School: Emory University School of Medicine

Educational/Technical Point(s): Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients.

Introduction:

Butterfly inlay tympanoplasty is a more recently described but validated technique for repairing select tympanic membrane perforations.¹ Following its validation in adult patients, small series have demonstrated its successful use in the pediatric population as well, including via endoscopic approach. ² Despite these findings, the indications for when to use this repair technique remain nebulous. We discuss our institution’s approach to the use of this technique and factors that influence its implementation through a case presentation.

Case Presentation:

We present a 14-year-old female with a history of long standing anterior tympanic membrane perforation. She was seen in consultation at our quaternary children’s hospital with a remote history of ear tube placement, subsequent extrusion, and ongoing perforation. Audiometry revealed a moderate conductive hearing loss and large volume type B tympanogram. Examination demonstrated an ~30% anterior central clean dry perforation. Her perforation was anterior to the handle of the malleus and demonstrated a significant intratympanic myringosclerotic plaque adjacent to the perforation. Given the location, and adjacent plaque whose removal would have resulted in nearly the double the size of the perforation, endoscopic butterfly inlay technique was recommended.

Technique:

The patient was brought to the operating room and injected and prepped in standard fashion including injection of local anesthesia to the donor tragal site. The perforation was rimmed using a Rosen needle and the subsequent tissue removed with cup forceps. Following recipient site preparation, the perforation was measured using a standard right angle hook whose length is 3 mm demonstrating a 4 mm by 3 mm perforation.

Attention was turned to harvesting a tragal graft in standard fashion. Using a 5 mm dermal punch, a full thickness portion of the cartilage was obtained ex vivo and the residual cartilage was replaced into the donor site for any future needs and the wound closed in simple interrupted fashion. The cartilage was scored circumferentially with a 15 blade creating locking flanges for the graft. The graft was then placed via alligator. The graft was purposefully placed through the perforation into the middle ear cleft, and then retracted by its perichondrium into the perforation, essentially “locking” it into place. Additional flange adjustments were made using a Rosen needle to ensure the graft was seated, appropriately. The tympanic membrane was coated with bacitracin and the patient was awoken from anesthesia.

Standard post operative tympanoplasty care was recommended including dry ear precautions and avoidance of heavy physically exercise until her post operative follow up. At follow up, she demonstrated 100% graft take and resolution of her prior hearing loss with a mobile tympanic membrane.

Conclusion:

Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients.