Myringotomy and Insertion of Ventilation Tube The indications of myringotomy and ventilation tube insertion have been discussed previously. Myringotomy is usually performed in the anteroinferior quadrant of the tympanic membrane in the region of the cone of light. The incision is made in a radial direction using a myringotomy knife. In cases with a hump of the anterior wall of the external auditory canal, myringotomy can be performed immediately inferior to the umbo in the posteroinferior quadrant. The incision should never be made in the posterosuperior quadrant to avoid injury to the ossicular chain. The operation is performed under general anesthesia in children. In adults, however, local anesthesia is sufficient. After making a radial incision of the tympanic membrane, the middle ear effusion is aspirated and the ventilation tube is inserted. In the majority of cases, hearing improves immediately. The patient is instructed to avoid water entering the ear by blocking it with cotton anointed with petrolatum when taking a shower or with rubber earplugs when swimming. Infection could occur if water were to enter the middle ear through the ventilation tube. Should this occur, ear lavage with a disinfectant solution consisting of 2% boric acid in 70% alcohol is indicated. When the tube is obstructed by cerumen or crusts, the administration of hydrogen peroxide drops is usually sufficient to restore its patency. There are many types of commercially available ventilation tubes, but they can be generally grouped into short- and long-term tubes. Tubes with a larger inner flange usually remain in place longer. Once extruded, the myringotomy site closes spontaneously in approximately 98% of cases. Refer to ▶ Fig. 14.1, ▶ Fig. 14.2, ▶ Fig. 14.3, ▶ Fig. 14.4, ▶ Fig. 14.5, ▶ Fig. 14.6, ▶ Fig. 14.7, ▶ Fig. 14.8, ▶ Fig. 14.9, ▶ Fig. 14.10, ▶ Fig. 14.11, ▶ Fig. 14.12, ▶ Fig. 14.13, ▶ Fig. 14.14, ▶ Fig. 14.15, ▶ Fig. 14.16. Fig. 14.1 Left ear. The Sultan ventilation tube. This type has two small wings: an outer one with which the tube can be held using the ear forceps and an inner one, viewed through the tympanic membrane, which facilitates tube insertion and prevents rapid extrusion. If properly inserted, the Sultan ventilation tube can remain for approximately 6 to 18 months before extrusion. Fig. 14.2 Left ear. In this case, the tube has been placed inferior to the umbo due to the presence of an anterior hump in the anterior canal wall. Fig. 14.3 Left ear. A long-term ventilation tube inserted 6 months after tympanoplasty because of an observed tendency for graft retraction. The graft is seen in an optimal condition with no evidence of retraction, indicating patency of the ventilation tube. This tube has been in situ for more than 10 years. Fig. 14.4 Left ear. Long-term ventilation tube. A large tympanosclerotic plaque that formed 1 year after the tube insertion can be clearly seen. Such plaques result from hemorrhagic infiltrate between the epidermal and fibrous layers of the tympanic membrane secondary to the myringotomy and are asymptomatic. Fig. 14.5 Left ear. Sultan ventilation tube placed in the anteroinferior quadrant. Anterior hump of the external auditory canal is visible. Fig. 14.6 Left ear. Example of a long-term “T” tube inserted in the anteroinferior quadrant of the tympanic membrane. After its insertion, the two wings of the tube open by virtue of their retained “memory,” thereby preventing tube extrusion. Fig. 14.7 Right ear. Another example of a long-term T tube. This type of tube unfortunately very often causes perforation of the tympanic membrane. Fig. 14.8 Right ear. Long-term T tube placed in the posteroinferior quadrant. Fig. 14.9 Right ear. The consequences of a misplaced ventilation tube is shown. A healed myringotomy is seen in the posterosuperior quadrant (at 9 o’clock position). Two months later, the tube was extruded. During tube insertion, however, dislocation of the incus occurred. The dislocated incus fell to the hypotympanum where its body and short process can be clearly seen (arrow). In the anteroinferior quadrant, immediately under the umbo, another healed myringotomy site (this time correctly placed) is visible. In the latter, tube extrusion occurred 1 year late. Fig. 14.10 Left ear. A ventilation tube in the process of extrusion. It is preferable not to take out the tube but rather wait for self-extrusion to occur. Closure of the myringotomy site occurs in