Annals of the Royal College of Surgeons of England (1977) vol 59

JOSEPH TOYNBEE MEMORIAL LECTURE, 1976

Tympanoplasty-four heterodox techniques Victor Goodhill

MD FACS

Division of Head and Neck Surgery, Department of Surgery, UCLA School of Medicine, Los Angeles, California

Summary Polarization between proponents of intact canal wall tympanoplasty and radical (modified) mastoidectomy in the treatment of cholesteatoma and other irreversible temporal bone lesions can be avoided in many cases by the use of one or more special techniques. These include (a) Gelfilm (no-graft) induction of tympanic membrane regrowth; (b) the use of tragal cartilage and perichondrium in columellization and in Type III neomyringostapediopexy; (c) the use of laboratory-prefabricated ossicular homografts to correct malleal-capitulum and malleal-footplate discontinuities more precisely; and (d) the circumferential approach (circumnavigation of patient's head) and anterior position of the surgeon in order to visualize the sinus tympani, retropyramidal, and retrofacial areas, obviating extensive posterior tympanotomy bone dissections. These techniques make possible a third alternative to the choice of either combinedapproach tympanoplasty or radical or modified radical mastoidectomy in the treatment of a number of advanced temporal bone lesions.

Introduction In tympanoplasty the laudable goals of canal wall preservation and total tympano-ossicular reconstruction are frequently difficult to attain. Problenms which interfere with these goals stem primarily from irreversible lesions in challenging anatomical locations; these factors of lesion location are further modified by the extent of functional losses (auditory and vestibular) and specific laboratory findings. Management of the archetypal example of keratoma (cholesteatoma) as the major lesion has evoked some controversy and polarization between advocates of intact canal wall tym-

panoplasty and proponents of open cavity (modified or radical) mastoidectomy in such cases. I shall limit my discussion to chronic otomastoiditis lesions. Thus the problems are primarily those involved with Type II and Type III tympanoplasty. The choice between tympanoplasty and radical mastoidectomy can frequently be avoided by using one or more of four 'heterodox' techniques, as I have done for a number of years. These four techniques are: (i) Gelfilm induction, (2) use of tragal penichondrium and cartilage grafts, (3) use of laborato-ry-prefabricated ossicular homografts, and (4) the circumferential surgical approach.

Otomastoiditis evaluation and the 4L formula It is necessary to consider four elements in deciding the management of temporal bone disease. These are: (i) lesion (histopathology); (2) location (anatomical extent); (3) loss of function (auditory, vestibular, and VIIth nerve deficits); and (4) laboratory findings (microbiological, haematological, metabolic, etc.). These four elements can be conveniently regarded as ingredients of the '4L' management formula. i) Lesion Two basic mastoid, middle ear, and tympanic membrane lesions require tympanoplasty. I have divided them into Types A and B. Type A lesions are usually primary, frequently reversible, and include cholesterol granuloma, polyposis, fibrosis and osteitiswvhich commonly involve mastoid cells, middle ear, and ossicles. Many Type A lesions respond to conservative medical and/or surgical management. Type B lesions, which are usually irrevers-

Delivered at the Royal College of Surgeons on 4th March 1976

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Victor Goodhill

ible and are frequently the sequelae of Type A primary lesions, include keratoma (cholesteatoma) and tympanosclerosis. They may be produced by: (i) migration of squamous epithelium from the tympanic membrane or external auditory canal into the mesodennal eustachian tube-middle ear-mastoid air cell system; (2) metaplastic changes in the mucosa of the middle ear; (3) hyalinization, collagenization, or calcification; and (4) osteitis and osteolytic bony changes. Some lesions are specifically Type A or Type B and others are mixed Type A and B lesions. The differences between Type A lesions (which are potentially reversible) and Type B lesions (which are irreversible) dictate different managements.

wall goal. The primary goal of the four techniques to be described is achievement of a higher percentage of successful intact wall procedures, especially in Type B lesions. Each of these four techniques was developed in response to a search for the solution of a problem. Illustrative examples of problems will be used to indicate the use of each of the four techniques.

