1. Principles of tympanoplasty
The term tympanoplasty was first used in 1953 by Wullstein to describe surgical techniques for reconstruction
of the middle ear hearing mechanism that had been impaired or destroyed by chronic ear disease.
Fritz Zöllner (born 1901).
Horst Wullstein (born 1906).
Eminent otologic surgeons who developed the concepts and techniques
of tympanoplasty.
By : Dr. Supreet Singh Nayyar, AFMC
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Tuesday, July 17, 2012

2. Layout History & evolution of middle ear surgery
Definition of tympanoplasty
The transformer mechanism in health and disease
Functional considerations of tympanoplasty
Classification
Principles of tympanoplasty surgery
Basics of ossiculoplasty
Reporting protocols
Pediatric tympanoplasty
Recent advances
Tuesday, July 17, 2012

3. Evolution of Middle Ear Surgery
Era of Experimentation
19th century
Era of Opposition
Late 19th & early 20th century
Era of Revival
1920’s
Era of Reorientation
1940’s ’s
Tympanoplasty is the final step in the surgical conquest of conductive hearing losses and is the culmination of over 100 years of development of surgical procedures on the middle ear to improve hearing.
Mechanics of the middle ear had been defined clearly by Helmholtz in 1868
The first of these procedures was the stapes mobilization of Kessel in 1878, soon followed by Berthold’s plastic repair of a perforated
tympanic membrane in the same year and Kiesselbach’s attempt in 1883 to correct a congenital meatal
atresia. These 7 eventful years might well have been the beginning of a fruitful development of operations for
conductive hearing losses because the. However, despite the successes with stapes mobilization reported by Boucheron6 in 1888 and
Miot in 1890, the new surgery for deafness declined and almost died out for reasons that are not entirely clear. By
the end of the nineteenth century, a determined opposition by the leaders in otology had arisen toward all
attempts to improve hearing by operations on the middle ear.
The strong opposition against surgery for deafness was reflected in the standard texts of otology and otologic surgery, which scarcely mentioned or mentioned only to condemn such operations. For example, Kerrison’s 627-page Diseases of the Ear, published in 1930, devoted less than a single page to surgical measures for relief of deafness, concluding that “These operations, mentioned for their place in otological history, are quite obsolete today.” It is even more surprising that Sir Charles Ballance, in his two-volume text, failed to mention any sort of operation to improve hearing.
Reasons for the opposition
lack of surgical microscopes
imperfect sterilization techniques
absence of protective antibiotics
iatrogenic injuries and infections
serious infections following the early operations
unfortunate unreported results contributed to the opposition
lack of audiometers
Intense preoccupation of the otologists of those days with infections of the ear and their complications
It is evident that the climate of otologic thought was favorable toward procedures to control infection
and quite unfavorable toward operations on the ear to improve hearing.
The revival of interest in the surgery of deafness began when Holmgren, with considerable courage in
the face of the concerted opposition, began his long series of operations on the labyrinth for otosclerosis,
demonstrating that with modern methods of aseptic technique, the non infected mastoid process and labyrinth
could, after all, be opened safely. The development of the operating microscope, first by Nylén in 1921, who
used a monocular instrument, and then by Holmgren, who introduced the binocular operating microscope in
1922, was an important advance destined to play an increasing role in the perfection of fenestration, stapes
operations, and tympanoplastic surgery. Sourdille’s ingenious and successful tympano-labyrinthopexy for
otosclerosis added to the reviving interest in surgery for deafness.
The real turning point in the reorientation of otologic surgery away from operations for infection toward reconstruction of the hearing mechanism occurred when Lempert combined Sourdille’s several-stage operation into
a more practical one-stage fenestration operation. At this time, sulfonamide therapy of acute otitis media and
otitic complications had begun to lessen the urgency and frequency of operations for acute mastoiditis. Lempert
emphasized careful aseptic technique in the postoperative period as well as during the fenestration operation.
With the later addition to sulfonamides of prophylactic penicillin, postoperative infections lost much of their
threat. Most important of all, Lempert taught his operation to otologists from all parts of the world. It was
inevitable, as the number of patients successfully treated by Lempert and his pupils increased to hundreds and then
thousands, that the traditional and often bitter opposition started to decline. Thanks to Lempert, the climate
of otologic thought finally became favorable toward surgery for deafness. This led first to the successful
operations for congenital meatal atresia in 1947 by Pattee and Ombrédanne and finally to the revival of
stapes mobilization by Rosen in 1953
It is interesting that tympanoplasty techniques for chronic otitis media began in Germany rather than in the
United States, where fenestration surgery had reached a high degree of maturity and perfection.
In 1950, Moritz first described the use of pedicled flaps to construct a closed middle ear cavity in cases of
chronic suppuration, to provide sound shielding or protection for the round window in preparation for a later
fenestration of the horizontal semicircular canal. The principles of Moritz’s procedure were immediately
apparent. Zöllner in 1951, and Wullstein in 1952, reported similar operations to provide sound protection
for the round window and to reconstruct sound pressure transformation for the oval window. Early on,
Wullstein advocated free skin transplants rather than pedicle grafts used by Moritz, and Zöllner soon after
changed from pedicle to free grafts as well.
Tympanoplastic techniques have subsequently undergone major changes. Zöllner replaced distant free skin
grafts with meatal skin removed as a free full-thickness graft. Shea and Tabb reported the use of vein as a
grafting material independently. Temporalis fascia was described by Heermann and was introduced in the United States by Storrs. Plastic prostheses for reconstruction of the ossicular chain were tried early on and abandoned by Zöllner and Wullstein; however, they continued to be used in the United States both for tympanoplasty and stapedectomy. Soon after, the tendency toward rejection and extrusion of the plastic prostheses used in tympanoplasties and stapedectomies became evident. Following these initial failures, it was soon realized that wire prostheses made of stainless steel, platinum, or tantalum were better tolerated in the middle ear.
Era of Modernity
From then on.....
Tuesday, July 17, 2012

