tymapanoplasty and ossiculoplasty

1. TYMPANOPLASTY AND
OSSICULOPLASTY
DR PRASHANT ZADE
GUIDE- DR ATISHKUMAR GUJRATHI

2. TYMPANOPLASTY
 According to the American Academy of Ophthalmology and Otolaryngology
Subcommittee on Conservation of Hearing 1965 definition, tympanoplasty is “A
procedure to eradicate disease in the middle ear and to reconstruct the hearing
mechanism, with or without tympanic membrane grafting."'

3. HISTORY
 1953- The term ‘Tympanoplasty’ was 1st used by Wullstein
 1640-Artificial animal-based plugs being used to cover perforated tympanic
membranes
 1850-Yearsley described an artificial eardrum consisting of moistened cotton wool
 Toynbee describes an artificial eardrum comprising a gutta percha disc and a silver
wire
 William Wilde and Roosa -uses cautery to the remnant tympanic membrane to
encourage healing.
 1878-Berthold described his technique of using a full-thickness skin graft,
Berthold first to use the term ‘myringoplasty’.
 1887-Blake first described the paper patch

4.  1950-Wullstein’s split skin graft and Zollner’s pedicled skin graft that higher rates
of successful repair.
 Nylen (1921): Monocular operating microscope.
 Holmgren, teacher of Nylen (1922): Binocular operating microscope
 GRAFT HISTORY
 1950-Moritz—Pedical flap
 1956-Zollner--fascia lata
 1958-Heerman--temporalis fascia
 1960-Shea--vein grafts
 1968-Glosscock and House—performed large series of homograft TM
 1970-Moon– Areolar tissue overlying temporalis fascia
 perichondrium, cartilage, periosteum, fat, subcutaneous tissue, amniotic
membrane, dermal matrix, fibroblasts, animal pericardium and sclera

5. TYMPANOPLASTY CLASSIFICATION
(ZOLLNER AND WULLSTEIN’S CLASSIFICATION-1953)
TYPE I-
 Intact ossicular chain, simple
tympanoplasty with inspection of
middle ear cavity with closure of
perforation.

6. Type II
 Sound transmission through a
functioning but deformed ossicular
chain
 Intact incus and stapes with erosion of
malleus
 Graft onto incus = incudopexy.
 II a –type II reconstruction.
 II b – malleus stapes assembly or
malleus footplate assembly.
 II c – new reconstruction of
independent of malleus.

7. TYPE III
 Destruction of TM and ossicular
chain but intact mobile stapes
 Graft onto head of stapes
 Columella tympanoplasty-Sheehy,
1987

8. TYPE IV
 Intact stapes footplate with absent or
eroded stapes superstructure.
 Footplate MOBILE.
 Graft covers RW (round window).
 Footplate of stapes left exposed.
 OVAL WINDOW/ CAVUM MINOR T-
PLASTY-Sheehy,1987

9. TYPE V
 Footplate is fixed
 Fenestra is made to horizontal
semicircular canal.

10. TYPE VI (Gracice Ibanez)
 Sono inversion
 RW left exposed and mobile
Footplate is protected by small
tympanic air space in continuity with
the eustachian tube.

11. Austin’s Classification of Anatomical
Defects in Ossicular Chain
 Incus is absent in all cases and TM repair required in all cases
 Group A - Malleus and stapes present. (M+,S+)
 Group B - Malleus and foot plate of stapes present, Stapes suprastructure
absent . (M+,S-)
 Group C – Handle of Malleus absent and stapes present.(M-,S+)
 Group D – Handle of Malleus and stapes suprastructure absent. (M-,S-)

12.  Kartush added 3 more classes as a modification of AUSTIN’S CLASSIFICATION it
include ossicular fixity even when all three ossicles are present.
 O - Intact ossicular chain.
 E - Ossicular head fixation.
 F - Stapes fixation

13. PHYSIOLOGY OF MIDDLE EAR
 Hydraulic Ratio- Large TM to Small Stapes footplate- 17:1
 Lever Ratio- Handle of malleus to long process of incus- 1.3:1
 It leads to air-borne sound vibrations of large amplitude but small force are
transformed into fluid-borne sound vibrations of small amplitude but large force
 Yields a total increase of pressure at the oval window of 22 times. This is termed
the sound-pressure transformer ratio of the normal human ear and equates to
approximately 27-dB gain
 TM "protects" the round window from competitive sounds, partly by damping and
partly by a phase difference.