Technique I: Gelfilm induction -'nograft' tympanoplasty The problem In certain lesion/location equations, as modified by loss of function and laboratory findings, a primary tissue graft is contraindicated. An example is a Type B chronic otomastoiditis due to non-responsive pseudomonas infection with 2) Location The anatomical locations of both tympanomastoid extensions. Is multilocular there an Type A and Type B lesions modify manage- alternative to radical mastoidectomy? ment crucially. The solution In some Type A lesions and 3) Loss of function This is the chief moti- many Type B lesions the 4L management vation for the development of tympanoplasty. formula may indicate a poor prognosis for a It usually involves a conductive hearing loss, tissue-graft tympanoplasty. Since it has been although secondary cochlear hearing loss does observed repeatedly that some tympanic occur. Vestibular problems, such as those membrane defects heal spontaneously my colproduced by fistulae and VIIth nerve erosions, leagues and I took advantage of this phenoalso require consideration. menon to create an alternative to the dilemma of intact canal wall retention in borderline 4) Laboratory findings These may modify cases. A safe 'bridge' to expedite spontaneous management of the first three elements. For formation of a new tympanic membrane can example, a resistant Gram-negative infection in frequently be realized by the use of the Gelfilm a diabetic patient with Type A disease may induction technique", 2. Such spontaneous cicatricial neomembrane require more radical management (both medical and surgical) than a responsive Gram- formation is due to an induction process positive infection in a patient with a limited probably related to chemical characteristics in the fibrous tympanic annulus. An inductive Type B keratoma. In most Type A cases conservative surgical signal originates from the cross-linked insolprocedures frequently suffice and intact canal uble structure of fibrous proteins through a chemical substance probably related to collagen wall tympanoplasty is possible. and mucopolysaccharides. Neomembrane formThe management of Type B lesions, with emphasis on keratoma (cholesteatoma), pri- ation from the fibrous annulus can be stimumarily stimulated the early development of lated in an inductive manner when Gelfilm radical mastoidectomy and its modifications and the fibrous annulus are in contact. Gelfilm (Upjohn), a sterile, non-antigenic, and now stimulates the advances in tympanoplasty. It is in the management of keratoma absorbable gelatin film, is non-porous and nonthat tympanoplasty techniques are disputed. haemostatic. It is 0.075 mm thick and when Earlier problems of the tympanoplasty era, drv it has the appearance and texture of cellosuch as mesodermal versus skin grafts, have phane. When moistened it assumes a rubbery largely been resolved; differences in opinion consistency and can then be cut to desired now exist with reference to the intact canal sizes and shapes and fitted to rounded or ir-

Tympanoplasty-four heterodox techniques

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ingrowth from the external auditory canal into the middle ear and thus expedites the possibility of a secondary-stage procedure. Total tympanic membrane formation occurs in 40% of cases and partial regeneration in 40%, but in 20% there is no

regeneration.

Technique II: tragal perichondrium and cartilage The problems i) Temporalis fascia and periosteum are flat, shapeless tissues. Since the tympanic membrane is a cone and not a flat structure, is there a more appropriately shaped mesodermal tissue as an alternative to the use of homograft tympanic membrane? 2) In total absence of the tympanic membrane and the three ossicles, are there alternatives to staging or to the questionable use of a composite homograft tympanic-membrane-three-ossicle graft ?

FIG. I Gelfilm technique: (i) endaural approach; (2) preservation of bony and fibrous annulus; (3) complete lateral de-epithelization; and (4) lateral placement of film disc.

regular surfaces. It is most commonly used in the form of circular or oval discs or as sectors prepared from discs. Gelfilm discs of assorted sizes are rapidly obtained by utilizing ear specula in 'biscuit cutter' fashion. The Gelfilm is placed on a plastic cutting block and discs and sectors of various sizes are prepared. After complete removal of the lesions of the middle ear and mastoid the Gelfilm disc and/ or sectors are placed lateral to the fibrous annulus and into contact with healthy ossicles to simulate a Type I, II, or III tympanoplastic 'repair' (Fig. i). Available external auditory canal skin is replaced in coaptation contact with the Gelfilm disc or partially covers it laterally. The external auditoiry canal is packed with Gelfoam and/or gauze for disc stabilization. Gelfilm induction of new tympanic membrane formation also prevents epithelial

The solutions Perichondrium obtained from the tragus has the advantage of providing a generous source of compatible tissue accessible in the operative site, with useful contour characteristics (concavity and convexity), which can be used for columellar and other reconstructive purposes35. Tragal perichondrium can be obtained either from the posteromedial (canal) side or from the anterolateral (facial) side as a hemigraft; or the entire tragal cartilage may be removed and both perichondrial surfaces used in continuity as a total graft. The choice of either hemigraft or total graft is based on the size of the defect and the geometric form requiring repair. The tragal dome shape makes possible the use of a total anteroposterior graft which has a concavity and a convexity, features which can be exploited in a number of ways (Fig. 2). Thus perichondrium has an advantage over shapeless tissues and can be used for both simple Type I repairs and for large tympanic membrane defects. If a cartilage columella is necessary the cartilage of the tragus is used (i) conjo;ntly wvith the perichondrium for the creation of a composite cartilage-perichondrium T vraft, or (2) for procurement of a separate cartilage graft to be used in contact with the perichondrial graft as a substitute for the stapedial

