Incidence of attic retraction after staged intact canal wall tympanoplasty for middle ear cholesteatoma

Temporalis Fascia and Cartilage-Perichondrium Composite Shield Grafts for Reconstruction of the Tympanic Membrane

Objectives

We sought to compare the long-term functional results of tympanic membrane reconstruction with temporalis fascia and cartilage shield grafting.

Methods

This study includes 113 patients who had tympanoplasty type I tympanic membrane reconstruction between 1997 and 2007, 47 with tragal cartilage and 66 with temporalis fascia. Fourteen patients in the cartilage group and 9 patients in the temporalis fascia group also had mastoidectomy. The average follow-up was 3.2 years. The hearing threshold was calculated as the mean value of the thresholds for 500, 1,000, 2,000, and 3,000 Hz. A paired-samples t-est was used for comparison of the preoperative and postoperative air and bone conduction hearing thresholds and air-bone gaps.

Results

Significant recovery was found in the postoperative air conduction threshold and air-bone gap in both the temporalis fascia and cartilage groups as compared to those before surgery (p < 0.001). However, the average air and bone conduction thresholds and air-bone gap were found to be statistically different after surgery in the cartilage group as compared to those in the temporalis fascia group. There was no significant difference in hearing parameters before and after surgery in patients with or without mastoidectomy in either the cartilage group or the temporalis fascia group.

Conclusions

The hearing gain in patients with cartilage shield grafting was better than that in those who had temporalis fascia tympanoplasty, although experimental analysis shows loss of acoustic energy for thick and large shield cartilage grafts.

Canal reconstruction and mastoid obliteration using floating cartilages and musculoperiosteal flaps

OBJECTIVES

To reduce the mastoid cavity-associated problems secondary to canal wall down mastoidectomy, we designed a new surgical procedure that includes canal wall reconstruction using free-floating cartilages and double musculoperiosteal flaps.

STUDY DESIGN

Retrospective study.

MATERIALS AND METHODS

Thirty-three patients were enrolled in this study. Preoperative and postoperative pure tone audiometry/speech discrimination score and postoperative status (complications and EAC status) were analyzed.

RESULTS

Air conduction thresholds were statistically improved (P = 0.008). The air-bone gap was significantly reduced following surgery (P = 0.001). There were no other major complications in any of the patients. Long-term follow-up demonstrated gradual widening of the neo-EAC in 18 patients (54.5%) but normal contour of the neo-EAC in the other 13 patients (39.4%). In just one case did the neo-EAC become extremely widened.

CONCLUSION

Mastoid obliteration and canal wall reconstruction using free-floating cartilages and double musculoperiosteal flaps is very useful to achieve optimal surgical view, eliminate the middle ear pathology, and prevent recurrence of cholesteatoma and cavity problem.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1153-1160, 2017.

Improvements to staged canal wall up tympanoplasty for middle ear cholesteatoma

Objective

To describe our improvements to staged canal wall up tympanoplasty with mastoidectomy (SCUT) for middle ear cholesteatoma, and to show more successful outcomes of the surgery compared with our data previously reported.

Study Design

Retrospective study in a tertiary referral hospital.

Setting

78 ears of 76 patients with extensive cholesteatoma were operated on using the improved SCUT between July 1998 and December 2006. Improved SCUT included new techniques such as scutum plasty and mastoid cortex plasty performed in a staged manner.

Results

Only 2 ears showed retraction pocket formation (7.7%) without recurrence in 26 ears followed for more than 5 years. In 48 followed for more than 3 years, frequency of postoperative retraction pocket formation (5/48; 10.4%) was significantly lower compared to our previous results (41/134; 30.6%, P 0.01).

Conclusion

Our improvements to SCUT contributed to the decreasing of frequency of postoperative retraction pocket that may lead to cholesteatoma recurrence, although a longer follow-up study is required.

