Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Late Results in Tympanoplasty Staging the Operation M. Tos To cite this article: M. Tos (1976) Late Results in Tympanoplasty Staging the Operation, Acta Oto-Laryngologica, 82:1-6, 282-285, DOI: 10.3109/00016487609120906 To link to this article: http://dx.doi.org/10.3109/00016487609120906
Published online: 08 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [137.189.171.235]
Date: 18 March 2016, At: 20:09
Acta Otolaryngol82: 282-285, 1976
LATE RESULTS IN TYMPANOPLASTY Staging the Operation
M. Tos
Downloaded by [] at 20:09 18 March 2016
From ihe ENT University Clinic, Geniofie Hospital, Copenhagen, Denmark
formed mastoidectomy and tympanoplasty in one sitting. Based on the late results of this procedure we wish to discuss the problems involved in the staging of operations. Most E N T departments in Scandinavia have a limited capacity with regard to operating rooms and beds which oto-surgery has to share with the other sections of the specialty, including broncho-oesophagology and maxillo-facial traumatology. Long waiting lists Several publications have appeared in recent force the otologist to operate on as many payears recommending planned two-stage opera- tients as possible, and to reduce the number tion on ears with extensive pathological of re-operations to a minimum. Of primary involvement of the middle-ear mucosa, importance, however, is the consideration for destroyed ossicles and cholesteatoma (Austin, the patient to whom two operations will mean 1969; Smith, 1970; Sheehy & Crabtree, 1973). added mental and physical strain. It is, thereStaging was used already in the first few years fore, of value to establish to what extent the of the evolution of tympanoplasty; Rambo results of two-stage operations are better than (1961), in the first stage, performed modified those of one-stage operations. radical mastoidectomy, using paraffin as a mold to re-form the middle ear, and, in the MATERIAL AND RESULTS second stage, fenestration. Tabb (1963) advocated a three-stage procedure, the first to The material is composed of two groups (1) eliminate inflammation and cholesteatoma, the 300 ears which were dry at the time of operasecond to reconstruct the drum, and the third tion. The pathological changes varied from the to reconstruct the ossicular chain. After the slightest with central perforations with or introduction of Silastic, large pieces of the without defective ossicles to the severest with Silastic sheeting were usually removed in the adhesive otitis, tympanosclerosis, cholessecond stage, in which also the ossicles were teatoma in the tympanic cavity and cavities from previous radical operations with absence reconstructed. We have in all cases-even in those of the of ossicles. According to the criteria set up by Sheehy & Crabtree (l973), two-stage most severely diseased middle ears-perAbstract. Based on the late results of tympanoplasty on 300 ears and of one-stage mastoidectomy and tympanoplasty on 296 discharging ears, the problems involved in staging tympanoplasty are discussed. The results of onestage operations were found to be satisfactory 2-10 years after operation. The frequency of recurrent cholesteatoma was low, 3.4%. Instead of two-stage operations, re-operation is recommended in cases of functional failure and in cases in which further improvement of hearing can reasonably he expected.
Acta Otolaryngol82
Downloaded by [] at 20:09 18 March 2016
Late results in tympanoplasty
283
operation would have been indicated in 30 of these ears. We performed tympanoplasty and in a third also inspection of the antrum or attic. (2) 296 ears which were discharging at the time of operation and which did not become dry despite pre-operative conservative therapy. Sixty-three per cent had cholesteatoma in the tympanic cavity and antrum, and the remaining 37% had granulating otitis, or had previously undergone radical surgery elsewhere. In over 75% of the cases, the operation could have been performed in two stages, either because of extensive cholesteatoma, pathological mucosa or destroyed ossicles. In 43%, the stapes arcade was absent. We performed modified radical mastoidectomy with removal of the posterior osseous wall of the meatus, in 50% leaving a small edge of the bridge. In the same sitting, the middle ear and the meatus were reconstructed with fascia, and the cavity obliterated by means of a muscle-flap.