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Victor Goodhill

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head and crura. Tragal cartilage can be used to create a composite perichondrium-cartilage 'batten' graft when a stiff tympanic membrane graft is desirable. Type III tympanoplasty (myringostapediopexy) is useful in cases in which there is adequate lateral projection of the stapedial capitulum, making possible a direct coaptation of a perichondrial 'sac' to the capitulum as a one-stage procedure without ossiculoplasty. The graft can be tailored from the tragal cartilage so that it also includes a circumferential cartilage 'batten' for increased stiffness to aid in maintaining a lateral graft position. If the stapedial arch, incus, malleus, and entire tympanic membrane are absent, a composite tragal perichondrium and tragal cartilage T graft can be used (Fig. 3) or a perichondrial tympanic membrane graft can be used with a separate cartilage graft.

Technique m: laboratory prefabricated ossicular homografts The problems i) Is there an alternative to 'wedging' transposition of a reshaped incus body or malleal head autograft between the 3 (A) Perichondrium elevated from both surfaces of tragal cartilage. (B) Tailoring of tragal cartilage to create T cartilage-perichondrial composite graft. (C) Medial aspect of columella thinned and perichondrium.

FIG.

capitulum of the stapes and the malleal manubrium in necrosis of the incus. 2) Is there an alternative for similar wedging techniques in columellization between the stapedial footplate and the malleal manubrium?

The solutions Trarsposition of the whole incus or part of an incus is frequently unwieldy, with predisposition to postoperative middle ear

Tympanoplasty-four heterodox techniques

adhesions. Audiologically, the mass effect of a large, bulky transplant is unpredictable. Autogenous tragal cartilage is functionally favourable only when used as a 'short columella'-that is, from malleus to capitulum -or as a T graft in shallow middle ear situations. Cartilage loses some stiffness and is unsatisfactory where great length is necessary. A solution to the problem is the use of lab-

either side (Fig. 4). The prefabrication is caxried out with diamond and cutting burrs. The ossicle may be held either in the hand or in a forceps. Since the essential process is microsculpture some technical dexterity is necessary. The short columella (golf tee) - maileal trough to stapes A malleus homograft is used. The final shape is an elongated cone with the base (medial end) hollowed out to form a concavity to fit over the capitulum, neck, and stapes tendon. The length is 3.5-4.5 mm. The medial concavity is 1.5-1.75 mm in diameter. The lateral end for attachment of the malleal trough is 0.75i mm in diameter and is scored to provide a slightly rough surface to expedite locking anchorage.

oratory-prefabricated 'sculptured' homograft ossicular columellae, which solve most ossiculoplastic problems6. Two basic types of columella are prepared in the temporal bone laboratory. The 'short columella' is interposed between the malleus and the stapedial capitulum. The 'long columella' is interposed between the malleus and the footplate or neofootplate membrane. Two essentials must be present: (i) a mobile, healthy stapes, stapedial footplate, or footplate substitute (mesodermal autograft), and (2) a mobile malleal manubrium with an intact tensor tympani insertion. The tympanic membrane defect may be repaired simultaneously. The prefabricated ossicular columella is 'locked' into a surgically prepared malleal neck 'trough' laterally. This trough (i.o X I.5 mm) is made with a cutting burr above the level of the chorda tympani-malleus crossover. The prefabricated homograft ossicles are prepared in an approved ear tissue bank laboratory following tested procedures, measured, tested for sterility, and preserved in 70% alcohol. Both the short and long columellae may be prepared from either right or left ossicles for use on

The long columella (rod) - malleal trough to oval window An incus homograft is used. The final shape is that of a slightly tapered 'rod' 5.7 5-6. ro mm long. The diameter of the lateral end is the same as that of the short columella. The medial end is slightly narrower-o.65o.8o mm.

Surgical technique The malleal trough technique is adaptable to most repair problems. It is assumed that adequate lesion removal has preceded the intended reconstruction. The columellae are premeasured so that the surgeon can request a

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FIG. 4 Left side: (A) Beginning sculpture prefabrication of golf-tee (short) homograft from malleus. Diamond burr is used. (B) Saddle concavity produced with diamond burr at base of pyramidal-shaped golf tee. (C) Lateral end scored. (D) Golf tee will vary from 3.o to 4..5 mm in ,ength. Right side: (A) Diamond burr sculpture to produce rod (long) columella from incus. (B) Scoring of lateral end. (C) Completed rod (long) colvmella measures 5.75-6.50 mm.

