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  • 1. Approach and Exposure
  • 2. Vascular Strip
  • 3. Postauricular Incision
  • 4. Canal Exposure
  • 5. Cartilage Harvest
  • 6. Canal Reconstruction
  • 7. Tympanic Membrane Reconstruction
  • 8. Closure
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Tympanoplasty (Revision)

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Calhoun D. Cunningham III, MD1; Alex J. Carsel2; C. Scott Brown, MD1
1Duke University Medical Center
2University of Toledo College of Medicine

Main Text

The tympanic membrane (ear drum) serves as a barrier between the middle and external ear, protecting the middle ear from infection. Additionally, the tympanic membrane is critical for hearing by providing impedance-matching between the air of the external canal and the fluid of the inner ear. When the membrane is disrupted, patients may experience hearing loss, recurrent infections, and ear drainage. Etiologies of perforations include infection and trauma. When perforations persist and cause symptomatic hearing loss or recurrent infections, they can be surgically repaired by an otolaryngologist. Although the success rates for primary tympanoplasty are high (75–95%), failures can make future attempts at repair more challenging. In this case, a 61-year-old female had undergone two prior tympanoplasties without success. Dr. Cunningham demonstrates intraoperative decision-making as well as the surgical approach and techniques for repair in these difficult cases.

Reconstruction; perforation; tympanic membrane; lateral; underlay.

The tympanic membrane (TM) is a thin, cartilaginous barrier that transmits vibrations from sound waves from the external ear to the inner ear. Perforation arising from trauma to the ear can disrupt hearing and cause pain. The incidence of traumatic tympanoplasty is reported at 6.8/1000 persons.1 Patients with TM perforations commonly experience symptoms of hearing loss, earache, tinnitus, otorrhea, and vertigo.2

The patient is a 61-year-old female with a past medical history significant for left-sided mastoidectomy and two prior tympanoplasties who presented for revision of a traumatic left-sided, anterior marginal TM perforation. The patient’s first tympanoplasty was successful, and the patient subsequently developed traumatic perforation of the ear drum that failed subsequent surgical correction.

Physical examination for a patient with a suspected traumatic perforation of the TM should begin with thorough inspection of the auricle and otoscopic inspection of the TM and external auditory canal for air fluid levels, erythema, or obvious perforations. The patient, in this case, presented to the clinic with a left-sided TM perforation clearly visible on otoscopy. It was a large anterior marginal perforation that extended all the way to the level of the annulus. In some cases where TM perforations may be unclear, pneumatic otoscopy can be used to aid in diagnosis; however, caution must be employed to prevent air from entering the otic capsule and manifesting neurologic symptoms. Also, baseline hearing testing with tuning forks can help identify conductive hearing loss that commonly accompany TM perforations. Given the obvious perforation visible on otoscopy, a lateral graph-type tympanoplasty was indicated for the reconstruction of the TM.

The use of CT imaging is recommended only in select circumstances to limit unnecessary irradiation. Patients with basilar skull fractures, significant middle ear trauma, or facial nerve dysfunction are generally accepted to receive further imaging. Our patient’s complicated surgical history consisting of two previous tympanoplasties in addition to a mastoidectomy may warrant CT imaging if the surgeon suspects distortions in normal anatomy that may change his/her approach. Thus, good clinical judgment should be made in certain instances where additional imaging may be warranted outside accepted recommendations. 

The success rates for subtotal and total TM perforation repair using lateral grafting are excellent overall. Jung and Park reported a 97% success rate in a series of 100 patients using a mediolateral graft technique and Angeli et al saw a 98% success rate in 46 patients with total or near total perforations.34 However, revision tympanoplasties report a greater incidence of tympanosclerosis and ossicle adhesions, erosions, and fixations that may complicate repair and demand enhanced technical dexterity.5 Recently, one large prospective study investigating outcomes in primary and revision tympanoplasties in adults with perforations >50% of the TM found graft success rates in 78.2% for revision tympanoplasty vs 96.6% for primary tympanoplasty (p=0.001).6 Although, hearing outcomes did not differ significantly between groups. It should be noted that there is considerable heterogeneity in the current literature reporting grafting success in revision tympanoplasties and larger cohort studies are warranted to accurately assess outcomes.   