4. Acoustic transformer mechanism
Ossicular coupling
Hydraulic lever
Ossicular lever
Catenary lever
Acoustic coupling
When animals emerged from the sea onto dry land, a mechanical device was needed to overcome the airwater
sound barrier. The middle ear mechanism, developed from the discarded bronchial apparatus no longer
needed for breathing, was the answer. By means of a rather large hydraulic ratio of large tympanic membrane
acting on the small stapes footplate, combined with a rather small lever ratio of the longer handle of the
malleus acting on the slightly shorter long process of the incus, airborne sound vibrations of large amplitude but
small force are transformed to fluidborne sound vibrations of small amplitude but large force.
In 1868, Hermann von Helmholtz[21] defined the principles of impedance matching by the middle ear. He proposed three levers to accomplish the required pressure transformation.The tympanic membrane, which is rigidly fixed at the periphery and mobile centrally, acts as a catenary lever, exerting its force on the malleus handle in response to pressure changes transmitted through the external auditory canal.[46] A twofold gain in sound pressure level is generated at the malleus. Although the pars flaccida seems to allow free movement of the malleus head in the epitympanum and may decrease middle ear-external ear atmospheric pressure differences, it has a only a minor acoustic role in humans.
The ossicular lever is produced when the incus and the malleus rotate as a unit around an axis, extending from the anterior mallear ligament through the incudal ligament.[11] The ossicular lever taken alone produces a small mechanical advantage for sound transmission. Further studies by Tonndorf and Khanna[46] showed the catenary lever was tightly coupled to the ossicular lever, because the tympanic membrane is extensively adherent to the malleus handle. Corrected calculations revealed a combined catenary-ossicular lever ratio of 1:2.3.
The hydraulic lever facilitates the transmission of the sound pressure, which is collected over the larger tympanic membrane and passed on to the much smaller stapedial footplate. For the hydraulic lever to be functional, the stapes should move in a "piston-like" fashion, which has been elegantly described by Guinan and Peake.[19] The increased force is proportional to the ratio of the areas of the tympanic membrane to the footplate. The area of the tympanic membrane is approximately 85 mm2 and that of the stapes footplate is 3.2 mm2.[17] After studying 43 human temporal bones, Saunders concluded that the "areal ratio" was the most important component of the middle ear impedance matching system. Ratios varied from ear to ear but averaged 20.8:1.
According to studies done on fresh cadaveric human temporal bones, the mean sound pressure gain produced by the human middle ear is 26.6 dB and is centered around its resonant frequency (0.9–1.0 kHz). Above 1 kHz, the pressure gain measured at the stapes footplate decreases at a rate of -8.6 dB/octave.
The pressure gain that results from ossicular coupling in normal ears is frequency-dependent, and its magnitude is less than traditionally believed. The mean middle ear gain is about 20 dB between 250 and 500 Hz, reaches a maximum of about 25 dB around 1 kHz, and then decreases at about 6 dB per octave at frequencies above 1 kHz
Preferential increase in sound pressure at the oval window
Damping effect of the TM
Free passive movement of RW upon stimulation of inner ear by stapes movement
Sound can be transmitted from the ear canal to the cochlea by two mechanisms: ossicular and acoustic coupling. Ossicular coupling is the sound pressure gain that occurs through the tympanic membrane and the ossicular chain. Acoustic coupling is the difference in the sound pressure that is acting directly on the oval and round windows. In normal ears, acoustic coupling is negligible, but it may play a significant role in diseased and reconstructed ears.
When sound input to the cochlea depends solely on acoustic coupling (e.g., ossicular interruption behind an intact tympanic membrane, complete absence of the tympanic membrane and ossicles), the stimulus to the cochlea depends on both the relative magnitude and the phase of the oval- and round-window pressures. The magnitude difference is more important than the phase difference.
The round window in the normal ear acts as a relief opening at the opposite end of the cochlear duct from
the stapes footplate to permit maximum to-and-fro vibratory movements of the relatively non compressible
cochlear fluid column in the rigid bony cochlea. In the intact ear, the round window membrane movements are largely passive in response to the stapes footplate movements. This is partly because the 22 times pressure increase at the oval window far exceeds any competitive pressure exerted on the round window from the tympanic cavity side. Furthermore, round window membrane movements are largely passive in response to the stapes footplate movements because the intact tympanic membrane “protects” the round window from competitive sounds, partly by damping and partly by a phase lag, so the modest intensity of sound that reaches the round window may actually strengthen rather than cancel the movements of the cochlear fluid column. The relative importance of damping and phase shifting in the sound protection afforded to the round window by the intact tympanic membrane remains to be determined.
Tuesday, July 17, 2012

5. Transformer in Diseased State
Effect on Ossicular coupling
Ossicular Discontinuity
Ossicular Fixity
Effect on Acoustic coupling
Loss of Round Window shielding
Effect of Stapes, Cochlear & RW Impedance
Middle ear aeration / fluid
An interruption of the ossicular chain does not add much to the loss of a large perforation, but behind an
intact tympanic membrane, an interrupted ossicular chain produces an enormous and maximum loss of
hearing of the conductive type because now both windows lie behind sound protection and there is no sound pressure transformation for the oval window. This is one situation in which the 60- to 65-dB loss, representing
a loss of sound energy transmission of a million times or more, may be improved to a 40-dB loss simply by
removal of the tympanic membrane.
In the diseased ear impaired by chronic ear disease, the round window begins to play a more active and disturbing
role in the mechanics of hearing. A perforation of the tympanic membrane removes sound protection
from the round window, with a tendency for sound to reach both windows at nearly the same moment, thus canceling the resultant movements of the cochlear fluid column. As long as the transformer ratio of the middle ear is larger, as in the case of a small tympanic membrane perforation with an intact ossicular chain, the canceling effect of sound reaching the round window is small. As the perforation enlarges and the transformer ratio diminishes, the canceling effect of sound on the unprotected round window rises rapidly until with a total perforation there is a loss of 40 to 45 dB or a loss of sound energy transmission of 10,000 times or more.
There is also a contribution of the stapes-cochlear impedance and the round-window membrane to middle ear function. Normally motion of the stapes footplate is "opposed" by the annular ligament, the cochlear fluids and partition, and the round window membrane. Pathologic changes in the impedance of the stapes annular ligament, the cochlea, or the round window can cause hearing loss such as that caused by otosclerotic stapes fixation. Also, in a nonaerated middle ear, the presence of fluid or fibrous tissue within the round-window niche can increase the round-window impedance and cause conductive loss.
   5.    Aeration of the middle ear plays an important role in sound transmission. In addition to contributing to normal stapes-cochlear impedance (see previous), aeration is critical for normal ossicular coupling. The compressible air within the middle ear allows the tympanic membrane and the ossicles to move.[33][57] Impaired middle ear aeration can adversely affect ossicular coupling by altering a pressure difference that is important to middle ear function. In the normal human middle ear, sound pressure in the ear canal is higher than sound pressure within the middle ear; tympanic membrane motion is driven by this pressure difference. Reductions in middle ear air volume that result from disease or surgery lead to elevated middle ear air space impedance and an increase in middle-ear sound pressure. This leads to a reduction in the pressure difference across the tympanic membrane, with a subsequent reduction in tympanic membrane and ossicular motion.[30] The minimum amount of air required to maintain ossicular coupling within 10 dB of normal has been estimated to be 0.5 mL.[36]
Tuesday, July 17, 2012

