Middle ear tympanoplasty was first performed under microscopic vision several decades ago. The technique of microscopic tympanoplasty has since matured; however, preservation of the functional structures of the middle ear has not yet been perfected. In addition, most microscopic tympanoplasties require posterior or intra-ear incisions, thus causing relatively major trauma and requiring a long postoperative recovery time. There are some reports of problems such as ear numbness, loss of taste, and prolonged postoperative ear drying time. It is difficult to ensure that the ventilation and drainage system of the middle ear is in good condition for microscopic surgery. However, middle ear surgery has been performed endoscopically since the 1970s. It provides a clear visual field, easy identification of tympanic structures, and the ability to preserve the functional structures of the patient's middle ear and maintain normal ventilation and drainage during surgery. Endoscopic surgery is minimally invasive, requiring only a small and hidden incision or even no skin incision, thus meeting the patient's aesthetic requirements and having a short recovery time. Therefore, endoscopic tympanoplasty has received increasing attention in recent years. In addition, it has been shown by studying learning curves for endoscopic tympanoplasty that achievement of expertise requires performing 150 surgeries. In this article, we analyze the outcomes and complications of endoscopic tympanoplasties and discuss the strategies for endoscopic revision surgeries.
Database search strategy
We conducted searches of various databases, including PubMed and Web of Science, using the key terms “endoscopy”, “tympanoplasty”, “surgical procedures”, and “middle ear” from April 2010 to October 2018, and excluded articles that did include the search terms in the combinations specified below. There were no restrictions on language or publication status. The search was conducted as follows: for inclusion of the article, one of the two equivalent terms (1) endoscopy or (2) tympanoplasty had to be combined with one of the other two search terms; that is (a) surgical procedures and (b) middle ear. For example, “middle ear tympanoplasty”, that is, (2) + (a); “tympanoplasty surgical procedures”, that is, (2) + (b), and so on.
Review of published reports
The duration of endoscopic tympanoplasty is significantly shorter than that of microscopic tympanoplasty. The available data indicate that the outcomes of endoscopic tympanoplasty are excellent and equivalent to those of microscopic tympanoplasty.[5–8] Özgür et al reported 53 cases of cartilage repair by endoscopic tympanoplasty with a success rate of 94.3%. Chai et al reported performing otoscopic tympanoplasty on patients with dry and wet ear. Three months after surgery, the tympanic membranes of 26 (89.6%) of the patients with dry ears had fully healed, as had those of 14 (87.5%) of the patients with wet ears. Thus, preoperative wet ear status was not a contraindication for surgery. The rates of healing of tympanic membranes and hearing improvement after surgery were comparable to those achieved by dry ear surgery; additionally, the preoperative waiting time, antibiotic dosage, and rate of complications were reduced. Yang et al reported complete healing of the tympanic membranes of 40 patients (95.2%) after otoscopic tympanoplasty. Kuo et al retrospectively compared the success rates of tympanoplasty on 126 patients (131 ears), 74 and 57 of which underwent endoscopic and microscopic tympanoplasty, respectively. The rate of graft uptake tympanoplasty was 97.3% in the endoscopy group and 98.2% in the microscope group. There was no statistically significant difference in hearing improvement between the two groups (Table 1).
Otoscopic tympanoplasty is sometimes unsuccessful and postoperative complications do occur. Our review of published reports revealed that approximately 5% to 11% of patients require reversion tympanoplasty for complications caused by the initial operation. What complications can we be faced with when we perform otoscopic tympanoplasty in clinic? Based on our data from published reports and our own clinical practice, we here summarize the complications of otoscopic tympanoplasty: (i) residual perforation on the margin of the tympanic membrane; (ii) displacement and collapse of cartilage graft; (iii) lateral healing of the tympanic membrane leads to fracture of artificial ossicles; (iv) extrusion of the ossicular prosthesis; and (v) tympanic adhesion leading to repeated perforation. The following three main factors contribute to the prognosis of otoscopic tympanoplasty: (i) transplant materials; (ii) the position of the graft relative to the annulus fibrosus and tympanic membrane residue; and (iii) treatment of the middle ear plica and ventilation pathway. Different revision tympanoplasties strategies are required for different postoperative complications (Table 2). The same three factors require attention to improve the outcomes of tympanoplasty.
