An Approach to Successful Tympanoplasty (eBook)
224 Seiten
Thieme Medical Publishers (Verlag)
978-81-966914-6-2 (ISBN)
An Approach to Successful Tympanoplasty is a comprehensive book covering most of the real-world topics related to this field. Major part of this book covers practical aspects of tympanoplasty, which are extremely useful for junior consultants as well as for postgraduate students.Most of the middle ear surgeries such as tympanoplasty and ossiculoplasty are quite demanding and require a very systematic approach. Proper selection of cases, counseling of the patients, preparation, surgical technique, and postoperative care are critical to make the surgery successful.Key Features:Various techniques of tympanoplasty, especially 360-degree full-cuff underlay technique, importance of canalplasty and mastoidectomy, tympanoplasty in wet ear, difficult situations in tympanoplasty, causes of failure of tympanoplasty, and revision tympanoplasty.Different techniques of ossiculoplasty, such as autograft ossiculoplasty, cartilage ossiculoplasty, ossiculoplasty in canal wall down surgery in cholesteatoma cases, ossiculoplasty along with canal wall reconstruction in cholesteatoma cases, ossiculoplasty failure, and revision ossioculoplasty.A series of clear and self-explanatory surgical photographs and high-quality videos to help the readers understand the surgical technique.
| 10 | Technique of Tympanoplasty |
Surgery is done either by an onlay technique or by an underlay technique.
In the earlier days, the onlay technique was more popular, but later the underlay technique became more popular as various advantages of the technique over the onlay technique were realized.
Onlay Technique
In this technique, the graft is placed lateral to the tympanic membrane remnants after removal of the epithelial layer and is placed medial or lateral to the handle of the malleus.
Underlay Technique
In this technique, the graft is placed medial to the tympanic membrane remnants with the annulus and medial to the handle of malleus. The success rate will be high with this technique with a 360-degree elevation of tympanomeatal. Here, the graft is supported by the bony meatal wall, which results in a high success rate.
Interlay Technique
In the interlay technique, the epithelial layer is separated from the endothelial layer. This separation is possible anteriorly and inferiorly and not possible posteriorly. Hence, the graft is placed interlay anteriorly and underlay posteriorly.
The full cuff (360-degree) interlay technique was developed by Dr. A.B.R. Desai with a high success rate, and there are many followers to his full cuff interlay technique.
The onlay technique for repairing tympanic membrane perforation has been replaced by the underlay technique because of various problems with the onlay techniques, which are the following:
•Lateralization of the graft: Here the graft falls away from the handle of the malleus, away from the tympanic membrane remnants.
•Blunting of the anterior sulcus: Here the anterior sulcus becomes thick and blunt due to formation of granulations with healing with fibrosis, as the anterior sulcus in not skin lined (Fig. 10.1).
•Epithelial pearl: The squamous epithelium remaining deep to the fascia leads to the formation of the epithelial pearl.
Fig. 10.1 Blunting of the annulus.
The underlay technique gives highly successful results:
•There are no chances of medialization of the graft, as the graft is well supported by the bony meatal wall on all the sides.
•There are no chances of blunting of the anterior sulcus, as the anterior sulcus is skin lined.
•There is no chance of lateralization of the graft, as the graft is medial to the handle of the malleus.
•There is no chance of epithelial pearl formation.
•While placing the underlay graft, the middle ear is entered by elevating the tympanomeatal flap. Once the middle ear is entered and the eustachian tube is visualized, its patency can be checked.
During healing, the endothelium from the edges of the perforation can grow over the graft.
Migration of this endothelium from the edges of the perforation over the fascia graft leads to granular myringitis, which can be prevented by destroying the endothelium, at the edges of the perforation by chemical cauterization.
For chemical cauterization, 50% trichloroacetic acid (TCA) or 30% silver nitrate should be used.
Cauterization also freshens the edges of the perforation; hence, there is no need to remove the margins of perforation.
Surgical Technique
Case 1: Type 1 Tympanoplasty
Surgery is done either under local or general anesthesia (Figs. 10.2–10.36). Either postaural or endaural incision is made. Whatever anesthesia or incision is selected, the basic technique remains the same. The ultimate aim is to achieve successful hearing results.
Fig. 10.2 Large central perforation. Tympanoplasty is done via an endaural incision. Bulging anterior bony canal wall hiding the anterior margin of perforation.
Fig. 10.3 A 360-degree circumferential meatal wall skin incision is made.
Fig. 10.4 A 360-degree circumferential meatal wall skin incision is completed.
Fig. 10.5 Circumferential tympanomeatal flap is elevated.