6. Definition of Tympanoplasty
“ Procedure to eradicate disease in the middle ear & to reconstruct the hearing mechanism with/without TM (tympanic membrane) grafting ”*
* American Academy of Ophthalmology & Otolaryngology Subcommittee on Conservation of Hearing
In 1965, the American Academy of Ophthalmology and Otolaryngology Subcommittee on Conservation of Hearing
set forth a standard classification for surgery of chronic ear infection and defined tympanoplasty as “a
procedure to eradicate disease in the middle ear and to reconstruct the hearing mechanism, with or without
tympanic membrane grafting.”47 This operation can be combined with either an intact canal wall (ICW) or a canal
wall down (CWD) mastoidectomy to eradicate disease from the mastoid area. Tympanoplasty with or without
mastoidectomy is indicated for chronic ear disease processes such as tympanic membrane perforations
resulting from previous middle ear infections, atelectatic tympanic membranes, retraction pockets, cholesteatomas,
tympanosclerosis, and chronic otitis media with effusion or mastoid cholesterol granuloma. In the same report,
myringoplasty is defined as “an operation in which the reconstructive procedure is limited to repair of a tympanic
membrane perforation.”
In this classification, types of tympanoplasty are distinguished according to the method of ossicular reconstruction.
In other words, the surgeon is expected to describe what was done. The original classification system
of Wullstein is illustrated in Figure 24–1. This classification system is still used in the vernacular of otology
(eg, a “type III mechanism” or a “type I tympanoplasty”) but is not used in reporting results.
The Subcommittee’s classification also enumerates a set of rules for describing the gross pathology present
at the time of surgery for chronic suppurative otitis media. These rules have to do with the type and location
of a perforation of the tympanic membrane, status of the ossicular chain, presence of otorrhea, and status of the
mucosa and eustachian tube. In addition, guidelines have been set forth for reporting results. In the past,
most workers described success in terms of hearing improvement only when, in fact, elimination of infection
and preservation or restoration of anatomy are of equal importance. Therefore, results today are reported in relation to control of pathology, anatomic status, hearing improvement, and postoperative complications.
Tuesday, July 17, 2012

7. Goals of Surgery To establish intact tympanic membrane
Eradication of middle ear disease & create an air containing middle ear space
Restore hearing by building a secure connection between the tympanic membrane & cochlea
Tuesday, July 17, 2012

8. Techniques Minimalistic techniques Formal Tympanoplasty
Cauterization & fat plug
Cauterization with trichloroacetic acid
Sealed tympanostomy tubes
Formal Tympanoplasty
Minimalist Techniques
There are some clinical situations in which a minimalist approach to tympanoplasty is possible or desirable. Small, uninfected, established perforations of 1- to 2-mm diameter can often be managed in an office setting in this way. The epithelium at the margins of the perforation is cauterized or removed, and a fat plug that is slightly larger than the diameter of the perforation is removed from the lobule to use as a graft. It is placed through the opening in a dumbbell fashion and covered with a dressing such as Gelfoam or Gelfilm (Pharmacia & Upjohn Company, Kalamazoo, Mi). Others prefer to simply cauterize the perforation edges with trichloroacetic acid or phenol and apply a patch of Gelfoam, Gelfilm, cigarette paper, or a hyaluronic acid film (Epidisc [Medtronic Xomed Inc., Jacksonville, Fl]). Traumatic perforations are also often managed by patching only after the perforation edges are realigned. In addition, a recent study described the use of a simple device in the shape of a sealed tympanostomy tube (Medtronic Xomed Inc., Jacksonville, Fl) that is designed to be inserted into tympanic membrane perforations in patients when surgery is contraindicated or refused by the patient.
Tuesday, July 17, 2012

9. Classification of Tympanoplasty
1956- Wullstein
Type 1
Type 2
Type 3
Type 4
Type 5
WULLSTEIN
I Intact Ossicular Chain. SS present. Incus Present. Repair of TM
II Handle of Malleus Missing, but otherwise intact chain
Graft placed on intact IS joint (Myringoincudopexy)
Rare situation
III SS present
Myringostapediopexy
IV SS Absent. Graft placed over RW for baffle effect
V Fixed Stapes FP. Fenestration of Lat SCC.
Tuesday, July 17, 2012

10. Classification of Tympanoplasty
Mirko Tos
1 - Intact chain
2 – Short columella
3 – Long columella
4 - Sound protection
5A - Fenestration
of LSCC
5B - Platinectomy
TOS
I Intact ossicular chain
Repair of Tympanic Membrane
II Stapes present
Interposition of ossicle/other prosthesis between grafted eardrum / malleus handle and stapes head / arch
SS present. Incus Absent. Interposition with Short Columella
(Austin subclassification on the basis of presence of malleus handle:
2A Malleus handle present
2B Malleus handle absent)
III Absent or severely defective stapedial arch
Interposition of ossicle/other prosthesis between the grafted eardrum / malleus handle and footplate
Stapes arch absent. Incus Absent. Interposition with Long Columella
Austin subclassification on the basis of presence of malleus handle:
3A Malleus handle present
3B Malleus handle absent
IV Absence of Ossicles & Mobile footplate
SS Absent. Graft placed over RW for baffle effect. OW exposed
VA Absence of Ossicles & fixed footplate
Fenestration of lateral semicircular canal in cases
RW protected
VB Platinectomy. Removal of Footplate . Fat/Fibrous tissue is placed in OW. Graft placed over it.
Oval window filled with fatty / fibrous tissue
Tuesday, July 17, 2012

11. Indications
Conductive hearing loss due to TM perforation or ossicular dysfunction
Chronic or recurrent otitis media
Progressive hearing loss due to chronic middle ear pathology
Perforation or hearing loss persistent for more than three months due to trauma, infection or surgery
Inability to bathe or participate in water sport activities
(Arun Gadre, Christopher Muller, University of Texas Branch, Texas)
Tuesday, July 17, 2012

12. Contraindications (Glasscock 1976 / Shambaug)
Absolute
Uncontrolled cholesteatoma
Malignant tumors
Unusual infections
Intracranial complications
Relative
Eustachian tube dysfunction / OME in other ear
Dead ear
Only hearing ear
Elderly patient
Very young children
Repeated failures
Uncooperative patients
Tuesday, July 17, 2012

