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  2. 2. OUTLINE: • Introduction • Definition of terms • Applied anatomy • Tympanic membrane perforation • Tympanoplasty • Ossicular chain reconstruction • Stapedectomy/Stapedotomy • Controversies • References
  3. 3. Introduction Definition of terms Tympanoplasty- entails grafting of the tympanic membrane with inspection of ossicular chain with/without reconstruction of the middle ear hearing mechanism. Ossiculoplasty- reconstruction of hearing ossicular chain using either autologous graft of prosthesis. Meatoplasty- Involves enlargement of the lateral cartilaginous portion of the external auditory canal. A narrow entrance to the ear canal within the cartilaginous portion of the canal prevents proper ventilation and self-cleaning of the ear canal, and may compromise hearing aid fitting. Canalplasty -is partial or total widening of the bony portion of the external ear canal. In order to visualize the tympanic annulus, particularly in anterior or subtotal perforations, canalplasty is essential and may be an integral part of myringoplasty or tympanoplasty.
  4. 4. Applied anatomy External ear • Outermost part of the ear • Separated from middle ear by a tympanic membrane • Aural components are used in harvesting grafts: tragus, concha, &/or perichondrium • Multiple flaps are raised from the EAC during tympanoplasty.
  5. 5. Blood supply of the external ear.
  6. 6. Nerve supply of the external ear
  7. 7. Cont… • Auriculotemporal nerve- innervates the anterior superior area of the EAC. • Arnolds nerve -innervates the Posterior inferior area of the EAC • Facial nerve –innervates the skin of the mastoid and posterior wall of the EAC.
  8. 8. Middle ear • It contains the tympanic cavity, mastoid ear cells, ear ossicles and eustachian tube. • Pressure balance between the middle ear and outer ear is essential for sound transmission(vibratory action of ossicles and tm)
  9. 9. Tympanic membrane
  10. 10. Cont… • Eustachian tube Ear ossicles
  11. 11. Chorda tympani
  12. 12. ARTERIAL SUPPLY OF THE MIDDLE EAR 1)Two main arteries a)Anterior tympanic branch of maxillary artery b)Stylomastoid branch of posterior auricular artery 2)Four minor arteries a)Petrosal branch of middle meningeal artery b)Superior tympanic branch of middle meningeal artery c)Branch of artery of pterygoid canal d)Tympanic branch of internal carotid VENOUS DRAINAGE Pterygoid venous plexus Superior petrosal sinus
  13. 13. Tympanic membrane perforation
  14. 14. Perforation size calculation Percentage of perforation= Perforation/Total area of TM x 100% Where; • Group-I (Small)-area in range of 0-8mm2 • Group-II (Medium)- area in range of 8.1-30mm2 • Group-III(large)-area in range ≥30.1 mm2 Percentage of perforation= Area of perforation/Total area of perforation x100. Therefore; • Small (area involved is ≤25% or one quadrant) • Medium (area involved is 25% -50% or two quadrants) • Large (area involved is 50%-75% or more than two quadrants)
  16. 16. History of tympanoplasty 1640- BANZER- first to repair perforated TM using pig’s bladder. 1853-TOYNEBEE- used a rubber disc attached to a silver wire over a perforated TM and improved hearing. 1878-BERTHOLD-First true tympanoplasty was done using a skin graft. 1950-WULLSTEIN & ZOLLNER- Introduced tympanoplasty using skin graft by overlay technique, wasn’t successful and other alternative of grafts were introduced. 1958-PLESTER- Introduced canal skin as free overlay graft.
  17. 17. Cont... 1959-GLASSCOCK & SHEEHY- Introduced inlay placement of vein graft, which was successful but later led to re-perforation. STORRS- Introduce the use of fascia solved all problems of skin grafts. 1964-NET CHALAT- First to perform Tympanoplasty using homograft. 1968 – Success of homograft have been reported worldwide. (loose areolar tissue, perichondrium, cartilage, fascia)
  18. 18. Why tympanoplasty? Achieve a dry, self-cleansing ear while preserving or restoring hearing.  Restore middle ear function by eradicating infection and middle ear pathology. To re-establish a tympanic membrane that resists infection and epithelial ingrowth.  To secure a durable connection between the tympanic membrane and the inner ear.
  19. 19. Types of tympanoplasty TYPE OF TPLASTY DEFECT POSITION/CONTACT OF GRAFT TYPE I(MYRINGOPLASTY) Tympanic membrane perforation TM or malleus TYPE II Tympanic membrane perforation with erosion of malleus Incus or remnant of malleus TYPE III Malleus and incus absent Stapes superstructure TYPE IV Stapes superstructure Stapes footplate TYPE V Stapes footplate fixed Fenestra of horizontal SCC
  20. 20. Indications of tympanoplasty  Tympanic membrane perforation of more than 20% of its total size.  Chronic infections of the ear unresponsive to antibiotic therapy.  High ear trauma due to piercing by a sharp object in the ear, loud explosive noises, head injury etc.  Ossicular chain dysfunction.
  21. 21. Types of grafts and selection • Cartilage: Tragal, concha. • Perichondrium: Tragal/concha perichondrium. • Periosteum: Temporalis muscle periosteum. • Fascia: Temporalis fascia. • Fat: Ear lobule fat pad. • Autologous fascia: AlloDerm CRITERIA FOR SELECTION OF GRAFTS. • Type of approach • Site/location of perforation. • Surgeons preference • Eustachian tube function/retraction pockets • Revision surgery