Spontaneous healing in traumatic perforations is largely dependent on the perforation size and etiology.7 Perforation size is often guided by Saliba’s subdivision,8 and it characterizes perforations based on TM size in percent and the quadrant affected. For example, a “small” perforation (Grade I) is considered less than 25% in size and less than one quadrant affected. Sayin et al used this classification and found that 94.8% of Grade I perforations spontaneously closed, and interestingly, 77% of Grade II injuries closed spontaneously as well.9  In cases where spontaneous healing does not occur within 2 months of the inciting event or if there is a posterosuperior perforation, surgical repair is warranted.2 The presence of wet (serosanguinous otorrhea) vs dry conditions and its effect on surgical outcomes has been controversial. The common perception was that a wet ear can predispose a patient to infection and worsen postoperative healing; however, recent studies have found either insignificant differences in the results of operations or accelerated healing in wet conditions compared to dry conditions.107 Lou et al proposed mechanisms to explain the different morphologies in healing over time in wet and dry conditions.7 Importantly, he investigated the patterns and sequence of granulation tissue formation and epithelial migration that may facilitate healing in wet conditions and delay healing in dry conditions. 

The lateral graft tympanoplasty or overlay graft technique, originally developed by Sheehy and Glasscock,11 involves the removal of the epithelium of the eardrum and the placement of a graft, commonly perichondrium or temporalis fascia over the ear drum. In this technique, insertion of the graft is lateral to the annulus and specifically allows for exposure of the middle ear and the anterior meatal recess, which is critical in repairs of large, anterior perforations.12 In contrast, the standard underlay technique, which places the graft medial to the malleus, does not permit adequate visualization of the middle ear, therefore making it a suboptimal strategy to repair the perforation presented in this case. Appropriately, this overlay technique has been reported with success in patients with total or near-total tympanic membrane perforations.13 In the present case, as mentioned in the physical exam section, preoperative examination demonstrated a large anterior perforation and scarce residual TM tissue, thus the standard underlay graft tympanoplasty was not preferential. Accordingly, a lateral graft tympanoplasty was chosen instead. 

Commonly, native temporal fascia is used as the graft material for tympanoplasty and is harvested using an endaural, retroauricular approach; however, in revision cases, cartilage grafts were found to be more robust to poor vascular supply and resist to infections to a greater extent.14 Specific to our case, a premade collagen graft, which is harvested from porcine intestinal submucosa was used in place of a native fascia graft due to a lack of harvestable tissue because of the patient’s prior surgical history. This approach is advantageous as an external graft limits the potential for added morbidity from a native fascia harvest. Although this type of graft is less commonly utilized, the success rate for the operation is equivalent to that of standard grafts; a recent study exemplified this finding, citing 72 patients who underwent an endoscopic tympanoplasty with a porcine small intestine submucosal graft demonstrated a 94.7% success rate for perforation closure and no immune reactions to the graft.15 

Contraindications to the lateral graft technique are minimal but include active middle ear infection.

A tympanoplasty is the repair of the TM with or without reconstruction of the middle ear bones.16 Although primary tympanoplasty has high success rates, in cases where primary repair of a TM perforation fails and a revision is needed, active inflammatory changes with excessive mucus membrane proliferation and hypertrophy (mucosalization) significantly reduce the rate of successful grafting.17 Tympanosclerosis and ossicular changes were reported in 29.5% of patients during primary tympanoplasty, whereas these pathologies present in 63.4% of revision cases.5 These pathologic changes further the degree of difficulty in successful grafting.

The Wullner classification on tympanoplasty published in 1956 is well known and describes the degree of damage found in the middle ear and the method of reconstruction. Many classifications have been described since then, yet there is no single classification that serves as an international standard.18

Intraoperative decision-making is paramount to successful repair in revision tympanoplasty due to the high likelihood of distorted anatomy and inflammatory changes that could rapidly alter the predetermined surgical approach. This case exemplifies how knowledge of multiple techniques is critical to success in revision cases. To illustrate, dehiscence of the annulus was discovered when separating the anterior canal wall skin from the underlying periosteum to facilitate placement of the lateral graft. This complicated the removal of skin from the annulus so that it could not be completed without significant damage to the skin. The extensive mucosalization of the canal also contributed to the friable nature of the skin, thus complete detachment from the canal wall and lateral grafting were unachievable. A large underlay graft was decided as the best surgical option even though this technique may predispose the graft to poor healing, owing to the high degree of mucosalization of the anterior canal. Other findings included resorption of a portion of the posterior canal likely from inflammation that necessitated the harvesting of a small cymbal cartilage graft to reconstruct the canal. Grooves were created in the posterior canal wall bone to anchor the cartilage graft using a diamond burr, and the canal was complete.

The worse-than-expected intraoperative findings resulted in conversion to a hybrid underlay graft technique and an unanticipated reconstruction of the posterior canal wall. Therefore, it is to be expected that revision tympanoplasties carry the risk of having more challenging technical requirements and demand sound decision-making in adapting surgical approaches when appropriate.

Author C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

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  15. Chen C, Hsieh L. Clinical outcome of exclusive endoscopic tympanoplasty with porcine small intestine submucosa in 72 patients. Clin Otolaryngol. 2020; 45(6):938-943. doi.org/10.1111/coa.13607.
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