13. Preoperative Evaluation
Extent & location of perforation
Ossicular status
Counseling
Nature of disease
Treatment options
Outcomes of surgical options
Post op morbidity – restriction of water activities, hearing deterioration
Detailed history and careful physical examination are essential to the planning of the surgical approach and the counseling of patients regarding the expected outcome. The extent of tympanic membrane perforation and the condition of the ossicular chain are evaluated. The size of the external canal is evaluated, and canalplasty is planned if a prominent anterior canal wall prevents complete visualization of the perforation. Comprehensive audiometric evaluation is performed, and tuning fork tests are used to confirm the audiogram. Radiographic evaluation is usually not needed if clinical examination reveals a dry central perforation.
As mentioned previously, postoperative aeration of the middle ear is key to the success of tympanic membrane repair and the restoration of hearing. However, the otologic surgeon has no direct control over this factor, which depends mostly on eustachian tube function. There is currently no test that accurately predicts postoperative eustachian tube function. Some indicators—the aeration of the opposite ear, increased age in children, fewer episodes of otorrhea, and normal middle ear mucosa—may suggest reasonable eustachian tube function. In many cases, however, surgery is the ultimate test and may actually result in improved eustachian tube function by preventing recurrent infections through contamination from the external auditory canal.
Tuesday, July 17, 2012

14. Approach Transcanal Endaural Postaural
Posterior moderate sized perforations
Favorable EAC anatomy
Endaural
Visualisation of annulus & ant sulcus is difficult
Limited atticotomy
Postaural
All perforation sizes
Better angle of visualisation
Second look ossiculoplasty
Tuesday, July 17, 2012

15. Graft Placement Lateral / Overlay Medial / Underlay Over-Underlay
In lateral technique tympanoplasty, which is also known as the overlay technique, the graft is placed lateral to the fibrous layer of the tympanic membrane remnant but medial to the malleus handle. This technique requires complete removal of the squamous epithelium from the lateral surface of the tympanic membrane remnant. During elevation of the tympanomeatal flap, the annulus is left in the tympanic sulcus and the dissection is transitioned from the bony external canal onto the lateral surface of the tympanic membrane, thus separating the superficial squamous layer from the middle fibrous layer. If the perforation is of medium size, the dissected epithelium can be left attached anteriorly and can be replaced on top of the graft. In total perforations, it is usually necessary to completely remove the skin of the external canal to ensure complete removal of squamous epithelium.
Medial Graft Technique
The medial technique can be used with any of the aforementioned approaches. The tympanomeatal flap is elevated as described above in the transcanal approach. If a prominent canal wall prevents complete visualization of the anterior edge of the perforation, canalplasty can be done. A segment of the anterior canal skin overlying the canal bulge can be removed and the bulge drilled down. The skin can then be replaced as a free graft at the end of the procedure. Another option is to create a medially based anterior canal skin flap down to the level of the annulus, which is left intact. The skin flap is laid over the tympanic membrane and covered by a template of suture packet aluminum foil to protect it from accidental injury during drilling. Canalplasty can be performed to remove the anterior canal bulge, and the anterior canal skin is then reflected back in place, where it usually stays as a result of surface tension. This technique can routinely expose the anterior annulus, thus allowing the use of this technique even for total perforations.
The most common area of failure involving tympanoplasty when repairing total perforations is the anterosuperior area as a result of a lack of support. A platform of Gelfilm is prepared and placed lateral to the Gelfoam but medial to the malleus and anterior annulus ( Figure 136-4, E and Figure 136-4, J ). The anterior edge of this platform extends into the protympanum area, which is packed with Gelfoam to support the platform and get it in contact with the annulus. It acts as a smooth surface over which the graft can slide and be tucked anteriorly medial to the annulus ( Figure 136-4, J ). The fascial graft is fashioned with a small hole in the anterosuperior part ( Figure 136-4, F ); this hole will accommodate the manubrium of the malleus. The umbo is introduced through the hole, and then the graft is pulled superiorly where the hole will surround the malleus neck ( Figure 136-4, G and H ). This provides good stability of the graft and prevents its movement if it is accidentally caught in the suction tip; it also provides a fulcrum around which the graft can be rotated for optimal positioning. The tympanomeatal flap is then returned back ( Figure 136-4, I ). Advantages of the medial graft include the avoidance of the disadvantages of the lateral technique, an easier-to-master technique for the general otolaryngologist, and, if the graft is performed properly, the achievement of high success rates as compared with lateral technique.
Tuesday, July 17, 2012

16. Contd… Overlay Underlay Adv Disadv Adv Disadv
Exposure of anterior meatal recess
High take up rate
Middle ear volume not reduced
Disadv
Precision is required
Long healing time
Blunting / lateralization
Underlay
Adv
Less blunting or lateralization
High graft take up in experienced hands
Simpler technique/less time consuming
Disadv
Limited visualisation of ant meatal recess
Less suitable for large ant perf
Difficult in small EAC with per meatal approach
Reduction in ME space
Tuesday, July 17, 2012

17. Results – Underlay / Overlay Technique
Review of Underlay versus Overlay tech *
Re-perf rate - 36% Overlay, 14% Underlay
Hearing improvement – 62% Underlay, 27% Overlay
Complication rate less in Underlay
Review of Overlay tech**
Graft uptake 97% - Temp fascia, 84% -Canal skin
Rate of Ant blunting & Lateralization 1.3%
AB gap within 10 dB – 80%
Review of Underlay versus Overlay tech***
Graft uptake - 89% Underlay, 96% Overlay
Hearing improvement – 85% Underlay, 80% Overlay
Complications – 7.8% Underlay, 9% Overlay
* Doyle et al(1972), ** Sheehy et al, *** Rizer (1997)
Tuesday, July 17, 2012

18. Graft Materials Autografts Skin Heterotopic skin graft Periosteum Vein
Canal skin
Pedicled
Free
Heterotopic skin graft
Periosteum
Vein
Temporalis fascia
Fatty tissue
Tragal perichondrium & cartilage
Subcutaneous tissue
Tuesday, July 17, 2012

19. Graft Materials Xenografts Allografts Historical Historical
Bovine
Periostem
Drum
Jugular vein
Allografts
Historical
Amnion
Cornea
Duramater
Peritoneum
Pericardium
Aorta valves
Ear drum
Lyophilised dura
Cartilage
Fascia
Risk of HIV, Hepatitis B, Creutzfeldt Jacob disease
Tuesday, July 17, 2012

20. Reasons for Graft failure
Technical/surgeon errors
Infectious complications
Poor tubal function
Patient factors
Tuesday, July 17, 2012

21. Ossicular status Austin / Kartush Classification Types
Ossicular chain status
M+I+S+ A
M+S+ B
M+S- C
M-S+ D
M-S- E
Ossicular head fixation F
Stapes fixation
The Austin/Kartush classification of ossicular defects has been found practical and includes the following
types: 0, ossicular chain intact (M+I+S+); A, malleus present, stapes present (M+S+); B, malleus present,
stapes absent (M+S–); C, malleus absent, stapes present (M–S+); D, malleus absent, stapes absent (M–S–);
E, ossicular head fixation; and F, stapes fixation. The most commonly encountered ossicular defect is that of erosion of the long process of the incus with an intact malleus handle and stapes superstructure (type A).
Tuesday, July 17, 2012

22. Materials used in Ossiculoplasty
Autografts
Bone
Cartilage
Adv
Immediate availability
Biocompatibility
Low cost
Low extrusion rate
Disadv
Disease recurrence
Fixation to adjacent structures
Skill & time to shape
Conchal /Tragal Cartilage
Because of their low extrusion and resorption rates, autografts and homografts fashioned from the body of the incus or the head of the malleus remain the "gold standard" for ossicular reconstruction. Concerns of infectivity of transplanted tissue, the need for often time-consuming intraoperative sculpting of autograph and homograph tissue, and a desire to avoid tissue banking have led to the development of alloplastic materials for ossiculoplasty
The materials used in the reconstruction of the ossicular chain are autografts, homografts, and allografts. Autografts are either bone or cartilage. Autograft ossicles are removed from the patient and sculpted to serve as an interposition graft; the incus is used most commonly. The advantages include immediate availability, obvious biocompatibility, low cost, and a low extrusion rate. Disadvantages include concerns about possible disease recurrence when used in patients with cholesteatoma, the potential for fixation to adjacent bone of the promontory or the canal wall, and ossicle unsuitability due to demineralization or erosion. In addition, both autografts and homografts require time and skill to shape them appropriately in the operating room. Autograft cartilage is usually taken from the tragus or occasionally from the auricular cartilage.
Tuesday, July 17, 2012

23. Homografts Irradiated Ossicles En Bloc TM with attached Ossicles
Risk of disease transmission
Homograft ossicles and en bloc tympanic membranes with attached ossicles are available through regional tissue banks, and graft rejection is extremely rare. However, their usage has decreased considerably, due in large part to the fear of potential transmission of human immunodeficiency virus, hepatitis, and Creutzfeldt-Jacob disease.
Tuesday, July 17, 2012