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Victor Goodhill

cases. The alternative is the simpler expedient of looking towards the disease intead of trying to look underneath the facial nerve from a posterior approach. In addition, extensive bone removal conducive to adhesions is avoided. The 'circumnavigation' surgical approach to the temporal bone from a posteroinferior to an anteroinferior position makes possible 2700 of visualization. This procedure begins with the conventional posterior position of the surgeon, the operating table being titled io° posteriorly. It is essential that sturdy shoulder and leg supports be used to maintain a secure and comfortable position of the patient. The table can be tilted manually in the standard older operating tables, but the newer electrical tables greatly facilitate such tilting. The posterior position of the surgeon is used for mastoid cell removal. When major lesions involving the sinus tympani, the facial sinus, the retropyramidal sinus, and related areas are encountered, where precise access to the posterior tympanum and its medial posterior extensions is necessary, the position of the surgeon and the Technique IV: circumferential approach microscope are reversed. The table is rotated and anterior position of surgeon The problem The complex relationships between the multiple 'ridges and hollows' of the sinus tympani as related to the VIIth nerve and the horizontal and posterior semicircular canals have been amply described710. Is there an alternative to the technically demanding posterior tympanotomy in combinedapproach tympanoplasty in order to deal with deep sinus tympani keratoma or is the only solution the classic radical mastoidectomy?

columella of appropriate dimensions during surgery. After adequate rinsing in distilled water or saline the columella is ready for placement. The lateral end of a short or long columella is snugly fitted into the prepared malleal trough. Minor modifications of trough dimensions may be necessary to secure snug engagement. When a short columella is used the 'golftee' concavity is manipulated into snug contact with the capitulum of the stapes, avoiding contact with the pyramidal eminence. In using a long columella the medial end contacts the oval window footplate after preliminary elevation of the mucoperiosteum. One or two 0.5 X 0.5-mm perichondrial grafts are placed anterior and posterior to the rod to stabilize its position (Fig. 5). If there is a pre-existing fibrous oval window membrane instead of a footplate it is examined to be sure that the membrane thickness is adequate to receive the rod without danger of perforation. If it is thin it is reinforced by a concave, canoe-shaped fresh perichondrial graft.

An alternative approach has The solution been in use for several years"1. The antero. posterior aspect of a circumferential access approach allows direct visualization of this critical area. The surgeon standing in front of the patient can look posteriorly to explore the sinus tympani (in a posterior, superior, and medial direction) as it relates to the eminentia pyramidalis and to the vertical segment of the facial nerve. Thus the difficult and occasionally hazardous posterior tympanotomyfacial recess bone removal approach in extensive keratoma can be entirely avoided in many

e. PERICIHONORIUM CARTILAGE COLUUE'LLA4~7

FIG. 5 (A) Golf-tee columella in position over stapedial capitulum. (B) Rod columella in position on footplate surrounded by tissue grafts for stabilization. (C) Cross-section of trough-columella junction showing closure of trough either by reflected soft-tissue posterior flap or by use of cartilage-perichondrium 'stopple'.

Tympanoplasty four heterodox techniques

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03

microscope through an arc of 2700 makes it possible to circumnavigate most of the patient's head (Fig. 7). Thus not only is it possible to get excellent visualization of the posterior tynpanum by the anteroposterior visualization, but by a cephalocaudal visualization the entire hypotympanum comes into view (Fig. 8). This circumferential approach allows complete visualization of all important surgical anatomical areas of the middle ear and mastoid process. Thus there is an alternative to the posterior tympanotorny-facial recess dissection of the combined-approach tympanoplasty technique. Conclusions The multiple problems of Type B pathology (keratoma-cholesteatoma and tympanosclerosis) in intact canal wall tympanoplasty can be approached with these four techniques, singly or combined. An intact canal wall procedure is desirable and attainable in the majority of cases. Planned, deliberate staging is rarely necessary since the flexibility attained with these surgical options will help to solve a number of problems. i) In a Type B lesion with necrosis of the posterior canal wall, malleus, and incus, which can prevent the use of a tissue graft, a Gelfilm disc frequently results in an inductive Type III regeneration with a sealed middle ear and hearing gain. 2) With a large monolocular keratoma involving the three ossicles and tympanic membrane total extirpation is usually possible, but eradication results in no tympanic membrane and an empty 'middle ear' with only an oval window footplate remaining. Use of a composite perichondrium-cartilage T graft as a one-stage procedure can result in a healed, sealed middle ear with Type III repair and postoperative 75%,0 air-bone gap closure. 3) The solution of problems of incus necro-

