The Challenging Chronic Ear

Educational Objectives

The goals of this program are to improve diagnosis and treatment of hearing disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Describe the indications for surgical repair of the tympanic membrane (TM).

2. Illustrate the advantages and disadvantages of the available surgical approaches and graft materials for repair of the TM.

Summary

Perforations of tympanic membrane (TM): most spontaneous perforations heal, but >50% of patients with blast injuries require surgery; predictors of persistent injury include age >30 yr, large perforation, kidney-bean shaped central perforation, and perforation in posterior superior quadrant; drops containing topical steroids may inhibit healing (other medications preferred for contaminated perforations)

Indications for repair: may observe if no drainage, conductive hearing loss, or infection; treat surgically if progressive hearing loss due to infection or tympanosclerosis, patient plans to swim in contaminated water, or cholesteatoma develops; goal of surgery to provide clean dry ear without perforation, rebuild hearing, and preserve normal contour and structure of ear

Graft materials: include dura mater, split-thickness skin graft, and veins; loose areolar tissue overlying temporalis fascia preferred; other good choices perichondrium from tragus or concha; cartilage lends stiffness to TM; if patient had previous surgery, consider using periosteum under temporalis muscle; periosteum may calcify in child, but good choice for adult; for patient with multiple failed procedures, consider sterile, irradiated, homograft of TM

Surgical approach: medial graft — most common approach; use transcanal approach for small posterior perforations and postauricular approach for difficult cases; lateral graft — possible with either approach; remove lateral surface of squamous layer of epithelium of TM and replace with graft; exposure — to aid hemostasis, use largest speculum possible and 1% lidocaine with 1:10,000 epinephrine; pan-TM perforations — anterior lip may not heal readily; repair with postauricular approach to gain exposure; make incision with angled beaver blade next to TM, then make vascular strip incision out EAC; make postauricular incision far enough forward to avoid occluding ear canal with soft tissue of pinna

Harvest graft: use loose connective tissue over temporalis fascia for first tympanoplasty; tissue located beneath superior and posterior auricular muscles; inject lidocaine into temporalis fascia to form bleb and demarcate overlying tissue; leave fascia behind; for postauricular approach, elevate skin flaps on each side to vascularize graft

Prepare site: elevate remnant of drum off malleus; remove small piece of cartilage from lateral process of malleus to allow elevation of periosteum and prevent skin remnant on malleus; for large perforations, when anterior remnant minimal, try to maintain anterior rim instead of perforating remnant; make tiny incision with sickle knife along edge of remnant; remove squamous epithelium at corner of perforation to create fresh margin for grafting

Internal packing: pack ear with 1:1000 adrenaline-soaked Gelfoam; oozing can displace graft; trim graft; may use Gelfoam soaked in fibrin sealant (Tissucol), hydrocortisone/polymyxin b/neomycin (Cortisporin), or ciprofloxacin/dexamethasone (Ciprodex); use ofloxacin (Floxin) on Gelfoam pledgets to decrease rate of infection

Graft: dry graft with heat lamp; large graft can shrink when wet, so obtain enough material to tuck graft under edges of TM remnant, pull it up under malleus to prevent lateralization or detachment, and extend portion of graft into EAC to promote stability and neovascularization

External packing: fill anterior two-thirds of EAC with bacitracin/polymyxin b (Polysporin) ointment; leave posterior third of canal open to replace vascular strip; close postauricular incision; finish filling canal with antibiotic; avoid moving graft when placing cotton in ear

Medial grafting: advantages — success rate mid 80s to 96%; anterior blunting or lateralization unusual; unclear whether medial graft heals more quickly; procedure less painful because wall of anterior canal not drilled; disadvantages — visualization limited; if EAC small, may perform canalplasty; theoretically reduces size of middle ear space; thin layer of Gelfilm reduces risk for adhesions; ear protrudes and feels numb for ≈2 mo

Technique for lateral graft: use postauricular incision; excise anterior two-thirds of skin of canal; place skin in saline with antibiotic; avoid cutting burr in EAC to prevent perforation of glenoid fossa or other structures; remove anterior hump to level of annulus with diamond burr; seat graft; lift epithelium off TM with round knife, leaving connective tissue; make small perforations in skin around anterior edge; use Gelfoam to secure TM graft and anterior skin graft, then put bacitracin/polymyxin b on top

Lateral grafting: advantages — 91% to 97% success rate; provides excellent exposure of anterior meatal angle; preserves middle ear space; disadvantages — graft may lateralize; blunting of anterior meatal recess may cause conductive hearing loss; inclusion cysts and tiny cholesteatomas common but treatable in outpatient setting

Outcomes: no significant difference between adults and children in reperforation rates; age, size, location, middle ear status, presence of cholesteatoma, and cause of disease not associated with outcomes

Cartilage: thicker and stiffer than fascia, resists retraction, and heals well; fascia and cartilage both atrophy over time; in atelectatic ear, atrophy of fascia problematic, but atrophy of cartilage possibly advantageous; fascia histologically disordered, with irregular gaps that can predispose to reperforation

Indications for cartilage: consider using in patient with chronic atelectasis, retraction pocket leading to cholesteatoma, or high risk for reperforation; revisions, certain types of perforations (anterior, marginal, large, or bilateral), and persistent otorrhea associated with reperforation