24. Allografts Biocompatible Bioinert Bioactive
1960’s – Polyethylene tubing, Teflon, Proplast
1970’s – HDPS (Plastipore), Thermal fused HDPS (Polycel)
Silastic, Stainless steel, Titanium
Bioinert
Al 2O3 Ceramic (Germany & Japan in 1970’s)
Bioactive
Bioactive glass – Bioglass, Ceravital (1970’s)
CaPO4 Ceramic - Hydroxyapatite
In the early 1960s, Austin and Shea[6] pioneered the use of polyethylene and Teflon implants but found an unacceptably high extrusion rate. Shea and Emmett[36] later introduced Proplast and Plasti-Pore implants with the concept of increased biocompatibility as a result of the porous properties of these materials. Extrusion rates and hearing results with these implants did not match those of homographs. Calcium phosphate-containing materials, such as hydroxyapatite, glass, and glass-ceramic (Cervital), offer advantages of biocompatibility and lack of resorption.[33] The calcium phosphate component is bioactive and reacts with surrounding soft tissue. The propensity for these implants to coalesce with adjacent bone offers the theoretical advantage of direct coupling to the stapes superstructure or footplate. Unlike glass and glass-ceramic implants, the hydroxyapatite prosthesis is resistant to easy cracking during sculpting. The use of interposed tragal cartilage between implants and the tympanic membrane lowers the extrusion rate even further. Table illustrates the reported extrusion rates and hearing results observed with the various implant materials. Although new to the market, titanium prostheses are showing promise for improved hearing results and infrequent extrusion. Long-term follow-up will determine the role of titanium in ossiculoplasty. Somewhat discouragingly, analysis performed at up to 15 years after ossiculoplasty in patients with chronic otitis media revealed a slowly progressive deterioration in hearing levels regardless of the implant material chosen.[45]
During the past 20 years, there has been increasing interest in and usage of allografts. The major advantages are sterility, availability, and, for some, the ability to bond to tissues. During their developmental history, the disadvantages of allografts have been difficulties with biocompatibility (extrusion) and cost. There have been three principal groups of allografts: polymers, ceramics, and metals. The polymers include polyethylene, polytetrafluoroethylene (Teflon [DuPont, Wilmington, De]), and silicone rubber (Silastic [Dow Corning, Midland, Mi]). Polycel and Plasti-Pore are high-density polyethylene sponge products. The ceramics include the glass ceramics Ceravital (Ernst Leitz, Wetzlar, Germany) and Bioglass and the calcium phosphate ceramic hydroxyapatite. Hydroxyapatite can achieve real integration with bone without encapsulation, and it can be made in a porous as well as a dense form; it is brittle and difficult to sculpt or modify.[21]
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25. Configurations of Allografts
Total Ossicular Replacement Prosthesis (TORP)
Partial Ossicular Replacement Prosthesis (PORP)
Prosthesis for ossicular discontinuity restricted to IS joint
Combined forms - Hydroxyapatite platform with Plastipore shaft
Allografts have been manufactured in two basic configurations: total ossicular replacement prosthesis (TORP) and partial ossicular replacement prosthesis (PORP). There are many variations in the shape of the platform of the tympanic membrane portion of the prosthesis. Some contact the undersurface of the tympanic membrane, whereas others are designed to conform to the undersurface of the malleus. In addition, there are prostheses that are designed to be used for ossicular discontinuity that is restricted to separation of the incudostapedial joint.
Attempts have also been made to combine various allografts. A hydroxyapatite platform is frequently combined with a Plasti-Pore shaft. The hydroxyapatite has less extrusion potential and can bond to tissue, whereas the Plasti-Pore can be cut to the appropriate length more easily. Other materials have been used in such composite prostheses. These include Polycel (thermal-fused Plasti-Pore), polytetrafluoroethylene, a mixture of hydroxyapatite and Silastic, and hydroxyapatite-reinforced polyethylene composites.[7][19]
The choices and preferences of ossicular prostheses by United States otologists have changed over time. In a 1989 survey, autograft and homograft bone were used by 83% of respondents, cartilage by 78%, and Plasti-Pore by 81%. Hydroxyapatite had just been introduced as a biomaterial. Ten years later, a similar survey revealed that hydroxyapatite prostheses were used by 82% of respondents, autograft and homograft bone by 72%, and autograft or homograft cartilage by 62% (only 4% listed cartilage as their first preference). Plasti-Pore prosthesis use had declined to 59% of respondents.[18]
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26. Different Types of Prosthesis
Cartilage is used to interpose between the prosthesis and the tympanic membrane to prevent extrusion. A recent review of alloplastic materials in ossiculoplasty showed that results are still comparable for the alloplastic materials that are currently in use, with different series reporting different success and extrusion rates using the same prosthesis.[53] In 2001, House and Teufert[25] reported on the use of Plasti-Pore in 1040 cases. The air-bone gap was less than 20 dB in 69% of PORP cases and in 61% of TORP cases. In 1990, Grote[22] reported on the long-term results achieved with hydroxyapatite prostheses with an air-bone gap less than 20 dB in 84% of PORP cases and in 64% of TORP cases. Dalchow and colleagues,[11] in 2001, reported on more than 1300 cases that involved the use of titanium prostheses, with 76% achieving an air-bone gap of less than 20 dB; PORPs and TORPs were combined.
to Colleague Print Version
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27. Ossiculoplasty Choice of prosthesis / placement Ossicular status
Med – lat distance / vertical position
Retracted umbo – severing of tensor tympani tendon
Certainly the major factor that affects the choice of the prosthesis is the status of the ossicles. When the undersurface of the manubrium of the malleus anchors the prosthesis laterally, consideration must be given to the anterior-posterior distance from the manubrium to the footplate as compared with the medial-lateral distance between them, which is really the depth of the middle ear. A favorable relationship should allow the interposed prosthesis to lie in a more vertical position ( Figure 136-5, A ). With a relatively wide anterior-posterior distance and a relatively narrow middle ear, an unfavorable vector for energy transfer will exist, and the hearing result will be poor ( Figure 136-5, B ). In that situation, it is preferable to anchor the lateral portion of the prosthesis to the posterior superior quadrant of the tympanic membrane, which is more directly lateral to the stapes capitulum or footplate ( Figure 136-5, C ). Another malleus consideration exists when the umbo is chronically retracted and lies near the promontory; this restricts malleus motion and, therefore, tympanic membrane motion. In these cases, the platform of a TORP or PORP will lie at an unfavorable angle to the tympanic membrane surface and therefore cannot be at the desired right angle to the shaft of the prosthesis. Severing the tensor tympani tendon will allow the tympanic membrane to lateralize to a more favorable angle and level and thus increase the prosthesis efficiency.
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28. Surgical Techniques in case of ossicular fixation
Tympanosclerosis
Disease restricted to attic
Disease restricted to stapes
Combined attic & stapedial disease
Acquired bony fixation
Removal of fixation with intact chain
Removal of incus/malleus head with interposition of allograft/autograft
Tos[45] has written extensively about the surgical treatment of ossicular fixation that results from tympanosclerosis. Whenever possible, an intact ossicular chain is preserved. When the disease is restricted to the attic, a wide atticotomy is performed, with preservation of the bony bridge, and the tympanosclerosis is progressively removed from the lateral, anterior, superior, and medial surfaces of the malleus and incus.
When the tympanosclerosis is restricted to the stapes, radical removal of the plaques without opening into the vestibule or removing the footplate is preferred. The dissection is performed without separating the incudostapedial joint and from a posterior to an anterior direction, using slow motions and using the stapedius tendon for stability. When both attic and stapedial tympanosclerosis are present, the attic is addressed first to see if a mobile intact malleus and incus can be achieved. If stapedectomy is unavoidable (or desirable), it is delayed until the end of the procedure. If the entire stapes is to be removed, it is extracted very slowly, only after a control opening has been made on the most accessible part of the footplate. Stapedotomy has also been reported in cases of tympanosclerotic fixation of the stapes. An air-bone gap of less than 20 dB was obtained in 70% of cases in one series.[47]
Acquired bony fixation of the malleus can be surgically managed in two ways: (1) by the direct removal of the bony fixation, with the restoration of an intact ossicular chain; or (2) by the removal of the incus and the malleus head, with the interposition of an allograft between the manubrium and the stapes. Tos[45] strongly advocates the former approach and performs an atticotomy that is large enough to provide adequate exposure. After the atticotomy, a small diamond burr is used to reduce the fixation point to a thin shell, which is then vaporized with a laser to avoid transmitting mechanical energy to a mobile stapes, thereby causing sensorineural hearing loss.
The attic bone adjacent to the fixation point is further removed with a drill, and a Silastic sheet is interposed between the malleus head and the adjacent attic wall. The alternative procedure also requires an atticotomy to remove the incus and the malleus head, because the malleus fixation does not allow the incus to be rotated out of its position in the usual manner. The long process of the incus often needs to be removed (after careful separation of the incudostapedial joint) before the incus can be rotated and extracted; the malleus head is then removed. The malleus to stapes interposition prosthesis is less stable, because the malleus is hypermobile after removal of its head. Both techniques are technically difficult.
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29. Surgical Techniques for ossicular discontinuity
Ossicular status
Lenticular process missing
Tip of Incus missing
Long process of Incus missing
Stapes superstructure +/-
Malleus handle +/-
Ossicular Discontinuity
When only the tip of the incus is missing, a specially designed allograft prosthesis that fits on top of the head of the stapes and has a concave arm that rests beneath and supports the distal incus works well.[2] A similar autograft cartilage prosthesis can be sculpted at surgery. Insertion does require simultaneous lifting of the incus and placement of the prosthesis on the stapes. A prosthesis that attaches to the incus and that has a cup that fits on the stapes capitulum is also available and is reported to give good results.[28] Maasesen and Zenner[28] also reported on the use of ionomeric cement to reconstruct the missing part of the incus and the incudostapedial joint, with good results. If only the lenticular process is eroded and the incus long process is intact, a simple cartilage block interposition can be used.
When the long process of the incus is absent, the two factors of greatest importance are the conditions of the stapes superstructure and of the malleus. When the stapes superstructure is present and connected to the footplate, most surgeons prefer to attach the prosthesis to the head of the stapes as a PORP, because the medial anchor of the prosthesis is then stable and cannot slip. If the superstructure is absent, the stapes footplate is the medial point of fixation, and a TORP is used. Securing this medial anchor point has been more difficult, and, generally, results of TORPs are poorer than those of PORPs.
Using the medial surface of the malleus handle as the lateral anchoring point for the prosthesis is more stable than the tympanic membrane alone, and extrusion is less likely. However, to successfully use the malleus, the surgeon should be able to affirmatively answer the following questions:    1.    Does the malleus have normal mobility?    2.    Is there adequate space between the umbo and the promontory?    3.    Is the vector between the malleus and stapes capitulum or footplate favorable? If the answer to all three questions is yes, then the malleus can be used. If not, then the posterior superior portion of the tympanic membrane is a better choice.
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30. Configurations of Prosthesis
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31. Factors affecting outcomes of ossiculoplasty
Intrinsic factors
Status of ossicular chain – mobility
Severity of disease
Eustachian tube function
Adequate control of allergy
CAUSES OF FAILURE
An occasional cause of ossiculoplasty failure is incomplete or erroneous diagnosis. Routine palpation of all three ossicles in middle ear surgery will train the surgeon to recognize the normal range of motion for each ossicle. When assessing stapes mobility, it is important to observe the footplate under high magnification and to identify one bright spot of reflected light, which is called the light reflex. The slightest motion of the footplate will cause that light reflex to move. Motion of the light reflex in response to palpation is the most accurate means of intraoperatively identifying that the footplate is mobile. Conversely, a lack of motion of the light reflex to palpation indicates that either the footplate is fixed, the superstructure is fractured, or there is ossicular discontinuity between the point of palpation and the footplate. Possible misdiagnoses include the following: (1) missing a fixed malleus in the presence of otosclerosis; (2) failing to identify a fractured stapes superstructure; and (3) failing to identify a bony incudostapedial disarticulation when the soft-tissue connection is preserved.
A much more common cause of ossiculoplasty failure is extrusion of the prosthesis; this is most common with allograft prostheses that directly contact the tympanic membrane (as opposed to the undersurface of the manubrium). Although the incidence is much lower if a thin piece of cartilage is placed between the tympanic membrane and the platform of the prosthesis, extrusion still occurs.
Finally, ossiculoplasty failure occurs most commonly in ears that continue to exhibit eustachian tube malfunction or that develop the problem after surgery. As mentioned earlier, aeration of the middle ear is an important factor in sound transmission. If the middle ear is not aerated, even a perfectly placed prosthesis will still result in a significant conductive hearing loss. Although it is not possible to predict this outcome, the status of the function of the eustachian tube in the opposite ear is a reasonable guide, at least in children.
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32. Contd… Extrinsic Factors Surgical technique Design of prosthesis
Composition of prosthesis
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33. Advantages of Titanium Prosthesis
Low wt (<4mg), high rigidity
Open head plate design- better visualisation during placement
Medial end has claw like design- better fit on stapes head
Unlike hydroxyapatite they are not top heavy, stay upright
More recently, titanium prostheses have been gaining increased popularity.[14][23][24][27][56] The titanium prosthesis combines low weight (less than 4 mg) and high rigidity. The prosthesis is the closest in mass to the ossicles it tries to replace. These characteristics lead to reduction in acoustic impedance and sound damping, particularly for higher frequencies.[42] All of the current designs of titanium prostheses have an open head plate (toward the tympanic membrane) that allows the surgeon better visualization of the medial end of the prosthesis during placement. The medial end of the titanium PORP fits better over the stapes head due to its "claw-like" design, which achieves a secure connection. In addition, titanium prostheses are not "top heavy" like hydroxyapatite prostheses and tend to stay upright. Titanium was also found to be more user friendly by the majority of surgeons as compared with hydroxyapatite
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34. Poor Eustachian Tube Function
Cartilage Tympanoplasty
Prevent recurrence of retraction pockets
May reduce extrusion rates
Mainly with Temporalis Fascia grafts
Posterosuperior TM/post Pars
Flaccida*
Entire TM**
Composite cartilage peri-
chondrium graft
Cartilage Palisade technique***
( * Poe & Gadre :1993; ** Dornhoffer :1997; *** Heerman )
Cartilage Tympanoplasty
When eustachian tube function is normal, small areas of atrophic tympanic membrane away from the perforation can also be left alone. In many instances, however, much of the dystrophic tympanic membrane is removed in an attempt to obtain a healthy mobile tympanic membrane from the graft. The atrophic posterior superior quadrant, whether retracted or not, presents a special situation. Tympanoplasty that involves a composite cartilage/perichondrial graft to provide structural support for this area while preserving tympanic membrane mobility is gaining wide acceptance. The cartilaginous graft can be made quite thin and of a small enough diameter to only bolster the weakened portion of the involved tympanic membrane. Many studies have established the efficacy of cartilage grafts in tympanoplasty and demonstrated no detrimental effect on hearing. * atelectatic ear poses a special problem. Many such ears are dry and produce no symptoms other than hearing loss. Many otologists think of the atelectatic ear as an end-stage ear with very poor eustachian tube function, and hence they only recommend regular follow-up to ensure the absence of cholesteatoma. Other otologists believe that hearing loss should be corrected and recommend cartilage tympanoplasty for such ears.[12]
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35. Poor ET Function (contd…)
Tympanostomy
Rarely at the time of TM grafting
Maybe during follow up if effusion or retraction develops
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36. Middle Ear Stents Teflon / Silicone pieces Silastic sheet
Biodegradable materials
Gelfoam
Gelfilm
Silastic sheeting or hyaluronic acid gel can fill the middle ear to prevent fixation of the graft to the promontory or to the facial ridge. If the interposed incus does not bridge the vertical distance between the capitulum and the malleus, the incus can be resculpted according to the Wehrs technique.[47] Alternately, prosthetic partial ossicular replacement prosthesis (PORPs) can be used ( Figure ). If the angle between the malleus and the footplate or capitulum of the stapes is >45 degrees, the reconstruction prosthesis should be fitted with a cartilage cap and placed directly to the posterior-superior drum.[18]
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37. Reporting protocols “ Fiction & fact need untangling, otherwise,
surgeons are little better than gossips ”
:Gordon Smyth

