Cartilage Tympanoplasty: Graft Placement

Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique.

Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique.

Conclusion :  This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.

Cartilage Tympanoplasty: Graft Harvest and Formation

Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique.

Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique.

Conclusion :  This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.

Pediatric Endoscopic Butterfly Inlay Tympanoplasty

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.

Endoscopic removal of TM cholestestoms

A 3 yo girl was referred to the ENT clinic after her PCP noticed an abnormal TM on the left.

She has a history of a 2 ear infections prior to presentation. She is asymptomatic, with no pain and no drainage from her TM. Her audiogram was normal. Her physical eventually revealed the presence of a relatively large keratin pearl on her TM, without obvious middle ear effusions. After a short period of observation the family decided to have it removed.

The case was performed endoscopically in a trans-canal approach. The lesion was dissected mainly with a straight pick. The fibrous layer underneath was found to be intact and no myringoplasty was necessary.

The patient was was seen again 2 months post-op and her TM was found to be normal with a normal audiogram.

Selective Stapedial tendon and Tensor Tympani tenotomy for the treatment of Middle Ear Myoclonus in a pediatric patient

Objective tinnitus is a rare phenomenon whereby a patient perceives sound in the absence of external auditory stimuli, that is also observed by the examiner. Unlike subjective tinnitus which is thought to be somatosensory and usually difficult to cure, objective tinnitus is more likely to have an identifiable cause amenable to treatment. The differential for objective tinnitus includes aberrant vascular anatomy affecting the temporal bone, patulous eustachian tube function, and abnormal myoclonic activity of the palatal or middle ear muscles.1  

We present a 16-year-old female who presented for evaluation of objective tinnitus. On physical examination, an intermittent rhythmic clicking was identified. Visualization of both the tympanic membrane and palate during active audible tinnitus was observed and found to be normal. A hearing test was performed demonstrating normal hearing and speech thresholds as well as normal tympanogram. Acoustic reflex testing demonstrated absent decay in both ears and  spontaneous discharge for the right ear in response to both high and very low stimulus indicating abnormal stapedial and tensor tympani function. MRA demonstrated normal vascular anatomy and MRI was obtained demonstrating normal anatomy without lesions of the brainstem, cochleovestibular nerves, or ear or mastoid pathology. The patients was subsequently diagnosed with isolated middle ear myocolonus (MEM). Treatment options including medical versus surgical therapy were discussed as has previously been described. The patient ultimately elected for surgical tenotomy of the stapedial and tensor tympani tendons. Using endoscopic technique, a middle ear exploration was performed. Canal injection was performed with standard tympanomeatal flap elevation was assisted with epinephrine pledgets. The Annular ligament was identified and the middle ear was entered. Additional dissections was performed superiorly, and the chorda tympani nerve was identified and preserved. The stapedial tendon was visualized emanating from the pyramidal eminence to the posterior crus of the stapes. Balluci scissors were used to sharply incise the tendon and the remaining ends were reflected using a Rosen needle to prevent re-anastamosis. Additional dissection along the malleus was performed to gain access to the tensor tympani tendon. A 30 degree angled endoscope was utilized to visualize the tensor tympani tendon extending forward from the cochleariform process to the neck of the malleus. The angled 6400 Beaver blade was used to sharply incise the tendon, requiring multiple passess due to the thickness of the tendon. The sharply incised ends of both tendons were clearly visualized. The tympanomeatal flap was re draped and secured with gel foam packing. The patient was seen in follow up three weeks post operatively with a well healed ear drum, resolution of her objective tinnitus, normal hearing, and absent stapedial reflexes. The patient and mother were happy. Endoscopic stapedial and tensor tympani tenotomy is a feasible technique for isolated MEM in the pediatric population.

Grace Medical Bojrab ALTO

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Grace Medical ALTO System

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Endoscopic Transcanal Transpromontorial Removal of an Intracochlear Schwannoma and Traditional Cochlear Implantation

Vestibular schwannomas (acoustic neuromas) develop due to mutations in Schwann cells that cause uncontrolled cell division. As a result, a tumor forms. As these tumors grow, they can compress the cochlear nerve causing unilateral hearing loss and tinnitus. Vestibular schwannomas may cause imbalance and occasionally vertigo. Intralabyrinthine schwannomas account for about 10% of vestibular schwannomas in centers that specialize in temporal bone imaging. Intracochlear schwannomas are the most common type of intralabyrinthine schwannomas. In this video, we describe an endoscopic transcanal transpromontorial approach to intracochlear schwannoma removal.

This surgery was performed by James Prueter, DO, of Southwest Ohio ENT Specialists in Dayton, OH.

Video editing was performed by Austin Miller, OMS-II, Ohio University Heritage College of Osteopathic Medicine.

Draping Technique for Major Ear Surgery during Pandemic!!!

Covid -19 Pandemic has changed the way we provide our healthcare services to our patients. ENT / Otolaryngology is one of the high risk speciality for contracting Covid infection. We as  professionals has to take maximum precautions not only to protect our patients but also all our healthcare staff working with us in to minimise the risk of contracting the virus ((Krajewska).

Unfortunately our patients do need appropriate necessary treatment for their otological problems during this pandemic. Drilling mastoid bone will generate significant aerosol during the procedure, putting everyone in the operating theatre at risk (Prof P Rae). Though every patient who undergoes any surgical procedure should have Covid test, self isolate and free from Covid symptoms. There is risk of contracting Covid infection from asymptomatic patient or staff. We should try and take every step to minimise the risk of  contracting Covid infection either from Covid positive / negative Or symptomatic / asymptomatic patient or staff.

There are few techniques been tried by our colleagues around the world to minimise aerosol during major ear surgery.  We tried to use of the technique proposed by our colleagues in UK ( W. Hellier), as it was too cumbersome during the procedure, we propose the modified technique to drape the surgical site during major ear surgery to reduce the aerosol.

Lateral Graft Tympanoplasty

Title: Lateral Graft Tympanoplasty

Description: A lateral graft tympanoplasty is performed to demonstrate the utility of this technically challenging approach. The technical pearls that contribute to the high success rate of this graft are highlighted.

Learning Points: The lateral graft tympanoplasty was popularized by Sheehy in the 1960s. Although technically more demanding than underlay graft techniques, the lateral graft is an essential method for Otologists to have in their armamentarium. The lateral graft is especially useful in cases of total perforation or anterior marginal perforation as well as revision tympanoplasty. Potential disadvantages of this technique include graft lateralization and anterior blunting as well as keratin pearl formation. When performed by an experienced surgeon, the results of lateral grafting are excellent. The technical considerations that promote successful lateral grafting are highlighted in this video.

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