[Attic exposure-antrum exclusion as an on demand surgical technique for cholesteatoma]

INTRODUCTION AND OBJECTIVE

Attic exposure and antrum exclusion (AE-AE) is an on demand surgical technique for the treatment of cholesteatoma. Several techniques have been described with variable recurrence rates. The aim of the study was to describe this surgical technique and its indications and to analyse long-term outcomes.

MATERIALS AND METHODS

Forty-two patients were included. They received AE-AE in a tertiary centre and were followed-up from 6 months to 7 years. The surgical technique exposes the attic by drilling the superior wall of the external auditory canal and excludes the antrum and the mastoid cells by closing the aditus with a cartilage graft. It is indicated if the lesion does not go beyond the aditus or, if it does, it is a delimited cholesteatoma not damaging the labyrinth. The patients were followed-up by physical examination and radiology (CT scan and Non-EPI diffusion-weighted MRI since 2009).

RESULTS

The recurrence rate of the cholesteatoma was 4.8%. At recurrence, an open canal-wall-down mastoidectomy technique was performed. The rate of otorrhea (2/42 cases), serous otitis (2/42) and other complications was low, so aquatic activities were not contraindicated. The AE-AE did not modify ossicular chain reconstruction with respect to the rest of surgical techniques.

CONCLUSIONS

AE-AE is a canal-wall-down technique. Its purpose is to remove the lesion and to reduce the recurrence of cholesteatoma. In addition, it allows the entrance of water and reduces the need for 2(nd) look surgery. Non-EPI diffusion-weighted MRI is a reliable technique for follow-up, especially for the excluded mastoid.

[Staging-based surgical results in chronic otitis media with cholesteatoma]

Discussions of surgical results in chronic otitis media involving cholesteatoma usually include hearing improvement, side effects, and cholesteatoma recurrence, although such talks could easily involve the influence on surgical results of the intraoperative extension of the cholesteatoma-affected area around the tympanomastoid cavity. Based on intraoperative chronic otitis media staging involving cholesteatoma proposed by the Japan Otological Society in 2010, we studied our tympanoplasty results between April 1997 and March 2010. Hearing improvement in all subjects with pars flaccida cholesteatoma was 79.0% (n= 100) and that with pars tensa 73.3% (n = 30)--results not significantly influenced by intraoperative staging grade but significantly dependent on stapes presence (tympanoplasty type I and III) or absence (type IV). Nine cases of recurrence were seen in pars flaccida and four in pars tensa. Intraoperative side effects and postoperative recurrence often occurred in advanced cases. These findings suggest that intraoperative chronic otitis media staging involving cholesteatoma may make it important to be aware of the need for more careful procedures during surgery and in follow-up.

Surgical treatment of retraction pocket with bone pate: scutum plasty for cholesteatoma

OBJECTIVES

Postoperative attic retraction pocket is a critical issue and may be indicative of disease recurrence after canal-up tympanoplasty for middle ear cholesteatoma. Although scutum plasty is an acceptable procedure that can be used to prevent the pocket formation, how the scutum is reconstructed has remained controversial. The aim of this study was to clarify the value of scutum plasty using bone pate.

STUDY DESIGN

Retrospective study.

SETTING

Bone pate scutum plasty was performed in 69 ears during first-stage operations. We attempted to reconstruct a smooth attic bony wall. At the time of the second-stage operations, the results of the scutum plasty were examined.

RESULTS

The incidence of retraction pocket was statistically reduced from 20.2% to 5.8%.

CONCLUSION

Although the reconstructed scutum showed atrophy to some extent, bone pate scutum plasty is effective in preventing postoperative retraction pocket if a smoothly shaped attic wall can be reconstructed.

How we do it: free conchal cartilage revisited for primary reconstruction of attic defects in combined approach tympanoplasty

Keypoints * There are concerns over the efficacy of free cartilage autografts in attic reconstruction (scutumplasty) for combined approach tympanoplasty (CAT). * Our operative technique uses free conchal cartilage autografts and an additional piece of conchal cartilage to buttress the reconstruction. * Of the 16 cases where this technique was used, there were two cases (13%) of failure of the attic reconstruction and a keratin pearl (residual disease) in one case (6%). This compares favourably with comparable series using a variety of reconstruction techniques.