approximately 98% of cases. Fig. 14.11 Right ear. Sultan ventilation tube placed in the anteroinferior quadrant. The tube is blocked by cholesteatoma squamae. During myringotomy it is of utmost importance not to introduce skin inside the middle ear, thus avoiding the formation of an iatrogenic cholesteatoma. Fig. 14.12 Right ear. Granulation tissue after ventilation tube insertion. This complication is generally resolved with removal of the tube. Fig. 14.13 Right ear. Long-term T tube placed in the anteroinferior quadrant. Infection with otorrhea and granulation tissue are present. Local antibiotics and steroids are sufficient for the healing. Fig. 14.14 Right ear. Partially extruded titanium tube. The ventilation tube has been placed in the area of the handle of the malleus. Ventilation tubes should be always placed away from the ossicles, thus avoiding injury of the ossicular chain and subsequent hearing loss. Fig. 14.15 Right ear. Extruded ventilation tube. The area of the previous myringotomy is visible as a scar in the posteroinferior quadrant (arrow). Fig. 14.16 Left ear. Extruded ventilation tube in the external auditory canal. Stapes surgery is performed when the footplate of the stapes is fixed in the oval window (i.e., in otosclerosis). This surgery is probably the finest otological procedure, requiring very delicate manipulation of instruments in a very narrow area with important structures all around. It should be done only by experienced surgeons performing this procedure routinely. Occasional surgery should be avoided because miscarriage of the procedure may cost the hearing of the operated ear, and contralateral hearing is frequently abnormal. Whenever possible, we perform stapedotomy as primary stapes surgery as it offers a calibrated hole in the footplate to stabilize both ends of the prosthesis. Compared with stapedectomy, the procedure also offers less trauma to the oval window and less possibility of damaging the inner ear. In addition, revision surgery, if required, is easier due to preserved anatomy. Refer to ▶ Fig. 14.17, ▶ Fig. 14.18, ▶ Fig. 14.19, ▶ Fig. 14.20, ▶ Fig. 14.21, ▶ Fig. 14.22, ▶ Fig. 14.23, ▶ Fig. 14.24, ▶ Fig. 14.25, ▶ Fig. 14.26, ▶ Fig. 14.27. Fig. 14.17 Right ear. Schwartze’s sign (arrow) is typical of otosclerosis, even if present in less than 10% of patients. This rosy glow visible through the tympanic membrane is due to vascular hyperemia of immature abnormal bone produced during the otosclerotic process. Fig. 14.18 Right ear. Otoscopy after stapedotomy. A small atticotomy is visible. The loop of the prosthesis has been correctly tightened all around the long process of the incus (arrow). Fig. 14.19 Right ear. Otoscopy after stapedotomy. In this case, atticotomy is wider than that in ▶ Fig. 14.17, but no tympanic retraction occurred. The loop of the prosthesis is firmly fixed on the long process of the incus. Fig. 14.20 Left ear. Another case of well-performed atticotomy for stapes surgery. Fig. 14.21 Left ear. Otoscopy view after stapedotomy. The atticotomy is visible; the prosthesis, dislocated from the incus, has adhered to the tympanic membrane (arrow). Fig. 14.22 Right ear. Otoscopy view after stapedotomy. A small retraction in the area of the atticotomy is visible (red arrow). Even in this case, the prosthesis, dislocated from the incus, has adhered to the tympanic membrane (black arrow). Fig. 14.23 Right ear. Otoscopy view after stapedotomy. The prosthesis is about to dislocate from the long process of the incus (arrow). The loop is loose, resulting in persistence of conductive hearing loss. Fig. 14.24 Right ear. Dislocation of a Causse (Teflon) prosthesis (arrow) in a patient who underwent stapedotomy. Fig. 14.25 Left ear. A rare case of extrusion of a stapes prosthesis. The metallic ring is seen extruding through a microperforation covered with epidermal squames. The Teflon shaft of the prosthesis can be visualized through the tympanic membrane. Fig. 14.26 Left ear. This 41-year-old woman underwent bilateral stapedotomy for otosclerosis elsewhere. After 2 years from the last surgery, she developed bilateral conductive hearing loss. On the left side, the prosthesis is clearly extruding for the middle ear (arrow). Fig. 14.27 Right ear. Same case. A clear iatrogenic cholesteatoma (Ch) is visible in the posterosuperior quadrant. The prosthesis (black arrow) is partially dislocated. A retraction pocket is present in the posteroinferior quadrant (red arrow). The patient underwent removal of the cholesteatoma through an endocanalar approach. A second-stage operation has been planned after 8 months. The aim of reconstructing a tympanic membrane perforation is twofold: first, to allow the patient to have a normal social life with no restrictions, even regarding water entry into the ear, and second, to correct the hearing loss resulting from the perforation. There are essentially two techniques for myringoplasty. The underlay technique is utilized in the presence of an anterior residue (at least the annulus) of the tympanic membrane, under which the graft can be placed. In the absence of any anterior residue of the membrane, the overlay technique is used. In such cases, the graft is positioned against the anterior wall of the external auditory canal. Normally, the tympanic membrane forms an acute angle with the anterior wall of the external auditory canal. While performing myringoplasty, it is generally possible to respect this angulation when the annulus is present anteriorly. The myringoplasty operation is considered a success when the reconstructed tympanic membrane is intact, is well epithelialized, and has normal angulation with the external auditory canal. These characteristics allow the patient to have a normal social life (hearing improvement and possibility of water entry into the ear). Reperforation is a frequent complication of myringoplasty that occurs in approximately 5 to 10% of cases in the best series. Reperforation occurs more commonly in the underlay technique, particularly in the anterior quadrant where the graft is detached from the anterior residues of the tympanic membrane and falls into the middle ear. When an overlay technique is utilized, blunting of the anterior angle can occur with resultant conductive hearing loss. Lateralization, in which the graft is detached from the handle of the malleus, is another possible complication that leads to conductive hearing loss. It occurs mostly when the graft is placed lateral rather than medial to the handle of the malleus. Stenosis of the external auditory canal, either due to inflammatory reaction or as a result of bad repositioning of the meatal flaps, can also occur. Refer to ▶ Fig. 14.28, ▶ Fig. 14.29, ▶ Fig. 14.30, ▶ Fig. 14.31, ▶ Fig. 14.32, ▶ Fig. 14.33, ▶ Fig. 14.34, ▶ Fig. 14.35, ▶ Fig. 14.36, ▶ Fig. 14.37, ▶ Fig. 14.38, ▶ Fig. 14.39, ▶ Fig. 14.40, ▶ Fig. 14.41. Fig. 14.28 Left ear. Normal aspect of the reconstructed tympanic membrane. The posterior quadrant is slightly elevated. In this case, a posterior perforation was grafted with temporalis fascia using an underlay technique. Fig. 14.29 Right ear. Myringoplasty with an underlay technique. The reconstructed tympanic membrane is thicker than normal. The anterior angle is maintained. The handle of the malleus is clearly visible except for the umbo, which is detached from the membrane. Tympanosclerotic plaques are also visible. Fig. 14.30 Left ear. Another example of a tympanic membrane perforation that was repaired using an underlay technique with preservation of the anterior residue. The posterior quadrants are slightly lateralized, making it difficult to see the handle of the malleus. Fig. 14.31 Left ear. Similar case. The repaired tympanic membrane is well attached to the malleus except for the area of the umbo due to lateralization of the posteroinferior quadrant. Fig. 14.32 Right ear. Underlay myringoplasty. The malleus is slightly medialized. The repaired tympanic membrane is whitish in its anterior quadrants and vascularized in the posterior ones. The anterior angle is normal. Fig. 14.33 Right ear. Underlay myringoplasty for a posterior perforation. The anterior angle is perfectly normal, as the thickness of the membrane. Fig. 14.34 Left ear. Another case of underlay myringoplasty for a posterior perforation. This image has been taken immediately after removal of the postoperative ear plugging (Gelfoam), approximately 30 days after surgery. The repaired tympanic membrane retains its normal position, with a perfect anterior angle. Fig. 14.35 Left ear. Underlay myringoplasty. The tympanic membrane is thicker on its posterior quadrants. A retraction of the anterior quadrants is also present. However, hearing function is normal. Fig. 14.36 Right ear. Cartilage myringoplasty for a mesotympanic retraction of the posterior quadrants with perforation (Grade V of Sadè classification). No epithelialization