Do the Angle and Length of the Eustachian Tube Affect the Success Rate of Pediatric Cartilage Type 1 Tympanoplasty?

Special Considerations for Tympanoplasty Type I in the Oncological Pediatric Population: A Case-Control Study

Introduction

Although cutting-edges antineoplastic therapies increase survival in children with malignancies, the optimal surgical strategy to address associated comorbidities such as chronic tympanic membrane perforation is still poorly documented. The aim of this study is to evaluate the outcomes of type I tympanoplasty in pediatric cancer survivors who received chemo and/or radiotherapy to the skull and to identify potential associated risk factors.

Methods

This case-control study included medical records review of oncologic patients (age <21) treated at the same Academic medical oncologic center between March 2015 and July 2021 and referred for conductive hearing loss and chronic tympanic membrane perforation. Patients and middle ear status-related variables were analyzed, and outcomes were compared with matched peers without any history of malignancies.

Results

A total of seven pediatric cancer survivors and seven paired children without any history of malignancies were included in this report. The mean age at tympanoplasty type I surgery was 10.2 years (range = 4.3–19.9; median = 7.9 years) for the pediatric cancer survivors' group and 10.1 years (range = 5.5–19.2; median = 7.9 years) in the control group. Three pediatric cancer patients had received chemotherapy alone, one patient had radiotherapy to the skull base, and three patients had received chemoradiotherapy. On average, surgery was performed 3.9 years after chemo and/or radiotherapy termination, except for 1 patient for whom the tympanoplasty was performed during chemotherapy treatment. A retroauricular approach was used for one of the pediatric cancer patients, a transcanal approach was performed in one other and five patients benefited from an otoendoscopic approach. Tragal perichondrium with cartilage was used in most of the pediatric cancer survivor cases (four out seven cases) while xenograft (Biodesign) and Temporalis fascia without cartilage graft were used in five out of the seven control cases. Rate of tympanic membrane perforation recurrence was similar between groups (28.6%). Mean functional gain for air conduction Pure Tone Average (AC PTA) was 2.6 and 7.7 dB HL for the oncologic and control group, respectively. Mean postoperative air-bone gap (ABG) was 10.7 dB HL [median = 8.7; inter-quartile range (IQR) = 13.8] for the oncologic cohort and 10.1 dB HL (median = 10.7; IQR = 9.6) for the control group.

Discussion

Chemo- and chemoradiotherapy to the skull are associated with damages to the inner and middle ear structures with secondary eustachian tube dysfunction and chronic middle ear effusion. Although healing abilities and immunological defenses are compromised as part of the expected effects of antineoplastic therapies, type I tympanoplasty can be safe and effective in this population. While different approaches may be considered, otoendoscopy showed excellent results with less morbidity in this vulnerable population.

Developmental Anatomy of the Eustachian Tube: Implications for Balloon Dilation

OBJECTIVE

To describe the developmental anatomy of the eustachian tube (ET) and its relationship to surrounding structures on computed tomography.

STUDY DESIGN

Case series with chart review.

SETTING

A tertiary care hospital.

METHODS

ET anatomy was assessed with reformatted high-resolution computed tomography scans from 2010 to 2018. Scans (n = 78) were randomly selected from the following age groups: <4, 5 to 7, 8 to 18, and >18 years. The following were measured and compared between groups: ET length, angles, and relationship between its bony cartilaginous junction and the internal carotid artery and between its nasopharyngeal opening and the nasal floor.

RESULTS

The distance between the bony cartilaginous junction and internal carotid artery decreased with age between the <4-year-olds (2.4 ± 0.6 mm) and the 5- to 7-year-olds (2.0 ± 0.3 mm, P = .001). The ET length increased among the <4-year-olds (32 mm), 5- to 7-year-olds (36 mm), and 8- to 18-year-olds (41 mm, P < .0001). The cartilaginous ET increased among the <4-year-olds (20 mm), 5- to 7-year-olds (25 mm), and 8- to 18-year-olds (28 mm, P < .0001). The ET horizontal angle increased among the <4-year-olds (17°), 5- to 7-year-olds (21°), and 8- to 18-year-olds (23°, P≤ .003), but the ET sagittal angle did not statistically change after 5 years of age. The height difference between the nasopharyngeal opening of the ET and the nasal floor increased among the <4-year-olds (4 mm), 5- to 7-year-olds (7 mm), and 8- to 18-year-olds (11 mm, P < .0001).

CONCLUSION

The ET elongates with age, and its angles and relationship to the nasal floor increase. Although some parameters mature faster, more than half of the ET growth occurs by 8 years of age, and adult morphology is achieved by early adolescence.

Morphologic measurements of 3D Eustachian tube model and their diagnostic value regarding Eustachian tube dysfunction - A cross-sectional observational study

PURPOSE

To investigate the diagnostic value of three-dimensional morphologic measurements of the Eustachian tube on computed tomography in Eustachian tube dysfunction.

METHOD

This prospective cross-sectional observational study includes forty patients with unilateral Eustachian tube dysfunction. The clinical diagnosis is verified using the Eustachian tube score - 7 and the Eustachian tube dysfunction questionnaire - 7. Computed tomography scans of the temporal bone are acquired while performing a Valsalva manoeuvre to improve the visualization of the air-filled Eustachian tube lumen. The Eustachian tubes are delineated on curved planar reconstructions, and three-dimensional models are constructed. Seven morphological parameters are measured for each Eustachian tube: the cross-sectional size of the tympanic and pharyngeal orifice; the visualization length; the inclination angles, and the curvature angles. Morphological measurements and Eustachian tube scores are correlated.

