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Endoscopic Tympanoplasty with Tragal Cartilage Graft in a Pediatric Patient (3:54)

Tympanoplasty is used to repair persistent perforations of the tympanic membrane. The procedure has traditionally been performed via a surgical microscope. In recent years an endoscopic approach has been increasingly used due to several advantages that it offers over the microscopic approach, chiefly the excellent visualization of middle ear structures provided by the endoscope. In this video we describe our technique for endoscopic tympanoplasty using a tragal cartilage graft in a pediatric patient.

 

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

 

Video editing was performed by Wesley Greene, MS-4 Wright State University Boonshoft School of Medicine with assistance from Britney Scott, DO, PGY-3 Kettering Health Network Otolaryngology Surgery.

Persistent perforations of the tympanic membrane (TM) can lead to chronic suppurative otitis media, conductive hearing loss, and other deleterious clinical consequences. Tympanoplasty is used to repair defects in the TM using a variety of graft techniques such as the medial tragal cartilage graft used in this video. The procedure can be performed using either a surgical microscope or an endoscope. In this video we describe out technique for tympanoplasty via an endoscopic approach. First, the endoscopic view is used to inject the external auditory canal with local anesthetic and epinephrine and to visualize the perforation in the TM. The edges of the perforation are then dissected with a sharp pick and removed with forceps which ensures that healthy TM tissue is available to incorporate with the cartilage graft at the edge of the perforation. Next, an ear dissector is used to elevate the tympanomeatal flap from the temporal bone and facilitate visualization of the middle ear space with the endoscope. A cartilage graft harvested from the tragus is placed into the middle ear and maneuvered into place on the medial aspect of the perforation. Gel foam is placed into the middle ear to support the graft and ensure that it remains in contact with the TM. With the graft in place the tympanomeatal flap is returned to its anatomical position. The TM is carefully inspected to confirm that the graft is in contact with all edges of the perforation. If the graft is not appropriately positioned then it must be adjusted which may require repeat elevation of the tympanomeatal flap and the addition of more gel foam to support the graft. Once the graft is in a satisfactory position antibiotic ointment is placed along the TM and layered laterally to cover the canal incision.
Most tympanic membrane (TM) perforations heal spontaneously or with medical management such as ototopical drops and dry ear precautions. Patients with TM perforations that persist despite these measures should be considered for surgical repair. Tympanoplasty may be especially beneficial for patients with perforations causing conductive hearing loss, chronic or recurrent otitis media secondary to contamination of the middle ear space, or an inability to bathe or participate in water sports (1,2).
This procedure is contraindicated for patients that are unable to tolerate anesthesia due to underlying medical comorbidities, are unable to lie flat for the procedure or are taking certain medications such as blood thinners. Other contraindications include active otitis media, uncontrolled cholesteatoma, malignant tumors, and complications of chronic ear disease such as brain abscess, meningitis or lateral sinus thrombosis. Clinical attributes that may be considered relative contraindications are eustachian tube dysfunction, underlying sensorineural hearing loss in the affected ear, especially young or old age, the ear with the perforated tympanic membrane is the better hearing or only hearing ear, and a history of multiple tympanoplasty procedures without improvement in symptoms (3,4).
The patient is placed in a supine position with the head rotated so that the diseased ear is oriented slightly upwards. In the pediatric population general anesthesia is typically used. Monitored anesthesia care or local anesthesia only may be considered for older pediatric patients that are able to tolerate it. Preoperative antibiotics were not used in this case but may be used depending on surgeon preference. Paralytic agents are avoided if intraoperative facial nerve monitoring will be utilized (3,5).
History The most common cause of tympanic membrane (TM) perforation is acute otitis media (AOM). AOM is very common in children with approximately 60% experiencing at least one episode by 3 years of age and 24% experiencing three or more episodes by the same age (6). TM perforations occur in approximately 2% of AOM cases treated with antibiotics and 5% of cases not treated with antibiotics (7). In the majority of cases TM perforations heal spontaneously within hours to days. However, perforations that fail to heal spontaneously may result in conductive hearing loss or recurrent contamination of the middle ear space which can cause chronic suppurative otitis media or chronic otomastoiditis. Other less common etiologies of TM perforation include ear barotrauma, mechanical trauma, and iatrogenesis (8,9,10). Physical exam Most TM perforations can be diagnosed using routine otoscopy. Some small perforations may require otomicroscopy for diagnosis (8). Audiology Audiometry should be performed upon the initial diagnosis of TM perforation and repeated before any attempt at surgical repair. Screening tympanometry may reveal abnormalities suggesting TM perforation but examination of the TM is required to confirm the diagnosis (8).
