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Principles of tympanoplasty

Principles of tympanoplasty. By : Dr. Supreet Singh Nayyar, AFMC For more presentations , visit www.nayyarENT.com. Layout. History & evolution of middle ear surgery Definition of tympanoplasty The transformer mechanism in health and disease Functional considerations of tympanoplasty

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Principles of tympanoplasty

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  1. Principles of tympanoplasty By : Dr. Supreet Singh Nayyar, AFMC For more presentations , visit www.nayyarENT.com www.nayyarENT.com

  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 www.nayyarENT.com

  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 - 1960’s Era of Modernity From then on..... www.nayyarENT.com

  4. Acoustic transformer mechanism Ossicular coupling Hydraulic lever Ossicular lever Catenary lever Acoustic coupling www.nayyarENT.com

  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 www.nayyarENT.com

  6. Definition of Tympanoplasty “ Procedure to eradicate disease in the middle ear & to reconstruct the hearing mechanism with/without TM (tympanic membrane) grafting ”* * 1965- American Academy of Ophthalmology & Otolaryngology Subcommittee on Conservation of Hearing www.nayyarENT.com

  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 www.nayyarENT.com

  8. Techniques Minimalistic techniques Cauterization & fat plug Cauterization with trichloroacetic acid Sealed tympanostomy tubes Formal Tympanoplasty www.nayyarENT.com

  9. Classification of Tympanoplasty 1956- Wullstein Type 1 Type 2 Type 3 Type 4 Type 5 www.nayyarENT.com

  10. Classification of Tympanoplasty • Mirko Tos • 1 - Intact chain • 2 – Short columella • 3 – Long columella • 4 - Sound protection • 5A - Fenestration of LSCC • 5B - Platinectomy www.nayyarENT.com

  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 (ArunGadre, Christopher Muller, University of Texas Branch, Texas) www.nayyarENT.com

  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 www.nayyarENT.com

  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 www.nayyarENT.com

  14. Approach Transcanal 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 www.nayyarENT.com

  15. Graft Placement Lateral / Overlay Medial / Underlay Over-Underlay www.nayyarENT.com

  16. Contd… Overlay Adv 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 www.nayyarENT.com

  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) www.nayyarENT.com

  18. Graft Materials Autografts Skin Canal skin Pedicled Free Heterotopic skin graft Periosteum Vein Temporalis fascia Fatty tissue Tragal perichondrium & cartilage Subcutaneous tissue www.nayyarENT.com

  19. Graft Materials Allografts Historical Amnion Cornea Duramater Peritoneum Pericardium Aorta valves Ear drum Lyophiliseddura Cartilage Fascia Risk of HIV, Hepatitis B, Creutzfeldt Jacob disease Xenografts Historical Bovine Periostem Drum Jugular vein www.nayyarENT.com

  20. Reasons for Graft failure Technical/surgeon errors Infectious complications Poor tubal function Patient factors www.nayyarENT.com

  21. Ossicular status Austin / Kartush Classification www.nayyarENT.com

  22. Autografts Bone Cartilage Materials used in Ossiculoplasty www.nayyarENT.com Conchal /Tragal Cartilage • Adv • Immediate availability • Biocompatibility • Low cost • Low extrusion rate • Disadv • Disease recurrence • Fixation to adjacent structures • Skill & time to shape

  23. Homografts www.nayyarENT.com Irradiated Ossicles En Bloc TM with attached Ossicles Risk of disease transmission

  24. Allografts www.nayyarENT.com • Biocompatible • 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

  25. Configurations of Allografts www.nayyarENT.com 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

  26. Different Types of Prosthesis www.nayyarENT.com

  27. Ossiculoplasty • Choice of prosthesis / placement • Ossicular status • Med – lat distance / vertical position • Retracted umbo – severing of tensor tympani tendon www.nayyarENT.com

  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 www.nayyarENT.com

  29. Surgical Techniques for ossicular discontinuity Ossicular status Lenticular process missing Tip of Incus missing Long process of Incus missing Stapes superstructure +/- Malleus handle +/- www.nayyarENT.com

  30. Configurations of Prosthesis www.nayyarENT.com

  31. Factors affecting outcomes of ossiculoplasty Intrinsic factors Status of ossicular chain – mobility Severity of disease Eustachian tube function Adequate control of allergy www.nayyarENT.com

  32. Contd… www.nayyarENT.com • Extrinsic Factors • Surgical technique • Design of prosthesis • Composition of prosthesis

  33. Advantages of Titanium Prosthesis www.nayyarENT.com • 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

  34. Poor Eustachian Tube Function www.nayyarENT.com • 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 )

  35. Poor ET Function (contd…) www.nayyarENT.com • Tympanostomy • Rarely at the time of TM grafting • Maybe during follow up if effusion or retraction develops

  36. Middle Ear Stents www.nayyarENT.com • Teflon / Silicone pieces • Silastic sheet • Biodegradable materials • Gelfoam • Gelfilm

  37. Reporting protocols “ Fiction & fact need untangling, otherwise, surgeons are little better than gossips ” :Gordon Smyth

  38. Reporting Protocols www.nayyarENT.com • Tympanoplasty Reporting Protocol based on AB gap (Kartush) AB gapResult 0 – 10 dB Excellent 10 – 20 dB Good 20 – 30 dB Fair >30 dB Poor

  39. Reporting Protocols www.nayyarENT.com • For Disease* • 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)

  40. www.nayyarENT.com

  41. Middle ear risk index MERI 0 Normal MERI 1-3 Mild disease MERI 4-6 Moderate disease MERI 7-12 Severe disease www.nayyarENT.com

  42. Tympanoplasty Reporting Protocol www.nayyarENT.com

  43. Reporting Protocols (contd…) www.nayyarENT.com • 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 : 180-185

  44. www.nayyarENT.com

  45. www.nayyarENT.com

  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 www.nayyarENT.com

  47. Paediatric Tympanoplasty www.nayyarENT.com • 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

  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 424-427, Head & Neck Medicine & Surgery ** Study on cadaveric human temporal bones www.nayyarENT.com

  49. Conclusion www.nayyarENT.com 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

  50. References www.nayyarENT.com Text book of Otolaryngology – Head & Neck Surgery : Charles W Cummings, 4thed , vol 4, 3058 – 74 Manual of Middle Ear Surgery : MirkoTos, vol 1 The Otolaryngologic Clinics of North America : Aug 1994; Ossiculoplasty, vol 27, No 4 Surgery of the Ear : Glasscock – Shambough, 5thed Scott Brown otolaryngology 7th edition Internet Journal articles

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