Hearing Detailed reports on the hearing results have previously been published (Tos, 1974), afid the primary results-3-9 months after the operation-have been compared with the late results-2-10 years after the operation. In 4 1 0 % of the cases, the late results were found to be poorer than the primary results. The most frequent causes of later reduced hearing were adhesive changes in the middle ear and presbyacusia. Related to the primary results, the late results were not poorer in the group of discharging than in that of dry ears. This means that in the long run a successful onestage reconstruction of a discharging ear can be maintained just as well as that of a dry ear.
Discharge and recurrent perforation In the group of discharging ears 90% were dry during the period of observation; 2 % continued to discharge, while 8 % discharged occasionally due to recurrent perforation.
Fig. 1 . State after conservative radical operation with obliteration of the cavity and reconstruction of the auditory meatus. A , re-pneumatized epitympanum and antrum; B , the epitympanum re-pneumatized, the rest obliterated; C , the epitympanum is a small open cavity, the rest has been obliterated.
Among the dry ears only one discharged occasionally; all the other remained dry. Recurrent perforation of the drum occurred in 8%. Recurrent cholesteatoma This occurred in 3.4% of the discharging, but in none of the dry ears. The finding of recurrent cholesteatoma did not lead to difficulties in the tympanic cavity. In 40% the epitympanum and antrum were re-pneumatized (Fig. 1A). The meatus was completely restored without cavity, but its superior wall was soft and consisted of skin and fascia which bulged by the Valsalva test. At follow-up, Aeta Otolaryngol82
284
M . Tos
recurrent cholesteatoma, if any, would easily Table I. Hearing results in staged tympanobe noticed through this soft wall. Likewise, plasty (Sheehy & Crabtree) compared with it would be easily recognizable in the 32% of those obtained in one-stage tympanoplasty the cases in which only the epitympanum had Postoperative bone-air been re-pneumatized (Fig. 1B)and the antrum gap, dB obliterated, and in the 27% in which the epiNo. of 0-10 0-15 0-20 0-30 cases (%) (%) (%) (%) tympanum was an open cavity (Fig. 1c). Sheehy & Crabtree Tos, discharging ears Tos , dry ears
Downloaded by [] at 20:09 18 March 2016
DISCUSSION The hearing results obtained in Sheehy & Crabtree’s series (1973) are very fine (Table I), especially in view of the extent of pathological changes and ossicular destruction. It should be borne in mind, however, that there were twice as many operations and that they were performed by surgeons of wide experience and high technical skill. The time of observation was short: 6 months in 32%, 1-2 years in 32% and 2-6 years in 36%, and hearing will probably be somewhat reduced at a later time, particularly in the patients with tubal malfunction. Our results of operation on discharging ears in one sitting are somewhat poorer but, with a period of observation of 2-10 years, not so much poorer that we would consider it justified, because of the hearing gain, to alter our present practice and employ planned twostage operations. Cases of complete functional failure and cases in which re-operation can reasonably be expected to improve the hearing can always be subjected to a second operation at a later time. Another argument against two-stage procedures is tubal function. Even though, in many cases, poor pre-operative tubal function will improve after the first operation (Tos, 1974), there will always be some ears in which tubal function remains poor after the operation and in which the second operation will not give the desired improved hearing, and in which adhesive changes will appear at a later time all the same. To prevent such changes Silastic has been used to an increasing extent, and this has been used as an argument for planned Acta Otolaryngol82
273 296
300
31
61 41
68
85 73 91
two-stage procedures in which the Silastic was removed in the second stage. Instead of Silastic, we have lately changed over to a gel film (Falbe-Hansen & Tos, 1975) which can be resorbed and with which we obtain better results than with Silastic. The most weighty argument in favour of staging is the high frequency of recurrent cholesteatoma which Sheehy & Crabtree experienced in their series: in the tympanic cavity in 25% of 314 revised cases, and in the epitympanum in 35% of 99 re-explorations of the mastoid. A high cholesteatoma frequency was found to follow especially the intact-wall technique, which was therefore staged to an increasing degree. In our series, we found recurrent cholesteatoma in 3.4%; and we do not feel that the fear of recurrent cholesteatoma should indicate staging. Our method of operation has been essentially different, however, as we have changed the posterior osseous meatal .wall into a narrow bridge and, at the least risk of incomplete removal of the cholesteatoma, removed the bridge either entirely or partially. The high frequency of recurring cholesteatoma is alarming, and one cannot be certain that the cholesteatoma is definitively removed at the second stage.