14. EFFECT OF TM PERFORATION ON
HEARING
 A TM Perforation removes sound protection from the round window with a
tendency for sound to reach both windows at nearly the same moment, thus
canceling the resultant movements of the perilymph.
 Total perforation results in a loss of 40 to 45 dB.
 Interrupted ossicular chain with intact TM cause nearly-CHL of 60 dB.

15. ETIOLOGY OF TM PERFORATION
 INFECTION- The commonest cause - acute otitis media, Spontaneous healing with
70–80% healing within 30 days.
Perforations secondary to tuberculous otitis media are rare.
 TRAUMATIC ETIOLOGY-
Trauma, Barotrauma, explosion, water pressure, cotton buds,
Iatrogenic causes

16. GOALS OF TYMPANOPLASTY
 To achieve a dry ear by eradicating Middle-ear disease.
 Hearing improvement by closure of any TM perforation by grafting and/or
ossicular reconstruction.

17. INDICATIONS FOR TYMPANOPLASTY
 TM perforations and associated hearing loss, with or without middle-ear pathology
such as tympanosclerosis, small retraction pockets, and cholesteatomas.
 Infections to middle ear
 Hearing loss
 To use hearing aids

18. CONTRAINDICATIONS FOR
TYMPANOPLASTY
 Absolute contraindications-Poor general health, malignant tumors of the
outer/middle ear, malignant otitis externa, meningitis, brain abscess, or lateral sinus
thrombosis.
 Only or significantly better hearing ear in order to avoid the risk of irreversible
sensorineural hearing loss.
 Non functioning ET tube.
 Smoking
 Age

19. PREOPERATIVE EVALUATION
 MICROSCOPIC EXAMINATION
 EAR SWAB
 AUDIOMETRY
 IMAGING-HRCT
 PRE-EXISTING SYSTEMIC DISEASE

23. TYMPANOPLASTY APPROACHES
 TRASCANAL APPROCH
 POSTAURICULAR APPROACH
 ENDAURAL APPROACH-Popular in Europe for chronic ear surgery and
stapedectomy.
• It was first described by Kessel in 1885 and '"as later popularized by Lempert.
• The first incision in this approach is Made along the entire posterior half of the ear
canal at the bony-cartilaginous junction. A second vertical incision is made in the
incisura and connects the previous incision

26. TYMPANOPLASTY GRAFTING TECHNIQUES
 UNDERLAY
 OVERLAY

28. TYMPANOPLASTY RESULTS
 Graft-take and hearing results following tympanoplasty depend upon multiple
factors.
 Eustachian tube dysfunction
 presence of cholesteatoma or atelectasis
 previous tympanoplasty failure
 smoking.

30. POSTOPERATIVE CARE
 Air travel to be avoided for 4 weeks
 Sneezing, Air blowing, Sniffing
 Avoid water entering the ear canal
 Ear drop instillation

31. COMPLICATIONS
1. Intraoperative bleeding
- involvement of superficial temporal artery
- Jugular bulb: Low pressure bleeding
- Internal carotid artery bleed
in case of pulsatile structure around eustachian tube area
2. Post operative wound hematoma
3. Chorda tympani nerve injury with 76% recovery rate
4. Wound infection/ perichondritis more in endaural approach
5. Tympanoplasty failure
- Persistent recurrent perforation
- Graft lateralisation
- Conductive hearing loss
6. Recurrent or residual middle ear cholesteatoma – 14 & 12% respectively
7. Sensorineural hearing loss
-labyrinthine fistula
-Acoustic trauma from high speed drill

32. OSSICULOPLASTY
 correcting ossicular chain abnormalities with the aim of improving hearing.

33. CAUSES
 CONGENITAL-
• Deformities of the ear occur in approximately 1 in 15000 births with isolated
middle ear abnormalities, MC is fixation of stapes foot plate.
• Epitympanic fixation of the ossicular heads and ossicular discontinuity are less
frequent.
• Result of ossiculoplasty depends upon-
• The status of the ossicles
• presence of the round window,
• pneumatization of the middle ear space,
• course of the facial nerve.