Harvest cartilage: take from under lateral tip of tragus; for cosmetic reasons, avoid excising lateral portion of tragus; excise up to incisura, removing 1 to 1.5 cm; remove perichondrium from side opposite EAC; if larger piece needed, use cartilage from cymba

Graft placement: in palisading technique, leave perichondrium attached, remove strips of cartilage to increase pliability, then piece into graft site in conical shape; drape attached perichondrium up wall of EAC to stabilize graft; resect strip down center of cartilage to accommodate malleus; place perichondrium and then cartilage under perforation; useful as scaffolding for ossicular reconstruction; for patient with poorly functioning Eustachian tube (ET), can place tube through cartilage; techniques for placing cartilage include inlay, onlay, and interdigitated technique in which perichondrium placed under epithelium; underlay most common technique, and allows cartilage to fill defects in wall of EAC; may also use butterfly-shaped graft for small perforations

Audiologic outcomes: 1000 cases reported using cartilage for recurrent perforations, atelectatic ears, and cholesteatoma; cholesteatoma — in 220 cases, of which 40% revisions, air-bone gap (ABG) decreased from 26 dB to 14 dB after procedure; complications recurrent cholesteatoma (3.6%), recurrent perforation (1%), and postoperative tympanostomy tube (5%); postoperative tube placement preferable to intraoperative placement; recurrent perforation — 47% of cases revisions; ABG improved; 4.2% had recurrent perforation, and few required insertion of tube; atelectasis — hearing results favorable; complications recurrent perforation (1%), intraoperative insertion of tube (7%), and postoperative insertion of second tube (12%)

Slicing cartilage: slice cartilage free-hand or with Kurz knife; shaping cartilage takes ≈5 min

Outcomes with cartilage: postoperative effusion and cholesteatoma difficult to identify, but audiologic results good; postoperative hearing similar with fascia and cartilage; stiffness of cartilage advantageous for anterior perforations; cartilage not proven superior to fascia for type I tympanoplasty

Topical growth factors: produce high closure rates; topical fibroblast growth factor gives 92% to 94% rate of closure

Readings

Cayé-Thomasen P et al: Ten-year results of cartilage palisades versus fascia in eardrum reconstruction after surgery for sinus or tensa retraction cholesteatoma in children. Laryngoscope 2009 May;119(5):944-52; Cueva RA: Areolar temporalis fascia: a reliable graft for tympanoplasty. Am J Otol 1999 Nov;20(6):709-11; Dornhoffer J: Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003 Nov;113(11):1844-56; Dornhoffer JL: Cartilage tympanoplasty. Otolaryngol Clin North Am 2006 Dec;39(6):1161-76; Eisenman DJ: Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings. Otol Neurotol 2011 Sep;32(7):1116-9; Gersdorff M et al: Overlay versus underlay tympanoplasty. Comparative study of 122 cases. Rev Laryngol Otol Rhinol (Bord) 2003;124(1):15-22; Hakuba N et al: Basic fibroblast growth factor combined with atelocollagen for closing chronic tympanic membrane perforations in 87 patients. Otol Neurotol 2010 Jan;31(1):118-21; Hol MK et al: Comparison between a new implantable transcutaneous bone conductor and percutaneous bone-conduction hearing implant. Otol Neurotol 2013 Aug;34(6):1071-5; Kalcioglu MT et al: Comparison between cartilage and fascia grafts in type 1 tympanoplasty. B-ENT 2013;9(3):235-9; Kanemaru S et al: Regenerative treatment for tympanic membrane perforation. Otol Neurotol 2011 Oct;32(8):1218-23; Lou ZC et al: Traumatic tympanic membrane perforations: a study of etiology and factors affecting outcome. Am J Otolaryngol 2012 Sep-Oct;33(5):549-55; Mattox DE and Hudgins P: Algorithm for evaluation of pulsatile tinnitus. Acta Otolaryngol 2008 Apr;128(4):427-31; Neumann A et al: Type III tympanoplasty applying the palisade cartilage technique: a study of 61 cases. Otol Neurotol 2003 Jan;24(1):33-7; Onal K et al: Functional results of temporalis fascia versus cartilage tympanoplasty in patients with bilateral chronic otitis media. J Laryngol Otol 2012 Jan;126(1):22-5; Otto KJ et al: Sigmoid sinus diverticulum: a new surgical approach to the correction of pulsatile tinnitus. Otol Neurotol 2007 Jan;28(1):48-53; Rizer FM: Overlay versus underlay tympanoplasty. Part I: historical review of the literature. Laryngoscope 1997 Dec;107(12 Pt 2):1-25; Rizer FM: Overlay versus underlay tympanoplasty. Part II: the study. Laryngoscope 1997 Dec;107(12 Pt 2):26-36; Sergi B et al: Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital 2011 Dec;31(6):366-71; Shah A et al: Otologic assessment of blast and nonblast injury in returning middle east-deployed service members. Laryngoscope 2013 May 17 [Epub ahead of print]; Zhang ZG et al: Three autologous substitutes for myringoplasty: a comparative study. Otol Neurotol 2011 Oct;32(8):1234-8.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Welling present information related to off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Welling was recorded at Kentucky Society of Otolaryngologists Annual Meeting, sponsored by University of Kentucky, College of Medicine, and held on April 20, 2013, in Lexington, KY.  For upcoming CME conferences from the University of Kentucky, College of Medicine, please visit cecentral.com. 

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT470401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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