~~
ZUSAMMENFASSUNG Auf Grundlage der Spatergebnisse in 300 Ohren, in denen Tympanoplastik und in 2% flieRenden Ohren, in denen Mastoidektomie und Tympanoplastik auf demselben
Lute results in tympunoplasty Sitz vorgenommen wurden, werden die mit Stufung der Tympanoplastik verbundenen Probleme diskutiert. Die Resultate 2-10 Jahre nach der einstufigen Operation wurden zufriedenstellend befunden, insbesondere die Cholesteatom-Rezidivfrequenz war niedrig, 3,4%. Anstelle zweistufiger Operation wird befiirwortet, die in funktioneller Hinsicht total mialungenen Falle, sowie die Fdle, von denen es mit einiger Sicherheit zu erwarten ist, d d Neuoperation das Horvermogen noch weiter verbessern wird, neuzuoperieren.
REFERENCES
Falbe-Hansen, J. & Tos, M. 1975. Silastic or gelatin film sheeting in tympanoplasty. Ann Otol Rhino1 Laryngol84, 315. Rambo, J. H . T. 1961. The use of paraffin to create a middle ear space in musculoplasty. Laryngoscope 71, 612. Sheehy, J. L. & Crabtree, J. A. 1973. Tympanoplasty: Staging the operation. Laryngoscope 83, 1594. Smith, G . D. L. 1970. Staged tympanoplasty. J Laryngol 84, 757. Tabb, H. G . 1963. The surgical management of chronic ear disease with special reference to stages surgery. Laryngoscope 73, 363. Tos, M. 1974. Tuba1 function and tympanoplasty. J Laryngol88, 1113. - 1974. Late results in tympanoplasty. Arch Otolaryngol 100, 302.
Downloaded by [] at 20:09 18 March 2016
Austin, D. F. 1969. Types and indications of staging. Arch Otolaryngol89, 235.
285
I9 -762959
Acta Otolaryngol82
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Late Results in Tympanoplasty Staging the Operation M. Tos To cite this article: M. Tos (1976) Late Results in Tympanoplasty Staging the Operation, Acta Oto-Laryngologica, 82:1-6, 282-285, DOI: 10.3109/00016487609120906 To link to this article: http://dx.doi.org/10.3109/00016487609120906
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 7
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [137.189.171.235]
Date: 18 March 2016, At: 20:09
Acta Otolaryngol82: 282-285, 1976
LATE RESULTS IN TYMPANOPLASTY Staging the Operation
M. Tos
Downloaded by [] at 20:09 18 March 2016
From ihe ENT University Clinic, Geniofie Hospital, Copenhagen, Denmark
formed mastoidectomy and tympanoplasty in one sitting. Based on the late results of this procedure we wish to discuss the problems involved in the staging of operations. Most E N T departments in Scandinavia have a limited capacity with regard to operating rooms and beds which oto-surgery has to share with the other sections of the specialty, including broncho-oesophagology and maxillo-facial traumatology. Long waiting lists Several publications have appeared in recent force the otologist to operate on as many payears recommending planned two-stage opera- tients as possible, and to reduce the number tion on ears with extensive pathological of re-operations to a minimum. Of primary involvement of the middle-ear mucosa, importance, however, is the consideration for destroyed ossicles and cholesteatoma (Austin, the patient to whom two operations will mean 1969; Smith, 1970; Sheehy & Crabtree, 1973). added mental and physical strain. It is, thereStaging was used already in the first few years fore, of value to establish to what extent the of the evolution of tympanoplasty; Rambo results of two-stage operations are better than (1961), in the first stage, performed modified those of one-stage operations. radical mastoidectomy, using paraffin as a mold to re-form the middle ear, and, in the MATERIAL AND RESULTS second stage, fenestration. Tabb (1963) advocated a three-stage procedure, the first to The material is composed of two groups (1) eliminate inflammation and cholesteatoma, the 300 ears which were dry at the time of operasecond to reconstruct the drum, and the third tion. The pathological changes varied from the to reconstruct the ossicular chain. After the slightest with central perforations with or introduction of Silastic, large pieces of the without defective ossicles to the severest with Silastic sheeting were usually removed in the adhesive otitis, tympanosclerosis, cholessecond stage, in which also the ossicles were teatoma in the tympanic cavity and cavities from previous radical operations with absence reconstructed. We have in all cases-even in those of the of ossicles. According to the criteria set up by Sheehy & Crabtree (l973), two-stage most severely diseased middle ears-perAbstract. Based on the late results of tympanoplasty on 300 ears and of one-stage mastoidectomy and tympanoplasty on 296 discharging ears, the problems involved in staging tympanoplasty are discussed. The results of onestage operations were found to be satisfactory 2-10 years after operation. The frequency of recurrent cholesteatoma was low, 3.4%. Instead of two-stage operations, re-operation is recommended in cases of functional failure and in cases in which further improvement of hearing can reasonably he expected.