  22. 22. Cartilage technique. Why cartilage use in tympanoplasty -If ongoing ET dysfunction -If ossiculoplasty is done-to avoid extrusion risk and to augment prosthesis- tissue interface for good hearing results. -Atelectatic ear -Second stage ossiculoplasty -Structural support for posterior superior retraction pockets Fascia and perichondrium need a new vascular supply but cartilage is supplied by diffusion
  23. 23. Cartilage preparation techniques. • Perichondria cartilage island technique • Palisade cartilage technique • Shield technique • butterfly technique • Crown cork technique Perichondria cartilage island technique –concha cartilage
  24. 24. Concha cartilage preferred. Indications: Subtotal perforation, adhesive processes eg. retraction pockets, tympanosclerosis, revisions surgeries.  It is resistant to barometric changes that occur during diving.  Restores same auditory function as temporalis fascia.
  25. 25. Indications: Total perforations, severely atelectatic tympanic membranes, and failures of previous tympanoplasty associated with chronic eustachian tube dysfunction. Although the graft take of this technique has been reported to be excellent, there have been concerns regarding hearing results because it replaces the entire tympanic membrane with cartilage.
  26. 26. Indications: Small and medium sized perforations with no middle ear disease or ossicular involvement. Sapna et al- Endoscopic Cartilage Butterfly Tympanoplasty2020. The hearing outcomes and successful closure rate are similar to those of other surgical methods.
  27. 27. Is a technique for the total reconstruction of the tympanic membrane, Indications: recommended in cases of ear malformation, blunting-phenomena and total deficiency of the membrane caused by chronic otitis media. Autologous tragal composite graft is used. Crowncork technique
  28. 28. Contraindications of tympanoplasty • Only hearing ear. • Active vestibulopathy • Multiple failed previous ear surgery
  29. 29. Pre operative assessment. • History -otorrhea • physical examination-Otomicroscopy. • Audiological assessment (PTA, Tympanometry). • Assessment of the contralateral ear. • CT scan of temporal bone. • Basic investigation. • ECG,ECHO
  30. 30. Approaches to middle ear • Postauricular aproach • Transcanal aproach • Endoaural
  31. 31. Equipments and uses • Suction tubes • Sicke knife • Round knife • Surgical blade #15,11 • Mollison mastoid retractor • Freer elevator • Microcrocodile forceps
  32. 32. Patient preparation Pre operative counseling • Change in hearing capability • Change in taste • Facial paralysis,Graft failure • Post aur numbness,vertigo Review of previous otological surgeries . Anesthesia • General anaesthesia • Local anaesthesia (lignocaine 2%+ Adrenaline +Norma saline) injected at BC junction of EAC Patient positioning • Bed turned 180 degrees with feet toward anesthesia • Supine with head turned to the contralateral side
  33. 33. Myringoplasty technique- Underlay • Simplest and commonly used • Suitable for anterior quadrant perforations. • Graft is placed medial to the remnant of TM and medial to the handle of malleus . • Perforations involving anteroinferior quadrant, tympanomeatal flap is divided posteriorly after it has been elevated.
  34. 34. Cont… Advantages • Simple technique and less time consuming. • Less blunting / lateralisation. • High graft take up rate Disadvantages • Less suitable for large anterior perforation. • Limited visualization of anterior meatal recess
  35. 35. Overlay technique • Graft is placed lateral to the fibrous layer of the TM. Advantages I. Good exposure of anterior meatal recess. Disadvantages I. Long healing time required II. Presence of blunting/Lateralization
  36. 36. Inlay technique • Graft is placed between inner endothelial layer and middle fibrous layer of the tympanic membrane. • Getting an interplay plane between fibrous layer and mucosa is easier and faster. Advantages No risk of lateralization or medialization Disadvantages Time consuming Requires addition skills used by experienced surgeons
  37. 37. Surgical steps POST AURICULAR APROACH Favors anterior perforations. Allows one to do a circumferential canalplasty. • Cleaning the middle and ear canal. • Lempet's speculum/Nasal speculum is used to visualize the BC junction to inject the 4 quadrants of the skin of the ear canal. • Local infiltration of the tissues is done anteroinferiorly and anterosuperiorly and post auricular region.
  38. 38. Cont.. • Post auricular incision(1-2cm from the post auricular sulcus. • Skin elevation while retracting the auricle anteriorly to reach the temporalis fascia. • Periosteal flap is developed, vertical incision is made with the superior incision extended anteriorly along linear temporalis up to 12 oclock relative to bony ear canal to harvest the graft.
  39. 39. Cont.. • Musculoperiosteal (MPF) flap is elevated 2mm deep to the lateral edge of bony canal at 12 oclock exposing the Spine of Henlé. • The auricle and MPF are retracted anteriorly using a retractor.
  40. 40. Cont.. • EAC is entered via transverse incision at 8oclock extending to 12 oclock and the lumen of the canal comes into view. • Further incision is made from 2oclock to 12 oclock and 5 oclock to meet 2oclock incision.(right ear)
  41. 41. Cont.. • Freshening of margins of a perforation using a sickle knife. • Removing the area of tympanosclerosis. • Assessment of the ossicular chain. • Assessment of the Eustachian tube.