FIG. 6 Operating table arrangement for posteroanterior (left) and anteroposterior (right) approaches. in the opposite direction with a tilt of 200. The position of the patient is unchanged, but the surgeon and the microscope reverse positions (Fig. 6). The microscope reversal may be carried out by simply moving the microscope stand to the opposite side. A ceiling-mounted microscope facilitates this manoeuvre. Inclined oculars are desirable. The endaural incision is advantageous but not critical in this circumferential approach since the auricle and tragus are separated by the retractor, allowing greater viewing freedom. The posterior meatal skin will have been transected laterally by the endaural incision. It is then possible either to remove temporarily the skin of the posterior canal wall lateral to the annulus or to reflect a posterior flap superiorly towards the roof of the external auditory canal. With the surgeon in the anterior position the posterior tympanum now comes into direct view. In certain instances the view is enhanced by thinning the anterior mastoid cortex with a diamond burr without opening into the mastoid cell system. In addition, a I-4-mm crescentic ledge of annular bone is removed, as is the usual custom in stapes surgery. Remaining fibrous annulus is preserved where possible. This anteroposterior approach brings into view the posterior tympanum with all of its contents. The sinus tympani may be only a shallow excavation posterior to the promontory or an enormously extensive group of cells or sintuses. It may extend to the jugular dome ANTERO- POSTERIOR POSTERO- ANTERIOR inferiorly and up to and even medial to the SUReICAL SURGICAL APPROACH APPROACH facial canal superiorly, but, especially critically, it may extend in a posteromedial relationship to the vertical couirse of the facial canal as it relates to the posterior semicircular canal. Continuous rotation of surgeon and FIG. 7 Circumferential access approach.

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Victor Goodhill

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sis in both Type A and B lesions is simplified by the use of laboratory-prefabricated homografts carefully measured and precisely sculptured to bypass ossicular defects with minimal possibilities of adhesions and/or discontinuity. Attachment to the malleus is via a drilled-out malleal neck trough. Unpredictable 'wedging' is avoided. This gives better hearing results than those obtained with the bulky body of the incus which, when transposed, is anatomically awkward and yields acoustically unpredictable final auditory results. 4) Problems of sinus tympani extension exposure, which requires the extensive bone removal of posterior tympanotomy dissection in an area which compromises the safety of the VIlth nerve and the horizontal and posterior semicircular canals, can be obviated in many cases by a circumferential approach, involving less critical temporal bone dissection. The surgeon circumnavigates the patient's head through 2700, making possible a direct anterior to posterior view of the sinus tympani and its extensions and precise removal of advanced Type A disease and/or Type B lesions from these areas. These four heterodox techniques are suggested as additions or alternatives towards the desirable goals of complete removal of patho-

logical lesions, avoidance of mastoid 'stoma', healed and intact middle ear, and hearing improvement. This address was accompanied by a surgical motion picture demonstration illustrating the clinical applications of each of the four techniques.

References I 2

3 4

5 6 7 8 9

Harris, I, et al. (i97I) Laryngoscope, 8i, I826. Goodhill, V (197i) Transactions of the Pacific Coast Oto-ophthalmological Society, 52, 217. Goodhill, V (I96I) Laryngoscope, 71, 975. Goodhill, V (I967) Archives of Otolaryngology, 85, 480. Harris, I, and Goodhill, V (I967) Laryngoscope, 77, II9I. Goodhill, V, Westerbergh, A, and Davis, C (I974) Transactions of the American Academy of Ophthalmology and Otolaryngology, 78, 4II. Jansen, C (I968) Journal of Laryngology and Otology, 82, 779. Smyth, G D L, et al. (I969) Journal of Laryngology and Otology, 83, II43. Smyth, G D L, Kerr, A G, and Goodey, R J (I97I) Journal of Laryngology and Otology,

85,

IOI3.

io

Smyth, G D L, Kerr, A G, and Goodey, R J (1971) Journal of Laryngology and Otology, 85,

ii

Goodhill, V (1973) Annals of Otology, Rhinology and Laryngology, 82, 547.

1021.

Joseph Toynbee Memorial Lecture, 1976. Tympanoplasty--four heterodox techniques.

Annals of the Royal College of Surgeons of England (1977) vol 59 JOSEPH TOYNBEE MEMORIAL LECTURE, 1976 Tympanoplasty-four heterodox techniques Victo...
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