Tympanoplasty and ossiculoplasty

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 1 st 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 - use s 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

20. 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

21. TYMPANOPLASTY GRAFTING TECHNIQUES UNDERLAY OVERLAY

22. 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.

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

24. COMPLICATIONS 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 Post operative wound hematoma Chorda tympani nerve injury with 76% recovery rate Wound infection/ perichondritis more in endaural approach Tympanoplasty failure - Persistent recurrent perforation - Graft lateralisation - Conductive hearing loss Recurrent or residual middle ear cholesteatoma – 14 & 12% respectively Sensorineural hearing loss -labyrinthine fistula -Acoustic trauma from high speed drill

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

26. 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.

27. 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

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

29. 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

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

31. 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.

32. 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%

33. 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

34. 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

35. BONE CEMENT

36. 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

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

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

39. 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.

40. 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.

41. 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.

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

43. THANK YOU!!!