  42. 42. Cont… • Meatal skin flap (Tympanomeatal) is circumferentially elevated from the bone. • Meatal skin is transected to 6oclock using a round knife at 2mm lateral to the annulus and the flap is elevated. • Canalplasty can be done. • Precautions to be taken here.
  43. 43. Cont.. • Gelfom to be placed medial and lateral to the graft to bolster it(soaked in ciprofloxacin ear drops) • In tympanoplasty type one, the graft in placed in either technique (inlay, overlay or underlay) • The graft is connected to the malleus. • In tympanoplasty type two and above the ossicular chain is reconstructed.
  44. 44. TRANSCANAL APROACH • Indicated in traumatic perforations or in cases where there is a wide ear canal with a posterior perforation. • Done microscopically or endoscopically . • The ear canal must be wide enough, and one should be able to visualize the entire margins of the perforation. • The anterior margin of an anterior perforation may be obscured by an overhanging canal wall
  45. 45. ENDOAURAL APPROACH • Better for posterior perforation. • An incision between the tragus and helix; the entrance to the ear canal is then stretched open with end aural retractors. • Infiltration of local anesthesia in four quadrants.
  46. 46. • A skin incision from 12 o’clock position, spiraling upwards between the cartilages of the helix of the pinna and tragus. The incision is 1,5cm in length and extends down to the bone. • Another skin incision is made in the posterior aspect of the bony EAC parallel to the annulus, starting at 8 o’clock and ascending in a spiral fashion to meet the endaural incision at 12 o’clock. • Skin and soft tissue is then reflected laterally and away from the edges of the tympanomeatal flap.
  47. 47. Cont… •An incision is made anteriorly in the bony canal skin, parallel to the annulus and remaining medial to the cartilage of the ear canal. It starts at 2 o’clock and meets the endaural skin incision at 12 o’clock •Retractors will then be placed in the canal to improve exposure •Before tympanomeatal flap elevation Edges of perforations are freshened using sickled knife
  48. 48. Cont… • The tympanomeatal flap is returned to its original position and gelfoam pledgets are placed over the graft to secure it over the posterior tympanic sulcus followed by the closure of endaural skin incision.
  49. 49. Cont.. • In case of tympanoplasty 2 and above, Ossicular chain reconstruction is done. • Austins classification of ossiculoplasty • Based of the status of malleus and stapes. Materials used; Cartilage, teeth, autograft or homograft and cortical bone. TYPE STATUS OF OSSICLE A M+,S+ B M-,S+ C M+,S- D M-,S- E OSSICULAR HEAD FIXATION F STAPES FIXATION
  50. 50. Ossiculoplasty TYPES OF OSSICULOPLASTY • Primary- ossiculoplasty done with mastoidectomy at the same sitting. • Secondary- staged ossiculoplasty.mastoidectomy first, 6- 12month after, ossiculoplasty can be done. TECHNIQUE OF OSSICULOLASTY 1.Partial OCR (POCR)- When malleus and stapes are mobile, stapes mobile but malleus fixed(aims to connect TM/Handle of malleus to stapes. 2.Total OCR (TOCR)-Total ossicular replacement prosthesis connected to the stapes or open vestibule.
  51. 51. Cont.. PROSTHESIS FOR OSSICULOPLASTY • Bone cement • Titanium • Perichondrium
  52. 52. Cont…
  53. 53. Cont… PLACEMENT OF PROSTHESIS •Prosthesis should be in minimal/slight tension and at a favorable angle. •The prosthesis should fit perfectly without tension before cartilage. •Middle ear filled with packs before placement of prosthesis
  54. 54. Complications of tympanoplasty • Worsening of hearing loss • Vertigo • Loss of taste • Graft failure/re-perforation. • Cholesteatoma formation • TM lateralization
  55. 55. CONTROVERSIES • Partial vs Full thickness cartilage-perichondrium. • Post operative mastoid pressure dressing vs post auricular simple dressing. • Tympanoplasty in total dry ear vs wet ear in term of failure rate.
  57. 57. History of stapes surgery 1704- Valsava’s first description of hearing loss due to stapes fixation 1878- Kissel, founder of stapes surgery –mobilization of stapes then removed stapes footplate 1888- Boucheron reported 60 mobilizations with best-early ankylosis 1890- Miot- 200 mobilizations with improved bone conduction 1892- Blake coined “stapedectomy” 1893- Jack reported series of cases of extraction of stapes Early attempts at stapes mobilization were fraught with complications, including fatal labyrinthitis, and provided hearing gain for only days.
  58. 58. Cont.. 1899 – The 6th International Otology Congress declared stapes surgery useless, dangerous, and unethical thus ending further work on stapes mobilization procedures. 1920- Holmgren “father of fenestration” accidental fenestration in the lateral scc 1930 - Soudrile –modification with 3 stage fenestration operation 1938- Lempert – popularized single stage procedure.
  59. 59. Cont… 1950 – current era of stapedectomy when he created the first stapes prosthesis from Teflon  1980-81- Rob perkins- first laser stapedotomy
  60. 60. Stapedectomy Definition: Restoration of the impedance transfer of the ossicular chain and the acoustic impedance of the annular ligament of the stapes footplate in order to achieve normal physiologic vibration of the inner ear fluid. Goals: • Open the oval window for sound transmission • Reconstruct sound conducting mechanism without complication
  61. 61. Biophysics of stapes surgery • Middle ear acts as impedance transformer It converts the incoming vibrations from large low impedance T.M to much small, high impedance oval window. This allows 60% of sound energy to dissipate in inner ear