38. Reporting Protocols 0 – 10 dB Excellent 10 – 20 dB Good
Tympanoplasty Reporting Protocol based on AB gap (Kartush)
AB gap Result
0 – 10 dB Excellent
10 – 20 dB Good
20 – 30 dB Fair
>30 dB Poor
Reporting Protocol for Prognosis : Stratification of pt groups (MERI *, Kartush)
In the past, most workers described success in terms of hearing improvement only when, in fact, elimination of infection and preservation or restoration of anatomy are of equal importance. Therefore, results today are reported in relation to control of pathology, anatomic status, hearing improvement, and postoperative complications.
A more practical tympanoplasty reporting protocol, developed by Kartush, generates a numeric indicator of
the severity of the middle ear disease (Table 24–1).44 In this protocol, a Middle Ear Risk Index (MERI) is used
to stratify patient groups and allow for meaningful study comparisons.* Suggested risk categories can be derived
from the MERI as follows: MERI 0, normal; MERI 1 to 3, mild disease; MERI 4 to 6, moderate disease; and
MERI 7 to 12, severe disease. Regarding reporting hearing results, the following guidelines for air–bone closure have been recommended by the same author: 0 to 10 dB, excellent; 10 to 20 dB, good; 20 to 30 dB, fair; and more than 30 dB, poor.44 It is recommended that the postoperative bone line be used.
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39. Reporting Protocols For Disease* For Results*
Type & location of perforation
Ossicular status
Status of mucosa
Status of eustachian tube
For Results*
Control of pathology
Anatomic status
Improvement in hearing
Post-op complications
(*American Academy of Ophthalmology & Otolaryngology Subcommittee on Conservation of Hearing )
Reporting Protocol for Prognosis : Stratification of pt groups (MERI *, Kartush)
In the past, most workers described success in terms of hearing improvement only when, in fact, elimination of infection and preservation or restoration of anatomy are of equal importance. Therefore, results today are reported in relation to control of pathology, anatomic status, hearing improvement, and postoperative complications.
A more practical tympanoplasty reporting protocol, developed by Kartush, generates a numeric indicator of
the severity of the middle ear disease (Table 24–1).44 In this protocol, a Middle Ear Risk Index (MERI) is used
to stratify patient groups and allow for meaningful study comparisons.* Suggested risk categories can be derived
from the MERI as follows: MERI 0, normal; MERI 1 to 3, mild disease; MERI 4 to 6, moderate disease; and
MERI 7 to 12, severe disease. Regarding reporting hearing results, the following guidelines for air–bone closure have been recommended by the same author: 0 to 10 dB, excellent; 10 to 20 dB, good; 20 to 30 dB, fair; and more than 30 dB, poor.44 It is recommended that the postoperative bone line be used.
Tuesday, July 17, 2012