Fig. 10.6 Elevation of the anterior and inferior meatal wall skin is made by a circular knife.
Fig. 10.7 Elevation of the anterior and inferior meatal wall skin is continued up to the annulus.
Fig. 10.8 Elevation of the anterior and inferior meatal wall skin is done up to the annulus. Bulging anterior and inferior bony meatal wall is hiding the annulus.
Fig. 10.9 Superior meatal wall skin is elevated up to the neck of the malleus.
Fig. 10.10 Bulging superior and anterior bony meatal wall is reduced by canalplasty. Tympanomeatal flap is protected by a thick sheet of silastic.
Fig. 10.11 Bulging bony anterior meatal wall is reduced by canalplasty to expose the annulus.
Fig. 10.12 Bulging anterior bony meatal wall is further reduced by canalplasty to expose the annulus.
Fig. 10.13 Diamond burr is used to reduce the medial part of the canal wall to prevent injury to tympanomeatal flap.
Fig. 10.14 The annulus is exposed after canalplasty.
Fig. 10.15 The anterior annulus is elevated from the tympanic sulcus.
Fig. 10.16 Annulus elevation from the tympanic sulcus is continued up to the neck of the malleus.
Fig. 10.17 Anterior part of the tympanic membrane, which was not seen earlier, is now completely exposed after canalplasty.
Fig. 10.18 Posterior tympanomeatal flap is elevated up to the annulus.
Fig. 10.19 The posterior annulus is exposed completely.
Fig. 10.20 Tympanic cavity is entered after elevating the tympanic annulus from the sulcus.
Fig. 10.21 The middle ear is entered, and the malleus handle and the incus are exposed.
Fig. 10.22 Mobility of the stapes is confirmed.
Fig. 10.23 Margins of the perforation is freshened by chemical cauterization by using 50% trichloroacetic acid (TCA).
Fig. 10.24 An underlay graft (fascia) is placed.
Fig. 10.25 An underlay graft is placed medial to the handle of the malleus.
Fig. 10.26 Anterior tympanomeatal flap is lifted to pull the graft anteriorly lying medial to the handle of malleus, to rest it on the anterior and superior bony meatal wall to prevent medialization of the graft.
Fig. 10.27 The graft is pulled anteriorly under the anterior tympanomeatal flap lying medial to the handle of the malleus, to rest it on the anterior and superior bony meatal wall to prevent medialization of the graft.
Fig. 10.28 The graft is pulled adequately anteriorly under anterior the tympanomeatal flap lying medial to the handle of the malleus, to rest it on the anterior and superior bony meatal wall to prevent medialization of the graft.
Fig. 10.29 After placing the graft on the meatal wall circumferentially, the annulus is reposited back into its original position, that is, into the tympanic sulcus area.
Fig. 10.30 Graft is resting on the bony meatal wall circumferentially and attempt is made to reposit the annulus into its original position.
Fig. 10.31 Tympanomeatal flap is reposited back into its original position so that anteroinferior tympanomeatal angle is maintained and it is skin lined; hence, there is no chance of blunting of the anterior sulcus.
Fig. 10.32 Finally perforation is closed by an underlay graft, which is well supported by the bony meatal wall on all the sides.
Fig. 10.33 Posterior tympanomeatal flap is elevated to reconfirm the placement of the graft on the posterior and inferior meatal wall.
Fig. 10.34 Anterior tympanomeatal flap is elevated to confirm the placement of the graft on the anterior bony meatal wall.
Fig. 10.35 The graft is covered by pieces of meatal skin for fast epithelialization.
Fig. 10.36 Gelfoam is placed in the external auditory canal and the incision is closed.
Case 2: Tympanoplasty in a Case with Intact but Eroded Lenticular Process of the Incus
Continuity of the ossicular chain is maintained. The eroded lenticular process is covered by Y-shaped cartilage to prevent further pressure erosion of the lenticular process of the incus by retracted tympanic membrane (long-term ossicular continuity is maintained; Figs. 10.37–10.51).
Fig. 10.37 The middle ear is entered after elevating the tympanomeatal flap.
Fig. 10.38 The lateral surface of the incus lenticular process...
| Erscheint lt. Verlag | 7.8.2024 |
|---|---|
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Medizinische Fachgebiete ► HNO-Heilkunde |
| Medizinische Fachgebiete ► Innere Medizin ► Pneumologie | |
| Schlagworte | middle ear surgery • Ossiculoplasty Strategies • Revision Tympanoplasty • Tympanoplasty Techniques |
| ISBN-10 | 81-966914-6-7 / 8196691467 |
| ISBN-13 | 978-81-966914-6-2 / 9788196691462 |
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