  62. 62. Cont.. The most important factor in the middle ear’s impedance matching are: • Area of tympanic membrane relative to oval window. • The lever action of the middle ear ossicles. • The shape the tympanic membrane The combined effects of the area ratio and the lever ratio give the middle ear output a 28-dB gain.
  63. 63. Cont… Acoustic impedance of annular ligament Resistance Mass Rigidity and elasticity
  64. 64. Indications for stapedectomy/stapedotomy • Conductive hearing loss due to stapes fixation with an air–bone gap greater than 30 dB & good speech discrimination (SDS 60% or more) • Stapes malformations (monolateral stable conductive hearing loss associated with a suggestive CT scan for a stapes malformation). The ear with poorer hearing, based on the patient’s report rather than audiography, should undergo the operation first. In bilateral cases, the second ear can be operated on 6 months later, assuming this is now the poorer-hearing ear.
  65. 65. Contraindications • Poor general condition of the patient. General medical illness Extreme of age(70 yrs) :sd score becoming worse in 40%of cases , risk of fistula is more Pregnancy- delayed untill 12 months post delivery • Physical strain –sports men risk of perilymph fistula is high. • Otitis externa/tm perforation • Unilateral otosclerosis • The affected ear being the only hearing ear. • Poor cochlear reserve as shown by poor speech discrimination scores • The patient having untreatable tinnitus and vertigo. • Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flamingo sign(shwartze sign) • Conductive deafness from other causes other than stapes fixation eg due to Ehlers–Danlos syndrome, otosclerosis.
  66. 66. Preoperative evaluation • Good history and physical examination. • Otoscopy • Preoperative binocular microscopy should be performed and with inspection of the tympanic membrane to rule out evidence of atelectasis or cholesteatoma/myringosclerosis can point towards fixation of any of the ossicles. • Tuning fork testing
  67. 67. • Audiometry. Pure tone thresholds and speech audiometry. A Carhart notch, decreased bone conduction threshold at 2000 Hz, is typical and is indicative of otosclerosis • Tympanometry. A subtype S.
  68. 68. Stapedial reflex • Two distinct patterns of abnormal stapedial reflexes are seen in otosclerosis. • If footplate mobility has decreased but it is not yet completely fixed, nearly all patients will show a biphasic response the so called “on – off effect” • If stapes is firmly fixed no reflexes can be elicited from the affected ear.
  69. 69. Preoperative imaging • Temporal bone CT scan. Preoperative analysis of oval window width and facial promontory angle to predict operative difficulty. Identifying anatomical variants (ie, dysplasia of the IAC or cochlea consistent with X linked gusher) that could pose problems during surgery or for possible factors that could explain surgical failure in revision operations.
  70. 70. Equipments. • Necessary equipment for stapedectomy includes a full set of middle-ear instruments with multiple sizes of otologic specula. • Various blades, eg sickle knife and round knife. • Microscope vs endoscope use=Similar hearing outcomes Ianella et al 2016-Endoscopic Versus Microscopic Approach in Stapes Surgery Huner et al –outcome of endoscopic stapes surgery. Challenges in endoscopic surgery include instrument limitation, single- handed work, lack of stereoscopic view, and a potentially high surgeon learning curve.
  71. 71. Cont.. • Creating the fenestration in the stapes footplate Skeeter drill or microdrill vs use of laser = no difference in drop of bone conduction thresholds.  Cuda et al 2009- Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative study. Somers et al 2006- Stapedotomy with microdrill or carbon dioxide laser: influence on inner ear function. Laser- Advantage: Drop in bone conduction thresholds from sensorineural hearing loss at high frequencies due to acoustic trauma at the basal turn. KTP and argon laser vs co2 laser = CO2 laser. Due to its high reflectance off of the perilymph, versus the KTP and argon laser, which have lower wavelengths allowing greater penetration into the perilymph and potentially greater energy absorption by the pigmented tissues of the membranous labyrinth in the line of laser fire at the base of the vestibule(saccule).
  72. 72. Cont.. • Facial nerve monitoring If general anesthesia is used. Use of the facial nerve monitor does not eliminate the risk of facial nerve injury during stapedectomy. The monitor can provide the surgeon with feedback while microdissection in the area of the facial nerve is performed, allowing the surgeon to modify technique to minimize risk of injury to the nerve.
  73. 73. Cont… • Types of prostheses Categorized as either hooked or handled prostheses. Materials evolved from Teflon, metal, to plastic, and most recently to gold and titanium. Initially the diameter of the pistons used was 0.8 and 0.6 mm, recently smaller dm are used in order to ease the procedure and reduce the risk of inner ear damage. Improvement in the way the prosthesis is fixed to the long incus process, resulting in different solutions like Teflon memory effect, platinum and gold band, titanium-gold clip prostheses or nickel-titanium alloy.