was found in the middle ear. Incus was not eroded. Cartilage could be useful in cases like this to reinforce the tympanic membrane, avoiding further retractions. Myringosclerosis of the anterior quadrants is also visible. Fig. 14.37 Right ear. Revision myringoplasty with cartilage for subtotal perforation of the tympanic membrane. The use of cartilage avoids further reperforations in revision cases. Sometimes, sensation of fullness could be referred by the patient, even in case of complete closure of the air–bone gap. Fig. 14.39 Right ear. Myringoplasty for a posterosuperior retraction pocket without cholesteatoma. The long process of the incus was absent, resulting in conductive hearing loss. A thick piece of cartilage was put directly over the stapes, resulting in complete closure of the air–bone gap. Fig. 14.40 Underlay myringoplasty for perforation of the anterior quadrants. A piece of cartilage was used to avoid anterior reperforation. Fig. 14.41 Right ear. Myringoplasty with an underlay technique. The reconstructed membrane is thicker than normal, with a tympanosclerotic appearance. The anterior angle is maintained. Refer to ▶ Fig. 14.42, ▶ Fig. 14.43, ▶ Fig. 14.44, ▶ Fig. 14.45, ▶ Fig. 14.46, ▶ Fig. 14.47, ▶ Fig. 14.48, ▶ Fig. 14.49, ▶ Fig. 14.50, ▶ Fig. 14.51, ▶ Fig. 14.52, ▶ Fig. 14.53, ▶ Fig. 14.54, ▶ Fig. 14.55, ▶ Fig. 14.56, ▶ Fig. 14.57. Fig. 14.42 Left ear. The repaired tympanic membrane retains a normal anterior angle and is well vascularized, though thicker than normal. A small cholesteatomatous pearl is observed. This pearl can be easily removed in the outpatient clinic under the microscope. Fig. 14.43 Right ear. The repaired tympanic membrane has normal thickness. The short process of the malleus can be observed, although the handle is not visible due to lateralization. Fig. 14.44 Right ear. Even in this case the repaired tympanic membrane has normal thickness, but the graft is detached from the handle of the malleus. Fig. 14.45 The external auditory canal is wide but the repaired tympanic membrane is lateralized and shows blunting. Fig. 14.46 Similar case. The reconstructed tympanic membrane is lateralized with marked blunting of the anterior angle. Fig. 14.47 Another case of lateralization of the reconstructed tympanic membrane with marked blunting of the anterior angle. Further revision has a high rate of failure. Fig. 14.48 Lateralization of the reconstructed tympanic membrane with initial stenosis of the external auditory canal. Fig. 14.49 Lateralization of the reconstructed tympanic membrane in an 8-year-old male patient. The posterior annulus is completely detached from the bony wall. The external auditory canal has not been calibrated during myringoplasty, so the anteroinferior quadrant is not completely under view. Middle ear effusion is also present (note the air bubble in the inferior quadrant). Fig. 14.50 Postoperative myringitis. The tympanic membrane is hyperemic, thickened, and lateralized following a tympanoplasty. The epidermal layer is substituted by granulation tissue. Myringitis is a rare complication that usually resolves with local steroid applications. In very rare cases, reoperation is necessary. The pathological tympanic membrane is removed followed by grafting. Fig. 14.51 A patient who has undergone quadruple myringoplasty. In these cases, myringitis and canal stenosis are frequent; therefore, it is necessary to remove the pathological tissues, perform canalplasty, and use free skin flaps. Fig. 14.52 Left ear. Reperforation of the tympanic membrane with granulations near the perforation. In such cases, curettage of the granulation and freshening of the edges under the microscope may lead to spontaneous closure of the perforation. Fig. 14.53 Reperforation of the tympanic membrane. Myringitis with otorrhea can be appreciated. Lavage and freshening of the perforation edges as well as insertion of Gelfoam (in the middle ear) can favor spontaneous closure of the perforation. Fig. 14.54 Small reperforation of the tympanic membrane during an acute attack of otitis media. Otorrhea is also present. Local therapy (lavage and antibiotic drops) as well as nasal decongestants and oral antibiotics are helpful for the healing process. In this case, the perforation could close spontaneously. Fig. 14.55 Left ear. Stenosis of the external auditory canal following myringoplasty. Fig. 14.56 Right ear. Partial stenosis of the external auditory canal following