gap (average: 500, 1000, 2000, 4000Hz)

Columella on stapes head

Collumella on stapes footplate

Auto ossicle (incus or malleus)

14.0 dB [n=41]

18.5 dB [n=14]

Cortical bone

14.4 dB [n=24]

18.4 dB [n=7]

Hydroxyapptite

14.5 dB [n=4]

26.3 dB [n=3]

Cartilage

23.1 dB [n=4]

11.3 dB [n=3]

Silastic plate

30.0 dB [n=1]

Total

15.4 dB [n=74]

18.5 dB [n=27]

Discussion

In the present study, good hearing results were obtained by mainly using autologous tissues including ossicles, cortical bone, and cartilage, which were used for columella. These autologous tissues are biocompatible and can achieve long-term success with hearing results.3 But, on the other hand, poor aeration of the middle ear space was associated with poor post-operative hearing more strongly than the problems of columella. Poor aeration of the middle ear space was due to Eustachian tube dysfunction, chronic infection, and mucosal adhesion, which result in severe attical and/or posterior wall retraction and atelectasis of the tympanic membrane. These problems can occur regardless of careful procedure for tympanoplasty. In such cases, it may be effective to use cartilage as a grafting material on account of its increased stability and resistance to negative middle ear pressure.4 Further study is needed to determine long-term results for each surgical procedure.

Conclusion

Post-operative hearing may be influenced more by middle ear conditions than columella itself. Control of inflammation and good aeration of the tympanic cavity are important to obtain favorable post-operative hearing.

References

1.Merchant S, McKenna M, Mehta R Ravicz ME, Rosowski JJ. Middle ear mechanics of type III tympanoplasty (stapes columella): II. Clinical studies. Otol Neurotol 24:186–194, 2003

2.Smith PG, Stroud MH, Goebel JA. Soft-wall reconstruction of the posterior external ear canal wall. Otolaryngol Head and Neck Surg 94:355–359, 1986

3.Sismanis A, Poe D. Ossicular chain reconstruction. In: Gulya A, Minor L, Poe D (eds.). Glasscock-Shambaugh’s Surgery of the Ear, 6th edition, pp.489–499. China: PMPH-USA 2010

4.Cabra J, Monux A. Efficacy of cartilage palisade tympanoplasty: Randomaized control trial. Otol Neurotol 31:589–595, 2010


Address for correspondence: Yuji Kanazawa, 2–1-1, Minatojima-minamimachi, Chuo-ku, Kobe 650–0047, Japan. kanazawayuji2000@gmail.com

Cholesteatoma and Ear Surgery – An Update, pp. 129–130

Edited by Haruo Takahashi

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