  74. 74. Patient Preparation • Anesthesia Either local monitored anesthesia care (MAC) or general anesthesia. Long-acting paralytics are not recommended owing to the inability to monitor facial nerve function. Local anesthetic of choice is used in incisions to be made depending on approach eg planned posterior canal skin incision area, anterior to the helical crus area .
  75. 75. • Positioning The patient is placed in the supine position on the operating table with the head turned to the opposite side from the operative ear, to about 30–45°.
  76. 76. Patient preparation. • Preparation and draping of patient. • Povidone-iodine solution irrigated out of the ear canal using warm saline. • Examination of TM -Perforations -Sclerosis
  77. 77. Stapedectomy vs Stapedotomy • Stapedectomy Complete removal of the posterior and anterior portions of the footplate leaving the membrane below the footplate intact. This is accomplished with various instruments angled appropriately to allow removal of the bone with preservation of the underlying membrane. Recently reserved only for select cases. • Stapedotomy Creation of fenestration in the footplate using laser once the stapes superstructure has been removed.
  78. 78. Approaches to middle ear • Endomeatal (Transcanal or Transmeatal) Approach Rosen incision (Endomeatal approach) • Endaural Approach (Lempert or Heerman incision)
  79. 79. Flap elevation ct, chorda tympani; in, incus; an, anulus; eac, external ear canal.
  80. 80. Displacement of the chorda tympani ct-chorda tympani; in, incus; ma, malleus; s, stapes; dr, eardrum; rw, round window.
  81. 81. Exposure of incudostapedial joint a-b: Curettage of the external auditory canal with a bone curette. . c–d: Exploration of the tympanic cleft ct, chorda tympani; in, incus; ma, malleus; s, stapes; dr, eardrum; pe, pyramidal eminence; cp, cochleariform process.
  82. 82. Establishment of anatomical landmarks. ct, chorda tympani; in, incus; ma, malleus; s, stapes; rw, round window; pe, pyramidal eminence; cp, cochleariform process;
  83. 83. Types of surgical procedure. • Traditional stapedotomy/stapedectomy without preservation of the stapedial tendon • Stapedotomy with preservation of stapedial tendon. When the anatomical conditions are favorable (wide and not too deep oval window niche, wide space between the facial nerve and the crura of the stapes) In order to respect the vascular supply of the long process of the incus.
  84. 84. ..without preservation of stapedial joint • The stapedial tendon is divided with small curved scissors. The stapes superstructure is down fractured with delicate force (or with a small drill or a laser) and removed, leaving the footplate.
  85. 85. Stapes removal a Disarticulation of the stapes. b Removal of the stapes. c Drilling of the footplate. d The footplate visualized after drilling
  86. 86. • Drilling fenestration techniques. • Fisch technique • Marquets’ microhook technique
  87. 87. Prosthesis placement Piston placement. a Endoscopic view of the oval window after stapedotomy. b–d Placement of the piston is carried out with a hook.
  88. 88. Cont.. a-b Placement of the piston on the incus. c, d The piston is secured by tightening the platinum hook
  89. 89. Tympanomeatal flap replacement The tympanomeatal flap is repositioned and sealed with antibiotic ointment or Gelfoam treated with antibiotic solution.
  90. 90. Stapedectomy vs stapedotomy
  91. 91. Cont …
  92. 92. Precautions. • Excessive heat dissipation, since endoscopes tend to transfer heat from the light source. • Suctioning of perilymphatic fluid is avoided to minimize postoperative vertigo and cochlear damage. • Tip of the endoscope can potentially be very hot. • Accidental movement of the endoscope and secondary direct trauma from the tip of the instrument particularly to the EAC, to avoid causing unnecessary bleeding or damage to the ossicular chain, eardrum, and facial nerve.
  93. 93. Surgical challenges • Narrow ear canal • Fixed incus/malleus • Dehiscent/prolapsed facial nerve (0.5%) • Floating footplate • Obliterative otospongiosis • Biscuit footplate • Perlymph gusher (0.03-0.3%) • Persistent stapedal artery • Adhesions in oval window niche
  94. 94. Post op care and follow up • Analgesics • Antipyretics • Antiemetics • Avoid straining
  95. 95. Complications • Complications during TM flap elevation Ear drum perforation Facial nerve palsy Chorda tympani injury Incus laxation (anterior/posterior/lateral) • Complications during removal of stapes Snhl Floating footplate
  96. 96. Cont… • Complications after stapedectomy Reparative granuloma Perilymph fistula Delayed snhl Delayed fn palsy Cholesteatoma Labyrinthitis / meningitis
  97. 97. Cont.. • Conductive hearing loss after stapedotomy Mechanism: Erosion of incus causing looseningof wire loop Collagen tissue seal contracts Prosthesis lifts out of stapedotomy/migrates to the fixed stapes footplate
  98. 98. • Surgical technique of stapedectomy • 1. total stapedectomy • Partial stapedectomy
  99. 99. • • Outcomes Following Endoscopic Stapes Surgery. Otolaryngol Clin North Am. 2016; 49(5):1215-25 (ISSN: 1557-8259) • Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative study. Otol Neurotol. 2009; 30(8):1111-5 (ISSN: 1537-4505) Cuda D; Murri A; Mochi P; Solenghi T; Tinelli N Stapedotomy with microdrill or carbon dioxide laser: influence on inner ear function.Ann Otol Rhinol Laryngol. 2006; 115(12):880-5; discussion 886 (ISSN: 0003-4894)Somers T; Vercruysse JP; Zarowski A; Verstreken M; Offeciers E

