Laser-assisted myringoplasty--technical aspects

[Experience of laser myringoplasty in children with juvenile ideopathic arthritis]

Surgeons' dissatisfaction with the surgical treatment for tympanic membrane perforations results leads to the constant improvement of the surgical technique and the emergence of new techniques. Difficulties arise in the surgical treatment of rheumatological patients treated with immunosuppressive drugs due to the high potential risk of postoperative complications. The most promising direction in this cohort of patients can be considered the use of laser exposure techniques under endoscopic control. The experience of performing endoscopic laser myringoplasty in 9 children aged from 6 to 16 years (mean age 10±3 years) with tympanic membrane perforation up to 6 mm in diameter and juvenile idiopathic arthritis treated with methotrexate and tocilizumab is presented. The effectiveness of the studied technique in relation to the closure of perforation of the tympanic membrane was 66.7%. Considering that in children, reconstructive ear surgery is considered less effective than in adults, and the presence of chronic systemic rheumatoid disease and immunosuppressive therapy are risk factors for recurrence of perforation after tympanoplasty, these results can be considered successful. The presented method is promising in this cohort of patients for the restoration of small tympanic membrane defects. However, further research is needed.

Lasers in endoscopic middle ear surgery: where do we stand today?

OBJECTIVE

To provide an overview of the current status regarding the parallel use of the endoscope and the laser in middle ear surgery.

METHODS

Comprehensive Pubmed search from 1975 to 2020 including clinical articles, of any type, reporting the combined use of a laser and an endoscope. Purely experimental and non-human studies were excluded.

RESULTS

Reports on the application of the laser in pediatric and adult endoscopic middle ear surgery (EES) are increasing since 2013. Laser-assisted EES is performed for cholesteatoma, non-squamous chronic otitis media, ossicular fixation, otosclerosis and tympanic paraganglioma. The improved haemostasis and the non-contact ablation of tissue around the ossicles and inaccessible areas, represent unique advantages. In stapes surgery, the resection of stapes superstructure with minimal force and the non-contact footplate fenestration are potential advantages. Proper use of the laser, i.e. direction away from the facial nerve and the open labyrinth and safe energy settings have resulted in minimal complications.

CONCLUSION

Based on the increasing number of publications, endoscopic ear surgeons show an interest in using a laser for specific operative tasks. The configuration of a hand-held laser probe does not differ significantly from other otological instruments and therefore is easy to use alongside the endoscope, even in children. The 'handicap' of single-handed surgery can be partially offset by the bloodless and non-contact laser ablation of tissue.

Minimally Invasive Laser Contraction Myringoplasty for Tympanic Membrane Atelectasis*

OBJECTIVE: We sought to develop a minimally invasive surgical technique using the CO2 laser to reduce or eliminate tympanic membrane atelectasis in a select group of patients.

STUDY DESIGN: Thirty-seven ears with varying degrees of tympanic membrane atelectasis underwent CO2 laser myringoplasty with the patients under intravenous sedation in the operating room setting. Atelectasis severity was graded for each patient and documented before and after laser myringoplasty through photodocumentation. Patients were followed for 1 year with comparison tympanic membrane photography.

SETTING: The study was conducted in a tertiary care private otology-neurotology practice.

RESULTS: Laser myringoplasty significantly reduced retraction pocket severity in most patients. No patients required resection of the retraction pocket or tympanoplasty. The most favorable outcomes were observed in patients with atelectasis addressed early rather than later in its more advanced stages.

CONCLUSION: Laser contraction myringoplasty can reduce or eliminate atelectatic areas of the tympanic membrane through immediate contraction and “tightening” of the tympanic membrane tissues. Clinicians should use a standardized tympanic membrane atelectasis grading format.

SIGNIFICANCE: A minimally invasive surgical technique for addressing tympanic membrane atelectasis is described, and a tympanic membrane at-electasis grading system is presented based on size, location, and depth of the atelectatic region.