40. Reporting Protocol for Prognosis : Stratification of pt groups (MERI
Reporting Protocol for Prognosis : Stratification of pt groups (MERI *, Kartush) (OP COMP)
In the past, most workers described success in terms of hearing improvement only when, in fact, elimination of infection and preservation or restoration of anatomy are of equal importance. Therefore, results today are reported in relation to control of pathology, anatomic status, hearing improvement, and postoperative complications.
A more practical tympanoplasty reporting protocol, developed by Kartush, generates a numeric indicator of
the severity of the middle ear disease (Table 24–1).44 In this protocol, a Middle Ear Risk Index (MERI) is used
to stratify patient groups and allow for meaningful study comparisons.* Suggested risk categories can be derived
from the MERI as follows: MERI 0, normal; MERI 1 to 3, mild disease; MERI 4 to 6, moderate disease; and
MERI 7 to 12, severe disease. Regarding reporting hearing results, the following guidelines for air–bone closure have been recommended by the same author: 0 to 10 dB, excellent; 10 to 20 dB, good; 20 to 30 dB, fair; and more than 30 dB, poor.44 It is recommended that the postoperative bone line be used.
MERI used for stratification of patients & to make comparisons
Preop / Intraop risk factors / Primary & adjunctive surgical procedures / Outcomes
Follow up period recommended
Preliminary – <1yr
Short term – 1-5 yr
Long term – 5-10 yr
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41. Middle ear risk index MERI 0 Normal MERI 1-3 Mild disease
MERI Moderate disease
MERI Severe disease
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42. Tympanoplasty Reporting Protocol
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43. Reporting Protocols (contd…)
Pure Tone Averages
Frequencies : 500 Hz, 1 KHz, 2 KHz, 3 KHz *
Most commonly affected frequencies by Conductive Hearing Loss
Glasgow Benefit Plot **
* Recommendation of The American Academy of Otolaryngology – Head & Neck Surgery
** Browning et al : Glasgow Benefit Plot : A new method for reporting results of middle ear surgery; 1991, Laryngoscope101 :
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44.
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45.
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46. Hearing Evaluation
Belfast Rule Of Thumb *
Post operative air conduction mean threshold over speech frequencies <30 dB
Inter aural air conduction mean threshold <15dB
*Smyth & Peterson, 1985
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47. Paediatric Tympanoplasty
Controversy - Mgt of pts with TM perforation(+/-otorrhea)
Factors affecting decision of surgery
Poor tubal function( perforation acts as natural grommet)
Frequent episodes of URTI
Negative middle ear pressure in contralateral ear
Traditionally, tympanoplasty was not recommended in young children younger than the age of 7 years, because it may affect the normal growth of the bony external canal and because it was thought to have a high rate of recurrence due to immature eustachian tube function. Several studies have demonstrated that tympanoplasty, even in children as young as two and a half years old, has a good success rate and long-term stability. It was suggested that evidence of ongoing eustachian tube dysfunction (as evidenced by otitis media with effusion and negative middle ear pressure in the contralateral ear) may predict poor outcome in pediatric tympanoplasty.
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48. Recent Advances – Uses of Laser
Extraction of ankylosed transposed ossicles in revision cases
Potassium Titanyl Phosphate LASER for amputation of malleus & incus & at the same time maintaining chain integrity *
LASER Soldering tech ( Solid State Diode LASER )**
* Nishizaki K et al; Nov 2001 vol 22 issue 6 Pg , Head & Neck Medicine & Surgery
** Study on cadaveric human temporal bones
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49. Conclusion Rich history
Antibiotics & binocular microscope major role brought turnaround
Better & better results with tympanoplasty
Newer materials for ossiculoplasty
Scope of further research e.g. in area of cartilage & pediatric tympanoplasty
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50. References
Text book of Otolaryngology – Head & Neck Surgery : Charles W Cummings, 4th ed , vol 4, 3058 – 74
Manual of Middle Ear Surgery : Mirko Tos, vol 1
The Otolaryngologic Clinics of North America : Aug 1994; Ossiculoplasty, vol 27, No 4
Surgery of the Ear : Glasscock – Shambough, 5th ed
Scott Brown otolaryngology 7th edition
Internet Journal articles
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51. For more topics, visit www.nayyarENT.com
Thank you
For more topics, visit
Tuesday, July 17, 2012