Dimensional Stability of Free Fascia Grafts: Clinical Application

OBJECTIVES/HYPOTHESIS

Animal experiments and human studies show that autologous fascia lata and temporal fascia change their dimensions during first 5 days of healing. Poor dimensional stability of the temporal fascia grafts may be responsible for the residual perforation sometimes seen in clinical practice.

STUDY DESIGN

Retrospective.

METHODS

Tympanoplasties performed for large perforations or granular myringitis using either fascia lata or temporal fascia as graft material are included. The ears are divided into two groups. Group I includes ears with fascia lata, and group II includes ears with temporal fascia as graft material. Ears with minimum 1-year follow-up are included in the study.

RESULTS

The results are studied in terms of 1) rate of primary closure of perforation, 2) rate of recurrent perforation, and 3) hearing improvement. It is noted that the ears with very large or subtotal perforations fared better (alpha = 0.05) in group I than similar ears in group II with respect to rate of primary closure of perforations. Similarly, ears in group I also have a lesser rate of recurrent perforation on long-term follow-up than ears in group II. No significant difference is noted in hearing improvement between the two groups.

CONCLUSION

Shrinkage of graft during healing phase appears to have significant relevance in the clinical situation. Ears having large perforations have high chances of residual perforations caused by limited margin of remnant tympanic membrane overlapping the graft. It seems logical to use fascia lata as graft material for large perforations because it has better dimensional stability.

Dimensional stability of the free fascia grafts: a human study

OBJECTIVES/HYPOTHESIS

In animals it has been shown that autologous free fascia grafts (fascia lata and temporal fascia) change dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations, particularly in large perforations. Dimensional stability of these fascias has been studied in humans.

STUDY DESIGN

Prospectively, 11 patients were studied.

METHODS

Patients who were subjected to open mastoid cavity surgery were included in the study. The mastoid cavity was exteriorized, and the fascia graft was used to seal the perforation and cover a part of the bare mastoid bone in the routine way. At this stage, equally cut pieces of temporal fascia and fascia lata were laid on the remaining part of the bare mastoid bone. The mastoid cavity was then packed with Gelfoam and wound sutured. The pieces of graft material under study were removed after 5 days, leaving the graft used to seal the tympanic membrane perforation undisturbed. The harvested grafts were measured for their dimensional variations, if any.

RESULTS

It was observed that free autologous temporal fascia grafts exhibited poor dimensional stability as compared with free autologous fascia lata grafts.

CONCLUSION

Poor dimensional stability of free temporal fascia grafts as seen in animals was confirmed in the present human study. This poor dimensional stability of temporal fascia grafts might be contributing to failure of closure of tympanic membrane perforations in tympanoplasty.

A study of recurrence of retraction pockets after various methods of primary reconstruction of attic and mesotympanic defects in combined approach tympanoplasty

The major drawback of combined approach tympanoplasty (CAT) is a relatively high rate of cholesteatoma recurrence compared to open-cavity techniques, which is thought to occur primarily by recurrence of retraction pockets. In this series of 63 CATs carried out by one surgeon, scutum reconstruction to prevent recurrent attic retraction was carried out in 43 cases. Repair with bone pate proved much more successful in achieving this (20.7%; 6/29 recurrent retraction pockets) compared to tragal cartilage (57.1%; 8/14) (Fisher's exact test, P = 0.0205) and was found to be a result of the greater incidence of cartilage resorption. Recurrence of retraction in pars tensa defects was more common as the only material used was a simple temporalis fascia graft. The mean time to development of recurrences was 21.1 months and that has important implications for follow-up. We conclude that the use of bone pate for scutum reconstructions reduces the incidence of attic retraction pockets, and therefore the risk of cholesteatoma recurrence following CAT.

Dimensional stability of the free fascia grafts: an animal experiment

OBJECTIVES/HYPOTHESIS

It appears that autologous free fascia grafts (fascia lata and temporal fascia) change their dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations. There has been no study regarding this dimensional instability.