Acta Otolaryngol82
Downloaded by [] at 20:09 18 March 2016
Late results in tympanoplasty
283
operation would have been indicated in 30 of these ears. We performed tympanoplasty and in a third also inspection of the antrum or attic. (2) 296 ears which were discharging at the time of operation and which did not become dry despite pre-operative conservative therapy. Sixty-three per cent had cholesteatoma in the tympanic cavity and antrum, and the remaining 37% had granulating otitis, or had previously undergone radical surgery elsewhere. In over 75% of the cases, the operation could have been performed in two stages, either because of extensive cholesteatoma, pathological mucosa or destroyed ossicles. In 43%, the stapes arcade was absent. We performed modified radical mastoidectomy with removal of the posterior osseous wall of the meatus, in 50% leaving a small edge of the bridge. In the same sitting, the middle ear and the meatus were reconstructed with fascia, and the cavity obliterated by means of a muscle-flap.
Hearing Detailed reports on the hearing results have previously been published (Tos, 1974), afid the primary results-3-9 months after the operation-have been compared with the late results-2-10 years after the operation. In 4 1 0 % of the cases, the late results were found to be poorer than the primary results. The most frequent causes of later reduced hearing were adhesive changes in the middle ear and presbyacusia. Related to the primary results, the late results were not poorer in the group of discharging than in that of dry ears. This means that in the long run a successful onestage reconstruction of a discharging ear can be maintained just as well as that of a dry ear.
Discharge and recurrent perforation In the group of discharging ears 90% were dry during the period of observation; 2 % continued to discharge, while 8 % discharged occasionally due to recurrent perforation.
Fig. 1 . State after conservative radical operation with obliteration of the cavity and reconstruction of the auditory meatus. A , re-pneumatized epitympanum and antrum; B , the epitympanum re-pneumatized, the rest obliterated; C , the epitympanum is a small open cavity, the rest has been obliterated.
Among the dry ears only one discharged occasionally; all the other remained dry. Recurrent perforation of the drum occurred in 8%. Recurrent cholesteatoma This occurred in 3.4% of the discharging, but in none of the dry ears. The finding of recurrent cholesteatoma did not lead to difficulties in the tympanic cavity. In 40% the epitympanum and antrum were re-pneumatized (Fig. 1A). The meatus was completely restored without cavity, but its superior wall was soft and consisted of skin and fascia which bulged by the Valsalva test. At follow-up, Aeta Otolaryngol82
284
M . Tos
recurrent cholesteatoma, if any, would easily Table I. Hearing results in staged tympanobe noticed through this soft wall. Likewise, plasty (Sheehy & Crabtree) compared with it would be easily recognizable in the 32% of those obtained in one-stage tympanoplasty the cases in which only the epitympanum had Postoperative bone-air been re-pneumatized (Fig. 1B)and the antrum gap, dB obliterated, and in the 27% in which the epiNo. of 0-10 0-15 0-20 0-30 cases (%) (%) (%) (%) tympanum was an open cavity (Fig. 1c). Sheehy & Crabtree Tos, discharging ears Tos , dry ears
Downloaded by [] at 20:09 18 March 2016