myringoplasty. For the management of this complication, it is usually sufficient to incise the skin of the canal and insert a plastic sheet for approximately 20 days, while using local medication of steroid lotion. Fig. 14.57 Retrotympanic cholesteatoma following myringoplasty. This iatrogenic cholesteatoma can be explained by the entrapment of epidermal residues in the middle ear or malpositioning of the meatal flap at the level of the anterior angle. It can be managed by incision of the cholesteatoma sac, aspiration of its contents, and insertion of a plastic sheet in the external auditory canal for approximately 20 days to favor healing. Tympanoplasty operations can be classified into those without mastoidectomy, performed with chronic otitis media in which the tympanic membrane perforation is associated with necrosis of the ossicular chain, and those with mastoidectomy, performed in chronic suppurative otitis media with cholesteatoma. As mentioned previously, tympanoplasty with mastoidectomy can be either closed or open. In closed tympanoplasty, the posterior wall of the external auditory canal is kept intact. This technique is employed in children and in patients with very pneumatized mastoids to avoid having a large cavity. Regular otoscopic follow-up is essential to identify the formation of a retraction pocket or a recurrent cholesteatoma. Should these occur, there should be no hesitation in switching to an open technique. In open tympanoplasty, the posterior wall of the external auditory canal is removed. The indications of this technique in the treatment of cholesteatoma include: a wide erosion of the posterosuperior wall, cholesteatoma in the only hearing ear, bilateral cholesteatoma, cholesteatoma in patients with Down’s syndrome, the presence of a contracted mastoid, a large labyrinthine fistula, and recurrent cholesteatoma following a closed tympanoplasty. Because the posterior canal wall is removed, the mastoid cavity is exteriorized and on otoscopy the external auditory canal and the mastoid appear as one communicating cavity. If properly performed, the cavity appears rounded in shape, dry, and well epithelialized. On the other hand, a badly performed cavity may appear wet, irregular, and be lined with granulation tissue in addition to accumulated debris. There may also be the possibility of a residual cholesteatoma. In cases of tympanoplasty, it is usually possible to see the reconstructed ossicular chain through the tympanic membrane. We generally prefer to utilize an autologous or homologous incus for reconstruction. In our experience (more than 7,000 tympanoplasties), we never encountered any case of extrusion when the incus was used. In contrast, variable rates of extrusion were noticed when biological materials (e.g., plastipore, ceramics, hydroxyapatite) were utilized. Although the use of homologous ossicles has never been proven to transmit slow viruses (e.g., Creutzfeldt–Jakob disease), the theoretical risk makes it more prudent to use predominantly autologous tissue or biomaterial of better characteristics that might appear in the future. Later on in this chapter, some otoscopic views of cases managed by the modified Bondy’s technique are shown. This is an open technique indicated in epitympanic cholesteatoma with a good preoperative hearing in which the tympanic membrane and the ossicular chain are intact. Some cases of radical mastoidectomy are also shown. This technique is used mainly in elderly patients with sensorineural hearing loss in which the only goal of surgery is to have a dry and safe ear. Closed tympanoplasty operations have been shown in ▶ Fig. 14.58, ▶ Fig. 14.59, ▶ Fig. 14.60, ▶ Fig. 14.61, ▶ Fig. 14.62, ▶ Fig. 14.63, ▶ Fig. 14.64, ▶ Fig. 14.65, ▶ Fig. 14.66, ▶ Fig. 14.67, ▶ Fig. 14.68, ▶ Fig. 14.69, ▶ Fig. 14.70, ▶ Fig. 14.71, ▶ Fig. 14.72, ▶ Fig. 14.73, ▶ Fig. 14.74, ▶ Fig. 14.75, ▶ Fig. 14.76, ▶ Fig. 14.77, ▶ Fig. 14.78, ▶ Fig. 14.79, ▶ Fig. 14.80, ▶ Fig. 14.81, ▶ Fig. 14.82, ▶ Fig. 14.83. Fig. 14.58 Right ear. Staged closed tympanoplasty. The tympanic membrane has a normal angle and is well attached to the handle of the malleus. The cartilage used for reconstructing the attic is visible. In this region, a small self-cleaning retraction pocket can be seen.
14.2 Stapes Surgery
14.3 Myringoplasty
14.3.1 Failures and Complications
14.4 Tympanoplasty
14.4.1 Canal Wall Up (Closed) Tympanoplasty
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