1. Pediatric Tympanoplasty
Incisions and Decisions

2. Tympanoplasty most common otologic procedure in children
focus on success rates
should focus on decision making
timing of surgery
technique
Eustachian tube health

3. Tympanoplasty pediatric tympanoplasty differs from adult:
etiology
growth
importance of audition
surgical results are variable
experiential data

4. Definitions myringoplasty tympanoplasty mastoidectomy drum middle ear

5. Tympanic Membrane Healing
normal healing
epithelialization
contraction
growth inhibition

6. Tympanic Membrane Healing
normal healing
epithelialization
contraction
growth inhibition

7. Tympanic Membrane Healing
normal healing
epithelialization
contraction
growth inhibition

8. Tympanic Membrane Perforation
middle ear needs aeration
ET dysfunction
recurrent OM
foreign body

9. Tympanic Membrane Perforation
middle ear needs aeration
ET dysfunction
recurrent OM
foreign body

10. Tympanoplasty set-up for normal repair initiate epithelialization
diminish obstacles
guide edges

11. Tympanoplasty set-up for normal repair initiate epithelialization
diminish obstacles
guide edges

12. Tympanoplasty set-up for normal repair initiate epithelialization
diminish obstacles
guide edges

13. Top Ten Tympanoplasty Tips
1. upper respiratory system 2. define the outcome 3. age 4. otorrhea 5. characteristics affects decisions
6. mind the jugular 7. material 8. pull-up don’t push-up 9. craniofacial anomalies 10. durability results from decisions

14. 1. Upper Respiratory System
ear is a component
Eustachian Tube
mucosa
allergy
irritative
environmental
immunologic

15. Middle Ear Ventilation

16. Contralateral Eustachian Tube
best predictor of success
generally paired system
½ Pressure
½ Pressure
Pressure with swallowing

17. 2. Define Outcome quality of life otorrhea hearing preservation
restoration

18. “Successful” Tympanoplasty
surgeon
intact drum
no morbidity
patient/family
ability to swim
symptom resolution
improved hearing
keratin growing from umbo into Right Ear Perforation, 8 year old boy

19. Morbidity taste disturbance ear sticks out noticeable scar pain
allergic reaction
hearing loss
facial palsy

20. Morbidity

21. Relative Contraindications
asymptomatic perforation
unfit for surgery
repeated failures
unfavorable conditions
unstable contralateral ear
cleft palate(?)
smoking
13year old, stable dry perforation, ++++ anxiety about operations

22. 3. Age
age is the only factor which affects rate of success in children

23. 3. Age
4 year old, no OME burned by arc welding spark
age is the only factor which affects rate of success in children
no it’s not!
11year old, CLP, bilateral CSOM, failed repair

24. 3. Age
age is the only factor which affects rate of success in children
no it’s not!
percentage of success 5 10 15 20

25. 3. Age
age is the only factor which affects rate of success in children
no it’s not!
yes it is!!

26. 3. Age
age is the only factor which affects rate of success in children
no it’s not!
yes it is!!

27. 4. Otorrhea is the otorrhea causing the perforation?
11year old, CLP, bilateral CSOM, failed repair
is the otorrhea causing the perforation?
is the perforation causing the otorrhea?

28. Middle Ear Physiology? Temperature 38oC Temperature 5oC Humidity 85%
30%

29. Middle Ear Physiology? Temperature 21oC Temperature 19oC Humidity 49%
47%

30. 5. Characteristics of the Perforation
size, position, revision and tympanosclerosis
don’t impact success
impact selection of:
technique
material
timing of OR

31. Characteristics difficult characteristics revision
total/subtotal TM perforation
anterior marginal perforations
tympanosclerosis

32. Lateral Graft Tympanoplasty with Alloderm

33. Lateral Graft Tympanoplasty
equal closure rate
“better” closure of air/bone gap

34. 6. Mind the Jugular Vein
elevating the annulus
right > left

35. Mind the Jugular Vein
elevating the annulus
right > left

36. Mind the Jugular Vein
elevating the annulus
right > left

37. 7. Choosing Materials temporalis fascia tragal perichondrium
tragal cartilage
allografts
Alloderm (human dermis)
Surgysis (porcine sub-mucosa)
anterior
inferior

38. 7. Choosing Materials temporalis fascia tragal perichondrium*
tragal cartilage*
allografts
Alloderm (human dermis)
Surgysis (porcine sub-mucosa)
anterior
inferior

39. Butterfly Graft Tympanoplasty
case selection:
<1/3 of drum
minimal contact with malleus
advantages
fast
efficacious

40. Forming the Graft tragal cartilage one side with perichondrium
form it into the shape of a ventilation tube

41. Forming the Graft tragal cartilage one side with perichondrium
form it into the shape of a ventilation tube

42. Forming the Graft tragal cartilage one side with perichondrium
form it into the shape of a ventilation tube

43. Butterfly Graft Tympanoplasty
great technique to have in your arsenal

44. 8. Pull-Up Don’t Push Down
gelfoam causes middle ear fibrosis
reduced aeration?
prefer to suspend graft
clips
pegs

45. 8. Pull-Up Don’t Push Down
gelfoam causes middle ear fibrosis
reduced aeration?
prefer to suspend graft
clips
pegs

46. 8. Pull-Up Don’t Push Down
gelfoam causes middle ear fibrosis
reduced aeration?
prefer to suspend graft
clips
pegs

47. Pegged Graft

48. Lifting the Tympanic Membrane
standard 12 to 6 tympanomeatal flap

49. Lifting the Tympanic Membrane
graft pulled into a straight line to peg

50. Lifting the Tympanic Membrane
standard 12 to 6 tympanomeatal flap
extended flap for inferior perforations

51. Lifting the Tympanic Membrane
graft pulled into position for coverage

52. 9. Craniofacial Anomalies
no difference in success rates!!
big difference in canal anatomy
big difference in decisions when to operate
operate later (surgical bias)
actual success rate by age is the same

53. 10. Durability all about decisions technique material
timing of operation
desired outcomes

54. Bonus Tip watch this space!! tissue engineering
application in the eardrum in use
hyaluronic acid/fat graft
growth factor and gelfoam

55. Conclusions understand patient’s: each ear is different needs
expectations
anatomy
physiology
each ear is different
“Ether Day” (October 16, 1846) by Robert C. Hinckley