Notas del editor

  • The goals myringoplasty and tympanoplasty are to achieve a dry, self-cleansing ear while preserving or restoring hearing.
  • Mucosal layer of the TM is the lateral border of the middle ear

    Rounded prominence produced by first basal turn of the cochlea(it is a site where glossopharyngeal nerve ramifies with the other nerve to form tympanic plexus).

    OVAL WINDOW; Reinform aperture located above and behind the promontory.
  • Tympanic membrane perforation is when the tympanic membrane (TM) ruptures, creating a hole between the external and middle ear.

    Tm perforation is classified according to;
    -duration: acute (<3months) or chronic (>3months)
    -presence or absence of otorrhea: wet or dry perforation
    -location: central, marginal, attic
    -size: can be estimated clinically, or calculated microscopically endoscopically or radiologically.

  • (In this method perforation is measured in pixels).
  • Wedge resection of concha cartilage with placement of perichondrium medial to the remnant tympanic membrane or tympanic annulus. The long handle of the malleus was placed into the wedge resected area of the graft using a lock-and-key approach
  • Perichondrium is removed from one side of the cartilage, then the cartilage is cut into several palisades on average 4-5 then placement in an over-under fashion (2 placed anterior to the malleus handle and 2/3 placed posteriorly) then the removed perichondrium is laid on the cartilage palisades.
  • Endoscopic Cartilage Butterfly Tympanoplasty: A Two-Handed Technique with Endoscope Holder
    Sapna R. Parab, Mubarak M. Khan & Asiya Zaidi
  • The graft consist of a round piece of tragal cartilage covered on the outer side (ear canal side) with perichondrium which continues in a large peripheral perichondrium flap. The diameter of the cartilage is slightly smaller than the diameter of the eac at the level of bony annulus. The exposed bare inner part is brough in contact with the handle of malleus or a prosthesis and the outer part with perichondrium is radically incised resulting in several perichondrial flaps with which after placement into the bony eac forms the shape of a crown cork.
  • Avoid to extend the incision below the mastoid tip,the risk of facial nerve injury is high.
  • Using a #11 blade, enter the ear canal via a transverse incision in the posterior ear canal skin at about 8 o’clock (right ear). The lumen of the ear canal is then visible through the incision

    Using a #11 blade, enter the ear canal via a transverse incision in the posterior ear canal skin at about 8 o’clock (right ear). The lumen of the ear canal is then visible through the incision

  • This incision runs lateral to the tympanosquamous suture line and also has to remain on bone and medial to tragal cartilage; if the incision is placed too laterally tragal cartilage will be injured. It is important to incise the skin fully into the bone to avoid tearing of the skin during elevation

  • Meatal skin flap is circumferencially elevated from the bone to expose posterior superiormargin of tm and anterior inferior overhang of bone is exposed.
    When drilling close to meatal skin, a diamond burr is used so that the meatal skin is not injured by the burr.
    Drilling of the bony overhang stating posteriorly inferiorly then anteriorly for proper visualisation.
    In presence of perforation gel foam are placed to avoid dust entering middle ear

  • A skin incision is made in the bony external canal with a #15 blade from the 12 o’clock position, spiraling upwards between the cartilages of the helix of the pinna and tragus (Figure 1). The incision is 1,5cm in length and extends down to the bone
  • Following the turn of the 20th century, interest in surgery for stapes fixation was again reignited when Holmgren developed the fenestration procedure, in which a fenestra is created in the lateral semicircular canal, allowing sound to bypass the fixed stapes altogether. This was modified again by Sourdille in the 1930s

    was Lempert who was credited with popularizing the fenestration procedure when, in 1938, he demonstrated a single-stage endaural fenestration procedure, which was quickly adopted as the procedure of choice for stapes ankylosis.
    The current era of stapedectomy was started by Shea in the 1950s, when he created the first stapes prosthesis from Teflon. Various prostheses were then created during the following decade

  • The concept of stapes footplate surgery also changed, with various authors suggesting removing only portions of the footplate before placement of the prosthesis, and ultimately to the concept of the stapedotomy, in which a small hole is created in the fixated footplate for placement of the prosthesis. This allowed placement of the prosthesis piston into an appropriately sized hole and minimized the potential injury to the inner ear. Such techniques are still used today as the primary method of stapes surgery.
  • Impedance is defined as the resistance offered by a medium for transmission of sound.