RESULTS

The mean value of the visualization length of the complete Eustachian tube and in its bony segment is significantly higher in healthy sides than in pathological sides (p = 0.034 and p = 0.029, respectively). There is a significant correlation between the Eustachian tube score - 7 and the cross-sectional size of the tympanic orifice (r_P = 0.361; p = 0.022). The Eustachian tube score - 7 correlates significantly with the visualization length of complete Eustachian tube (r_P = 0.436; p = 0.005) and its bony segment (r_S = 0.598; p < 0.0001), respectively.

CONCLUSIONS

The cross-sectional size of the tympanic orifice may be a specific imaging feature indicating the obstructive Eustachian tube. However, 3D morphologic measurements of the Eustachian tube are insufficient to yield useful data about its function.

The effect of age on ossiculoplasty results: A retrospective evaluation of 60 cases

OBJECTIVE

There are only a few studies evaluating ossiculoplasty results in the pediatric age group. Although the effect of different factors on the results of ossiculoplasty is investigated, the effect of age on ossiculoplasty results is not known. In this study, the effect of age on ossiculoplasty results has been investigated.

METHODS

This retrospective clinical study was performed in 60 patients (30 female, 30 male; mean age 15.5±14.3 years, range 9-57 years) who underwent ossiculoplasty. The cases were divided into two groups according to their age. Group A consisted of pediatric cases younger than 18 years of age and group B consisted of adult subjects (>18 years). The comparison of the groups was made by taking into consideration the air-bone gap in the 3rd and 12th weeks of the pre- and postoperative period.

RESULTS

There was no statistically significant difference between preoperative air-bone gaps of the groups (p=0.086). In the third postoperative month, the air-bone gap gain of group A was statistically significantly higher than group B (p=0.0001). The air-bone gap gain of group A was significantly higher than group B in the postoperative 12th month (p=0.026). The air-bone gap gain of the patients with malleus in group A and group B was higher in the postoperative 3rd month than in the patients without malleus (all p values <0.05). There was no statistically significant difference between the air-bone gap gain in patients with the stapes suprastructure and the air-bone gap gain of the patients without stapes suprastructure in group A and group B in the postoperative 3rd month (p values >0.05).

CONCLUSION

The results of ossiculoplasty were found better in the pediatric age group. We think that ossiculoplasty should be carried out without delay in the pediatric age group.

The significance of selected prognostic factors in pediatric tympanoplasty

OBJECTIVES

The aim of this study was to determine the importance of selected prognostic factors on outcomes of tympanoplasty in children.

MATERIALS AND METHODS

241 children classified into three age groups (3-7, 8-12 and 13-18), had undergone tympanoplasty between 2001 and 2007 and were subsequently observed for at least 2 years. Prognostic factors were assessed with regard to their impact on the functional and anatomical outcome of the tympanoplasty defined, respectively, as postoperative air-bone gap and state of the middle ear.

RESULTS

In 85% of children, a tympanic membrane reconstruction was performed. An unchanged TM was achieved in 85% of the patients in early results and in 76% in later results. Air-bone gap closure was observed in 66% of cases. The earlier preventive retraction pocket tympanoplasty was performed, the better anatomical results were obtained-ranging from 91% in the 3-7 age group versus 75-70% in 8-12 and 13-18 age groups. The results of total or subtotal perforation reconstructions were worse than for small perforation with closure rates of 76.5% vs 94.5%, respectively.

CONCLUSION

Age is not a factor determining the success rate in pediatric tympanoplasty. A better surgical outcome can be achieved in children with a dry ear, and better middle ear condition, because of previously performed surgeries. Preventive tympanoplasty is also advantageous. The hearing results in type 2 and 3 tympanoplasty are similar, but type 1 tympanoplasty has superior efficacy to the former two types.

Results of pediatric endoscopic and endoscopically assisted tympanoplasty

Objectives

To evaluate the success of pediatric endoscopic and endoscopically assisted transcanal cartilage inlay tympanoplasty.

Methods

Retrospective review of single surgeon experience.

Results

During a 3 year period, 30 children underwent 31 endoscopic or endoscopically assisted transcanal tympanoplasties by the senior surgeon using tragal cartilage/perichondrial inlay grafts. There were 22 boys and 8 girls, ranging in age from 3.5 to 17 years (median 6 years). All tragal cartilage grafts (31/31; 100%) survived. Twenty-seven surgeries (27/31; 82%) resulted in an intact drum (17/31; 55%) or a microperforation (10/31; 32%). In four cases (4/31; 13%) significant perforations formed in previously unaffected portions of the drum.

Conclusion

Transcanal endoscopic cartilage inlay tympanoplasty offers a practical, minimally invasive approach to tympanoplasty for children of any age. It avoids postauricular or endaural incisions, tympanomeatal flap elevation, and canalplasty. Graft survival is uniform. Microperforation at the graft margins remained in 1/3 of children. Technical modifications may lead to higher rates of tympanic closure.