DISCUSSION The hearing results obtained in Sheehy & Crabtree’s series (1973) are very fine (Table I), especially in view of the extent of pathological changes and ossicular destruction. It should be borne in mind, however, that there were twice as many operations and that they were performed by surgeons of wide experience and high technical skill. The time of observation was short: 6 months in 32%, 1-2 years in 32% and 2-6 years in 36%, and hearing will probably be somewhat reduced at a later time, particularly in the patients with tubal malfunction. Our results of operation on discharging ears in one sitting are somewhat poorer but, with a period of observation of 2-10 years, not so much poorer that we would consider it justified, because of the hearing gain, to alter our present practice and employ planned twostage operations. Cases of complete functional failure and cases in which re-operation can reasonably be expected to improve the hearing can always be subjected to a second operation at a later time. Another argument against two-stage procedures is tubal function. Even though, in many cases, poor pre-operative tubal function will improve after the first operation (Tos, 1974), there will always be some ears in which tubal function remains poor after the operation and in which the second operation will not give the desired improved hearing, and in which adhesive changes will appear at a later time all the same. To prevent such changes Silastic has been used to an increasing extent, and this has been used as an argument for planned Acta Otolaryngol82
273 296
300
31
61 41
68
85 73 91
two-stage procedures in which the Silastic was removed in the second stage. Instead of Silastic, we have lately changed over to a gel film (Falbe-Hansen & Tos, 1975) which can be resorbed and with which we obtain better results than with Silastic. The most weighty argument in favour of staging is the high frequency of recurrent cholesteatoma which Sheehy & Crabtree experienced in their series: in the tympanic cavity in 25% of 314 revised cases, and in the epitympanum in 35% of 99 re-explorations of the mastoid. A high cholesteatoma frequency was found to follow especially the intact-wall technique, which was therefore staged to an increasing degree. In our series, we found recurrent cholesteatoma in 3.4%; and we do not feel that the fear of recurrent cholesteatoma should indicate staging. Our method of operation has been essentially different, however, as we have changed the posterior osseous meatal .wall into a narrow bridge and, at the least risk of incomplete removal of the cholesteatoma, removed the bridge either entirely or partially. The high frequency of recurring cholesteatoma is alarming, and one cannot be certain that the cholesteatoma is definitively removed at the second stage.
~~
ZUSAMMENFASSUNG Auf Grundlage der Spatergebnisse in 300 Ohren, in denen Tympanoplastik und in 2% flieRenden Ohren, in denen Mastoidektomie und Tympanoplastik auf demselben
Lute results in tympunoplasty Sitz vorgenommen wurden, werden die mit Stufung der Tympanoplastik verbundenen Probleme diskutiert. Die Resultate 2-10 Jahre nach der einstufigen Operation wurden zufriedenstellend befunden, insbesondere die Cholesteatom-Rezidivfrequenz war niedrig, 3,4%. Anstelle zweistufiger Operation wird befiirwortet, die in funktioneller Hinsicht total mialungenen Falle, sowie die Fdle, von denen es mit einiger Sicherheit zu erwarten ist, d d Neuoperation das Horvermogen noch weiter verbessern wird, neuzuoperieren.
REFERENCES
Falbe-Hansen, J. & Tos, M. 1975. Silastic or gelatin film sheeting in tympanoplasty. Ann Otol Rhino1 Laryngol84, 315. Rambo, J. H . T. 1961. The use of paraffin to create a middle ear space in musculoplasty. Laryngoscope 71, 612. Sheehy, J. L. & Crabtree, J. A. 1973. Tympanoplasty: Staging the operation. Laryngoscope 83, 1594. Smith, G . D. L. 1970. Staged tympanoplasty. J Laryngol 84, 757. Tabb, H. G . 1963. The surgical management of chronic ear disease with special reference to stages surgery. Laryngoscope 73, 363. Tos, M. 1974. Tuba1 function and tympanoplasty. J Laryngol88, 1113. - 1974. Late results in tympanoplasty. Arch Otolaryngol 100, 302.
Downloaded by [] at 20:09 18 March 2016
Austin, D. F. 1969. Types and indications of staging. Arch Otolaryngol89, 235.
285
I9 -762959
Acta Otolaryngol82