    Middle ear by its impedance matching property allows 60% of sound energy to dissipate in inner ear

  • The human tympanic membrane has a surface area approx 20 times larger than the stapes footplate (69 vs. 3.4mm2).
    Effective areal ratio is 20:1
    So force produced by sound concentrated over small area
    Amplifying Pressure on Oval window, net gain of 26 dB.

    Handle of malleus is 1.3 times longer than long process of incus
    Overall this produces a lever action that converts low pressure with a long lever action at malleus handle to high pressure with a short lever action at tip of long process of incus.
    In humans, the lever ratio is about 1.31 : 1 (2.3 dB
    Eustachian tube equilibrates the air pressure in middle ear with that of atmospheric pressure, thus permitting tympanic membrane to stay in its most neutral position.
    A buckling motion of tympanic membrane result in an increased force and decreased velocity to produce a fourfold increase in effectiveness of energy transfer.

  • Important for any surgery-Reasonably good health to tolerate anesthesia, especially if general anesthesia is needed

    Other literature ab gap atleast 15db. Bc level 0-25db in the speech range and ac 45-65db.
    Surgery to those with stapes fixation os done prior to prescribing hearing aids .

    Good cochlear reserve as assessed by the presence of good speech discrimination is also important although not a universal requirement. Stapedectomy does not treat sensorineural hearing loss (SNHL). A significant conductive component (as demonstrated by air-bone gap) is pertinent to patient selection especially when considering stapedectomy in patients with advanced otosclerosis (a patient with otosclerosis who has severely decreased speech recognition). Severe retrofenestral sclerosis and speech recognition scores of < 30% are associated with poor results.

    Indications for the endoscopic approach are the same as for the microscopic approach
  • Conductive deafness from other causes other than stapes fixation eg due to Ehlers–Danlos syndrome, otosclerosis. Bse in other causes there is high incidence of snhl.

    Untreatable tinnitus and vertigo or recent hx of clinical diagnosis of labyrinthine hydrops--
  • A thorough preoperative evaluation including a comprehensive physical exam should be performed to identify conditions that may present similarly to otosclerosis or may occur in conjunction with otosclerosis. For example, a history suggestive of a congenital dysplasia, as in the case of an enlarged vestibular aqueduct, or autophony, with accompanied sound induced vertigo, would be more suggestive of a semicircular canal dehiscence.

    Turning fork test- Rinne and Weber testing should be performed with 512 Hz (and optionally 1024 Hz and 2048 Hz) tuning forks to document conductive hearing loss.

    acoustic reflex (also known as the stapedius reflex, stapedial reflex, auditory reflex, middle-ear-muscle reflex (MEM reflex, MEMR), attenuation reflex, cochleostapedial reflex or intra-aural reflex/ Immittance testing is necessary for all patients undergoing stapedectomy surgery. Acoustic reflex testing is a requirement, as the presence of intact acoustic reflexes must compel the surgeon to search for other causes of conductive hearing loss, such as superior semicircular canal dehiscence or other third-window fistulae

  • Audiometry. Preoperative audiometry should be performed in all patients undergoing stapedectomy. Pure tone thresholds should be confirmed with tuning-fork tests prior to surgery for documentation of true hearing loss. Speech audiometry is important to document integrity of speech discrimination.

    The usual pattern of otosclerosis is a normally shaped tympanogram with a large air-bone gap with absent stapedial muscle reflexes for both ipsilateral and contralateral stimulation. Occasionally, an A subtype S tympanogram may be identified, signifying normal tympanometry with decreased compliance in ossicular chain mobility. A Carhart notch, decreased bone conduction threshold at 2000 Hz, is typical and is indicative of otosclerosis.
  • Necessary equipment for stapedectomy includes a full set of middle-ear instruments with multiple sizes of otologic specula. Some surgeons use a speculum holder for steadying the speculum and freeing the hands for other instruments. Various blades, including a sickle knife and round knife, must also be available.

    An operating microscope with a 200- to 250-mm objective is used for the entire procedure. Various microscopes are available with both fixed and adjustable focal lengths. The microscope is typically covered with a sterile drape for the procedure.
    Recently, the endoscope has been used as an alternative approach to visualization during stapedectomy/stapedotomy. However, the mainstay of stapes surgery remains the transcanal approach utilizing the operating microscope. One study analyzed the audiological outcomes achieved by endoscopic surgery versus those with the microscope and showed similar hearing outcomes. However, the endoscopic approach required longer initial operative times. Challenges to stapes surgery with the endoscope include instrument limitation, single-handed work, lack of stereoscopic view, and a potentially high surgeon learning curve. [16, 17, 18]

    Ianella ett al….OBJECTIVE: Analyze the surgical outcomes of endoscopic stapes surgery, comparing the results with a conventional stapes surgery under microscopic approach. Estimate the operation type of each surgical approach and show a learning curve of endoscopic stapes surgery.
    STUDY DESIGN: Retrospective study.
    RESULTS: The group of patients who underwent endoscopic stapes surgery showed a mean operative time calculated to be 45.0 min. The group of patients treated by microscopic approach had an estimated mean value of 36.5 min. Statistical difference was evident (p value = 0.01). The average duration of endoscopic surgery varied as the surgeon gained experience. There were no statistical differences between the average surgical times for the endoscopic and microscopic approaches (p >0.05) in the last 4-month period of surgery. Through the endoscopic approach the percentage of ears with a postoperative air-bone gap ≤20 dB was 95%. No difference from the percentage of the microscopic group (90%) (p >0.05) was reported. No difference regarding the incidence of intraoperative findings and postoperative complications between endoscopic and microscopic approaches was found.