The tympanic membrane (TM) consists of three layers. The lateral layer is composed of stratified squamous epithelial cells that are continuous with the skin of the EAC, the middle layer is composed of fibrous connective tissue, and the medial layer is composed of cuboidal and columnar epithelium that is continuous with the mucosal lining of the rest of the middle ear. The periphery of the TM is surrounded by a dense fibrous layer called the annulus which is elevated along with the tympanomeatal flap during the procedure. Elevation of the tympanomeatal flap facilitates endoscopic visualization of the middle ear space and structures. The cartilage graft used to repair the TM defect is harvested from the tragus. The graft placement is carried out as described in the Procedure section above (2).
The major advantage of performing a tympanoplasty using the endoscopic approach rather than the standard microscopic approach is the more panoramic view offered by the endoscope. This allows for better visualization of certain middle ear structures, for example, the isthmus tympani and epitympanic diaphragm can be visualized far better using an endoscope than a microscope. The endoscopic approach has also been shown to require a shorter average operating time and duration of anesthesia when compared to the microscopic approach in certain endoscopic ear surgeries(11). The endoscopic approach also has disadvantages when compared to the microscopic approach. Using a microscope allows a surgeon to use surgical instruments with both hands simultaneously. With an endoscopic approach the endoscope must be held in one hand leaving only one hand to use instruments. The endoscope lens can become obscured in cases of extensive bone removal or bleeding. Finally, use of the endoscope requires a different type of depth perception compared to the binocular view offered by the microscope. Camera movement and muscle memory are required to achieve depth perception while using the endoscope (12–14).
Possible complications of tympanoplasty include failure to repair the perforation, recurrent perforation after successful repair, infection, otorrhea, cholesteatoma formation, worsening of conductive hearing loss, damage to the ossicular chain, injury to the chorda tympani nerve resulting in temporary or permanent alteration in taste, and facial nerve injury resulting in facial weakness (1,8). Complication rates have been found to be very low in endoscopic ear surgery with minor intraoperative complications occurring in less than 5% of cases, early postoperative complications occurring in approximately 1% of cases, and delayed complications occurring in less than 1% of cases (15).
No conflicts to disclose.
Thank you to Dr. James Prueter and Dr. Britney Scott for offering their time and expertise to help with this project.
1. Pediatric Post Auricular Tympanoplasty | Iowa Head and Neck Protocols. Accessed July 7, 2020. https://medicine.uiowa.edu/iowaprotocols/pediatric-post-auricular-tympanoplasty 2. Tympanoplasty: Background, Pathology, Indications. Accessed July 7, 2020. https://emedicine.medscape.com/article/2051819-overview 3. Stapedotomy | Iowa Head and Neck Protocols. Accessed July 3, 2020. https://medicine.uiowa.edu/iowaprotocols/stapedotomy 4. Glasscock ME. Symposium: Contraindications to Tympanoplasty. II. An Exercise in Clinical Judgment. Laryngoscope. 1976;86(1):70-76. doi:10.1288/00005537-197601000-00015 5. General Considerations of Otologic Surgery | Iowa Head and Neck Protocols. Accessed July 3, 2020. https://medicine.uiowa.edu/iowaprotocols/general-considerations-otologic-surgery 6. Kaur R, Morris M, Pichichero ME. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics. 2017;140(3). doi:10.1542/peds.2017-0181 7. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;2015(6). doi:10.1002/14651858.CD000219.pub4 8. Middle Ear, Tympanic Membrane, Perforations: Practice Essentials, Epidemiology, Etiology. Accessed July 7, 2020. https://emedicine.medscape.com/article/858684-overview 9. Ear barotrauma - UpToDate. Accessed July 7, 2020. https://www.uptodate.com/contents/ear-barotrauma?search=tympanic membrane perforation&source=search_result&selectedTitle=8~72&usage_type=default&display_rank=8#H4 10. Acute otitis media in children: Epidemiology, microbiology, and complications - UpToDate. Accessed July 7, 2020. https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?search=tympanic membrane perforation&topicRef=91002&source=see_link#H2 11. Hsu YC, Kuo CL, Huang TC. A retrospective comparative study of endoscopic and microscopic Tympanoplasty. J Otolaryngol - Head Neck Surg. 2018;47(1). doi:10.1186/s40463-018-0289-4 12. Wick CC. Endoscopic Stapedotomy - CSurgeries. Accessed July 3, 2020. https://www.csurgeries.com/video/endoscopic-stapedotomy/ 13. Preyer S. Endoscopic ear surgery – a complement to microscopic ear surgery. HNO. 2017;65(1):29-34. doi:10.1007/s00106-016-0268-x 14. Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G. Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: Anatomical study. J Neurosurg. 2006;104(3):419-425. doi:10.3171/jns.2006.104.3.419 15. Marchioni D, Rubini A, Gazzini L, et al. Complications in endoscopic ear surgery. Otol Neurotol. 2018;39(8):1012-1017. doi:10.1097/MAO.0000000000001933

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