34. ACQUIRED
1) The majority of ossicular chain defects arise as a consequence of chronic
otitis media with or without cholesteatoma.
-The most common acquired abnormality is erosion of the long process of
the incus.
-The stapes superstructure may be partially or completely eroded
-the malleus handle is the most frequently preserved.
2) Ossicular disruption secondary to trauma, barotrauma or temporal bone fracture

36. Austin’s Classification of Anatomical
Defects in Ossicular Chain

37. Prognostic Factors
 Kartush (1994) proposed a scoring system called
the middle ear risk index (MERI) to form an index
score to determine the probability of success in
hearing restoration surgery.
 MERI is used to describe the preoperative middle
ear environment at the time of ossiculoplasty
 The MERI was originally scored 0–12, and was later
modified in 2001 to include smoking and increase
the weighting for cholesteatoma and granulation
thus giving a score of 0–16

39.  ALTERNATIVE SCORING SYSTEM
 Ossiculoplasty Outcome Parameter Staging (OOPS) index,14
 SPITE factors (surgical, prosthetic, infection, tissue, Eustachian)

40. Ossicular grafts and implants
 The ideal material for ossicular reconstruction should be biologically stable
(resistant to resorption and nonreactive), of the correct mass and stiffness, be easy
to handle, and ideally low cost.
 Autologous : Ossicle grafts: Incus/ Head of the malleus
Cortical bone grafts
Cartilage
 Homologous-human ossicles.

41. Alloplastic materials
 first described in 1952 by Wullstein who used a ‘palavit’ (vinyl–acrylic resin).
• Solid plastics: polytetrafluoroethylene, polyethylene
• Solid metals: stainless steel, gold, titanium
• Porous sponge-like plastics: Proplast®, Plasti-Pore®
• Ceramics: aluminium oxide, hydroxyapatite.
Titanium implants were introduced in the early 1990s,and have excellent mechanical
properties due to high rigidity allowing low-weight prosthesis designs
Titanium is biocompatible with low extrusion rates of less than 5%

42. SURGICAL OPTIONS TO CORRECT SPECIFIC
DEFECTS
Terminology
 PORP = Partial Ossicular Replacement Prosthesis. Generally used to mean a
prosthesis that is designed for situations with an intact stapes superstructure.
 TORP = Total Ossicular Replacement Prosthesis. For use in situations where there is
no stapes superstructure and the prosthesis restores a connection with the stapes
footplate.
 Columellae when the sound transmission is restored with an ossicle to tympanic
membrane connection
 Assemblies where there is an ossicle-to-ossicle connection

43. Eroded long process of the incus
 Most common ossicular chain defect encountered in patients with chronic middle
ear disease
 Stapediopexy – The tympanic membrane is brought into direct contact with the
stapes head.
 BRIDGING WITH AUTOLOGOUS TISSUE BY autologous cortical bone harvested
from the mastoid or external auditory canal or cartilage
 PROSTHESIS- basic cuboidal hydroxylapatite with a circular aperture for the
stapes head and a groove to accommodate the long process remnant.
 BONE CEMENT/BONE PATE

44. BONE CEMENT

46. Eroded incus with malleus and stapes
present (Austin–Kartush type A)
 AUTOLOGOUS OSSICLE INTERPOSITION
Repositioning the incus as a method for restoring the function of the ossicular chain
was first described in 1957 by Hall and Rytzner
 PARTIAL OSSICULAR REPLACEMENT PROSTHESIS
- Stapes to malleus
- Stapes to tympanic membrane

48. Malleus present, stapes absent (Austin–
Kartush type B)
 HOMOGRAFT OSSICLE
 TOTAL OSSICULAR REPLACEMENT PROSTHESIS

49. Malleus absent, stapes present (Austin–
Kartush type C)
 NEOMALLEUS
 MALLEUS REPLACEMENT PROSTHESIS

50. Malleus and stapes absent (Austin–Kartush
type D)
 Poorest outcome
 Managed with a combination of the
above techniques and will require
reconstruction with autologous
tissue, ossicle interposition or TORP.

51. All OCRs are held in place by tension. When placing a TORP, Gantz will
frequently put a second piece of cartilage to support the prosthesis.

54. OPERATIVE CONSIDERATION
 Length of prosthesis-Lower-tension reconstructions with a short prosthesis
resulted in better sound transmission than higher-tension reconstructions with a
long prosthesis
 The beneficial effect of a more loosely fitting prosthesis on hearing must be
balanced against the potential increased risk of displacement.
 Staged reconstructions-In ears at higher risk of retraction or residual disease it
may be prudent to delay reconstruction until a disease-free, aerated middle ear
space has been achieved.

55. REFERENCES
 Scott-Brown’s Otorhinolaryngology Head and Neck Surgery
( VOLUME 2, 8TH EDITION)
 GLOSSCOCK-SHAMBAUGH SURGERY OF THE EAR
(6TH EDITION)
 TEXTBOOK OF EAR,NOSE,THROAT AND HEAD-NECK SURGERY Clinical and
Practical (P HAZARIKA, 4TH EDITION)

56. THANK YOU!!!