STUDY DESIGN

Prospectively dimensional instability of the free fascia grafts studied in 14 mongrel dogs.

METHODS

Fourteen healthy Mongrel dogs were operated on twice. During the first surgery, fascia lata and temporal fascia grafts of measured dimensions (length, breadth, and thickness) were implanted in the subcutaneous pockets on the thoraco-abdominal wall of the same dog (autograft). Five dogs were operated on again after 2 days, and 7 dogs were operated on again after 5 days to harvest the implanted grafts. The dimensions of the harvested grafts were noted. Changes with respect to their implant dimensions after 2 days and after 5 days were calculated.

RESULTS

It was found that free fascia lata exhibits significantly superior dimensional stability when compared with free temporal fascia during the early healing phase, before graft integration has occurred. Shrinking and thickening of temporal fascia are greater and are also most unpredictable.

CONCLUSIONS

Poor dimensional stability of temporal fascia may compromise a well-sealed perforation at the time of surgery, and it may reopen by the 5th day. This must be one of the causes of failure of tympanoplasty, which needs to be studied further.

Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: a pilot study

OBJECTIVE

Evaluation of suitability of flexible composite sheets (hydroxylapatite and polymer) for outer ear canal (OEC) wall reconstruction in tympanoplasty.

STUDY DESIGN

Prospective, open label pilot study.

SETTING

University and regional hospital.

PATIENTS

Forty-two randomly selected patients with chronic otitis media (n = 20) and cholesteatoma (n = 22) among 356 patients admitted between 1996 and 1997.

INTERVENTIONS

Eradication of disease through a partial or total canal wall down mastoidectomy; immediate reconstruction of canal wall with flexible composite sheet (hydroxylapatite and polymer) and connective tissue graft.

OUTCOME MEASURES

Anatomic integrity of the OEC and neotympanum, extrusion rate, complications.

RESULTS

At minimum follow-up of 24 months: recurrent cholesteatoma (n = 0), residual cholesteatoma (n = 3/22) (13.6%) in the mesotympanum (none behind the hydroxylapatite sheet or in the attic or antrum). The neotympanum was intact in 38 ears (90.4%), reperforated in 2, and severely retracted and lateralized in 1, respectively. Anatomic integrity of the OEC was obtained in 37 (88%) of 42 patients; stenosis or membranous synechiae were observed in 5 ears and treated in the office. Extrusion of the hydroxylapatite sheet occurred in 7 patients (16.6%) because of purulent otorrhea and granulation tissue formation. Surgical revision achieved complete epithelialization of the rebuilt canal wall in 33 ears (78.6%).

CONCLUSIONS

A dry, disease-free ear and normal anatomy may be expected 2 years postoperatively in more than three-fourths of the patients treated using the described surgical technique. Complete protection with a connective tissue graft is essential to avoid extrusion of the implant. The failure rate is significantly higher if otorrhea is present at the time of the operation.

Residue of middle ear cholesteatoma after intact canal wall tympanoplasty: surgical findings at one year

The rate of residual disease after surgery for acquired middle ear cholesteatoma was investigated in 167 ears of 164 patients who had undergone planned second-look tympanoplasty by the intact canal wall technique. Overall, operative findings at the second stage revealed 65 cases of residual disease in 48 ears (29%). These consisted of 50 squamous pearls, 11 cases of the flat, open type, and 4 cases of the extensive type. The configuration of residual disease is closely related to the technical difficulty of eradication, since en bloc removal is much easier in the squamous pearl than in the open or extensive type, mainly because of the unclear margin with the surrounding tissues. The proportion of cases of the open type was greater in children than in adults, in pars tensa cholesteatoma than in pars flaccida cholesteatoma, and in severe primary middle ear disease than in moderate or mild disease, although these differences were not statistically significant. The extensive type occurred in 4 ears with severe primary disease, 3 of which were in children. These results support the value and importance of the staged procedure for middle ear cholesteatoma, particularly when operated on by the intact canal wall technique.