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. TM Perforation and Tympanoplasty. Tympanic Membrane. Develops from three sources:Ectoderm: first branchial groove ? keratinizing squamous epithelium.Mesoderm: first and second branchial arches ? sup. layer of radial fibers, deep layer of circular fibers.Endoderm: tubotympanic recess from first pharyngeal pouch ? mucosa..

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    1. Case Presentation 81 yo M w Hx of SCC of larynx. Underwent XRT several years ago. Then developed otitis media w/effusion that required placement of BMTs over a year ago. Pt has significant hearing loss in the left ear. Occasionally has drainage from left ear.

    4. TM Perforation and Tympanoplasty

    5. Tympanic Membrane Develops from three sources: Ectoderm: first branchial groove ? keratinizing squamous epithelium. Mesoderm: first and second branchial arches ? sup. layer of radial fibers, deep layer of circular fibers. Endoderm: tubotympanic recess from first pharyngeal pouch ? mucosa.

    6. Tympanic Membrane Oval shape. Approx. 8x10 mm. 55 angle w/ respect to floor of meatus. 130 m thick.

    8. Tympanic Membrane Perforations Etiology: Middle ear infections. EAC infections. Trauma. Iatrogenic.

    9. Tympanic Membrane Perforations Middle ear infections: ?-hemolytic strep: necrotizing toxins and proteolytic enzymes. TB: multiple, small perforations. Viruses.

    10. Tympanic Membrane Perforations Traumatic: Blunt trauma. Penetrating trauma. Barotrauma. Blast injury. Thermal injury. T-bone fx: longitudinal.

    11. Tympanic Membrane Perforations Iatrogenic: 40% of pts w/ retained tubes longer than 36 months. 19% of pts w/ tubes for less than 36 months. 80% heal spontaneously. Nichols TP et al. Relationship between tympanic membrane perforations and retained ventilation tubes. Arch Otolaryngol 1998;124(4):417-419

    12. Tympanic Membrane Perforations Risk factors for persistent perfs: Thermal injury. Age greater than 30. Large central perfs. Postero-superior location. Infection. Malnutrition. Immunosuppression.

    13. Tympanoplasty: Indications for Surgery CHL due to secondary to perforation or ossicular dysfunction. Chronic or recurrent otitis media. Chronic middle ear pathology causing progressive hearing loss. Perforation for more than three months.

    14. Tympanoplasty: Goals of Surgery Establish an intact TM. Eradicate middle ear disease by creating an air-containing middle ear space. Restore hearing by reconnecting TM w/cochlea.

    15. History Banzer (1640): repair of TM w/pigs bladder. Toynbee (1853): rubber disk. Blake (1877): paper patch. Wullstein and Zollner (1950s): tympanoplasty w/STSGs. Shea (1957): medial TP w/vein graft. Storrs (1961): temporalis fascia. House, Glasscock, Sheehy (1967): lateral TP.

    16. Tympanoplasty: Classification (Wullstein, 1956) Type I: All three ossicles are present and mobile. Involves repair of a TM perforation or retraction pocket w/o OCR.

    17. Tympanoplasty: Classification (Wullstein, 1956) Type II: Eroded malleus. Involves grafting of the TM to an intact incus and stapes remnant of malleus.

    18. Tympanoplasty: Classification (Wullstein, 1956) Type III: Eroded lateral ossicles. Stapes intact and mobile. prosthesis placed in contact w/stapes suprastructure.

    19. Tympanoplasty: Classification (Wullstein, 1956) Type IV: Absent or eroded stapes suprastructure. Graft or TM overlying a mobile stapes footplate.

    20. Tympanoplasty: Classification (Wullstein, 1956) Type V: Fixed staped footplate. Va: graftingover a fenestration created in horizontal SCC. Vb: stapedectomy.

    21. Tympanoplasty: Techniques Approaches: Retroauricular approach. Transcanal approach. Endaural approach.

    22. Tympanoplasty: Basic Steps Post-auricular incision. Graft (temporalis fascia). T-shaped incision. Elevation of periosteum towards canal. Canal incision (12 to 6 oclock), 2-5 mm lateral to annulus. Vertical incisions: superior limb follows tympanosquamous suture, inferior limb follows tympanomastoid suture. Rimming of perf. Elevation of TM flap (anteriorly). ME inspection, palpation of ossicles. Packing w/Gelfoam. Placement of graft, tucked anteriorly. Repositioning of annulus, vascular strip. Packing of EAC. Closure.

    28. Tympanoplasty: Techniques Underlay technique (medial grafting). Pros: ideal for small, easily visualized perforations, faster, easier, avoids lateralization and blunting. Cons: poorer visualization of anterior meatal recess, reduction in ME space, increased failure when graft bed side reduced (in large anterior perfs). Jackson GC, Glasscock ME, Strasnick B. Tympanoplasty: The undersurface graft technique-postauricular approach. In: Brackman DE, Shelton C, Arriaga MA, eds. Otologic Surgery 2nd ed. Philadelphia, Pa: W.B. Saunders; 2001:113-124

    29. Tympanoplasty: Techniques Overlay technique (lateral grafting): Pros: good exposure of anterior meatal recess, higher success rate (TM pretty much left intact), no reduction of ME space. Cons: more demanding, lateralization and blunting of TM, development of cholesteatoma over TM, longer healing time. Sheehy JL. Tympanoplasty: The outer surface grafting technique. In: Brackman DE, Shelton C, Arriaga MA, eds. Otologic Surgery 2nd ed. Philadelphia, Pa: W.B. Saunders; 2001:96-103

    30. Grafts Temporalis fascia. Loose areolar tissue. Alloderm. Vein. Cartilage (tragal). Canal skin. STSG.

    31. Complications Infections: associated with graft failure. Graft failure due to inadequate packing. Chondritis. Drum cholesteatoma (pearls): in lateral (overlay) technique. Chorda tympani injury: sensory disturbance of tongue, metallic taste. SNHL. Vertigo. VII injury.

    32. Results Closure of perf: Causes for failure: technical, infection, persistent ET dysfunction. Smyth (1992): 90% success at 1 year. Kalik and Smith: 81% success, 91% avoidance of atelectatic pocket formation. Better results w/fascia and when ears are dry.

    33. Results Hearing: Mucosal status: most important predictive factor. Presence of malleus handle. 80% success in closing air-bone gap within 10 dB (at years after surgery) [Halik and Smith].

    34. Results Under- vs. overlay: Reperforation: 365 in overlay, 14% underlay (Doyle 1972). Hearing better w/underlay. Underlay yields better results in less experienced hands. Rizer (1997): successful healing 88.8% in underlay, 95.6% in overlay.

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