  • Various methods are used for creating the fenestration in the stapes footplate. A Skeeter drill or microdrill has been used by some surgeons. Other authors suggest using a laser to minimize the vibrations caused by the drill on the stapes footplate, with a possible drop in bone conduction thresholds from sensorineural hearing loss at high frequencies due to acoustic trauma at the basal turn. [19] Multiple types of lasers have been advocated, including argon, KTP, and CO2 lasers. [20, 21, 22] Reports have shown no apparent difference between microdrill and the various laser techniques regarding drop in bone conduction thresholds. [23, 24, 25, 22, 26] Various modifications, including hand-held laser delivery devices (eg, Omniguide), are also available.

    Potential damage to the membranous labyrinth due to the different absorptive properties of the various laser wavelengths in relation to the inner ear structures has caused some stapes surgeons to advocate for specific laser modalities over others. There are theoretical advantages to the use of the CO2 laser, due to its high reflectance off of the perilymph, versus the KTP and argon laser, which due to their lower wavelengths allow greater penetration into the perilymph and potentially greater energy absorption by the pigmented tissues of the membranous labyrinth in the line of laser fire at the base of the vestibule (ie, the saccule). [27]

    KTP- potassium titanyl phosphate

  • When patients are under general anesthesia for the procedure, a facial nerve monitor is often used during the case. It is important to realize that the use of the facial nerve monitor does not eliminate the risk of facial nerve injury during stapedectomy. There is no substitute for a thorough knowledge of the middle-ear anatomy in order to avoid complications. The monitor can provide the surgeon with feedback while microdissection in the area of the facial nerve is performed, allowing the surgeon to modify technique to minimize risk of injury to the nerve. Electrodes are usually applied above the eye on the operative side within the orbicularis oculi muscle and above or below the lip on the operative side within the orbicularis oris. Grounding electrodes are placed in the forehead, upper chest, or shoulder.
  • Hook prostheses have shepherd’s crook–type open loops that hook around and are mechanically crimped or self-crimp around the incus, whereas handled prostheses have an articulating handle that swings above the incus to secure the incus lenticular process into a bucket-shaped hollow within the prosthesis shaft.
  • There have been few studies comparing the many available prostheses, and a true comparison of outcomes is not feasible due to outcomes being heavily dependent on experience of the operating surgeon
  • epinephrine. Some surgeons use diluted epinephrine (ie, 1:100,000) without anesthetic since injected solution sometimes migrates into the middle ear in the vicinity of the facial nerve, with resultant inability to monitor facial nerve function. Currently, however, no published literature supports the necessity of this practice. [29]

    In patients who undergo surgery under MAC anesthesia, routine facial nerve monitoring is not required.

    Approximately 2.5–3 mL of the anesthetic of choice is used. Injection is also performed at the vascular strip in order to reduce bleeding during the incision. Some surgeons also include an incision just anterior to the helical crus for improved exposure for the procedure. [30] If this is to be included, additional anesthetic should also be injected into this area.
  • The patient is placed in the supine position on the operating table with the head turned to the opposite side from the operative ear, to about 30–45°.
    The head is held in place by tape placed across the patient’s forehead, securing him or her to the bed. The bed is almost uniformly turned 180° and the patient’s head positioned as close to the operating side as possible. The patient’s arms are tucked to his or her sides with adequate padding. Additionally, the patient is secured to the table with a waist band in case the bed must be rotated during the procedure.
  • Left ear. a, b Using a diamond bur, the posterior crus is removed. c, d The stapes tendon is cut with scissors.

    ct, chorda tympani; in, incus; ma, malleus; s, stapes; dr, eardrum; pe, pyramidal eminence; cp, cochleariform process; pr, promontory; fn, facial nerve; pc, posterior crus of stapes.
  • ct, chorda tympani; in, incus; ma, malleus; s, stapes; pe, pyramidal eminence; cp, cochleariform process; fn, facial nerve; fp, footplate; lsc, lateral semicircular canal.
  • fn, facial nerve; in, incus; ma, malleus; pe, pyramidal eminence; cp, cochleariform process; pr, promontory; lsc, lateral semicircular canal.
  • in, incus; ma, malleus; dr, eardrum; pe, pyramidal eminence; cp, cochleariform process; pr, promontory; fn, facial nerve; lsc, lateral semicircular canal.
  • eac, external auditory canal; in, incus; ma, malleus; dr, eardrum; pe, pyramidal eminence; fn, facial nerve.