Residual or recurrent tympanic membrane marginal perforation
A residual perforation on the margin of the tympanic membrane is the most common cause of dissatisfaction after otoscopic tympanoplasty. We repair residual or recurrent tympanic membrane marginal perforations by performing autologous fat and cartilage transplantation (Fig. 1; the study was approved by the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China (approval No. 2020-0045-1)). Transplantation of autologous fat particles is effective in filling some small residual perforations. According to published reports, autologous fat is a safe and effective material for embedded transplantation in small tympanic membrane marginal perforation. The success rate is 76% to 92%, the fat particles filling the perforation like a sticker. In addition, fat grafts secrete angiogenic growth factors that promote neovascularization and tissue repair, thus increasing the blood supply to the tympanic membrane around the perforation. In cases in which autologous fat transplantation is ineffective, it is usual to use small cartilage strips for impaction filling. Compared with other graft materials, cartilage strips provide a more powerful stent function. A small 0.3 mm thick cartilage strip, one side of which is covered with a membrane, is obtained from the tragus for this purpose. The cartilage strip is trimmed to ensure that it is the same size as the site of the tympanic membrane perforation. The cartilage strip is adhered to the perforation site and fixed with fibrin glue. Thus embedding a small cartilage strip is the most effective means of treating a perforation on the margin of the tympanic membrane.
Graft collapse and displacement
Graft collapse is another common postoperative complication of tympanoplasty. Graft collapse is usually caused by pressure imbalance between the two sides of the tympanic membrane as a result of eustachian tube dysfunction, in the presence of which the pressure of the atmosphere via the external auditory canal can collapse the tympanic membrane over time. In addition, rhinitis, pharyngitis, or the common cold can cause eustachian tube disorders and create pressure imbalance between the 2 sides of the tympanic membrane. The area of tympanic membrane collapse can be treated as a large perforation; a new cartilage–perichondrium complex from the other side is the most effective material for repairing tympanic membrane collapse (Fig. 2A–D). According to published reports, cartilage–perichondrium complex is a better graft repair material than temporal muscle fascia, a 500 μm thick cartilage sheet being considered the most appropriate in that such a sheet has sufficient tension resistance and good sound transmission characteristics.[12,13] Moreover, the middle ear has good tolerance for cartilage, on which can induce very little tissue inflammation and resist infection during the recovery process. Cartilage can survive even after delayed epithelialization due to its nutritional characteristics and the effect of diffused nutrients. Therefore, cartilage is the transplantation material of choice when a high risk of eustachian tube dysfunction is predicted preoperatively; the advantages of cartilage also expand its application in tympanoplasty repair.
Graft displacement is another postoperative complication of tympanoplasty. If a graft collapses and progressively deforms, atrophy of that graft increasingly deforms the tympanic membrane, leading to displacement of the graft and a large perforation in the tympanic membrane. When this occurs, we still implement the treatment measures for graft collapse, using a new cartilage-perichondrium complex from the other side to replace the displaced graft (Fig. 2E–H).
Lateral healing of the tympanic membrane and prosthesis fracture
Rupture of artificial ossicles caused by lateral healing of the tympanic membrane is another postoperative complication of tympanoplasty. The pressure in the middle ear is imbalanced postoperatively. During the healing process, the tympanic membrane is pushed outward by the pressure to expand, putting tension on the ossicular chain, causing it and the artificial ossicles to fracture. In such cases, an external auditory canal tympanic membrane flap is created and the tympanic membrane is lifted. If the malleus–incus and incus–stapes joints and artificial ossicles have broken, the malleus, incus, and artificial ossicles should be removed and the activity of the stapes floor assessed. If the stapes moves well and the oval and round windows are functioning normally, a new partial ossicular replacement prosthesis is placed between the tympanic membrane flap and stapes neck (Fig. 3). The imbalance in middle ear pressure must also be addressed: it is necessary to restore the middle ear pressure to normal and prevent the tympanic membrane from expanding outward again during the healing process.
Some patients will develop tympanic membrane perforation after tympanoplasty and, even more seriously, artificial ossicles may fall out through the perforation. This situation also requires re-implementation of reversion tympanoplasty and repair of the perforation with cartilage–perichondrium complex. If the auditory ossicle protrudes from the external auditory canal, the artificial auditory ossicles need to be re-implanted. Additionally, auricular cartilage is placed between the transplanted cartilage membrane and the artificial auditory ossicle to prevent the partial ossicular replacement prosthesis from adhering to the transplanted cartilage membrane again (Fig. 4).
Middle ear adhesion leads to residual perforation
Some patients develop tympanic adhesion after surgery because of postoperative middle ear infection, suppurative otitis media, or secretory otitis media. When the otitis media is severe enough to damage the middle ear mucosa, it can cause fibroblasts in granulation tissue to produce new fibrous tissue, or the effusion can become organized. This process can lead to adhesion between the inner wall mucosa of the tympanic cavity and tympanic membrane and even to adhesion and fixation of the ossicular chain. Adhesions are mostly located at the rear of the middle tympanum, resulting in thickening of the tympanic membrane and its adherence to the promontory. One or all of the auditory ossicles can adhere around the oval window. Fibrous tissue can embed both the stapes and long legs of the incus together in the oval window. The oval window may be partially or completely closed. Tympanic membrane invagination may then adhere to the ossicular chain, resulting in residual perforation postoperatively and seriously affecting hearing. Otoscopic tympanoplasty can be performed again to peel off the adhered tympanic membrane and ossicular chain. If it can be completely peeled off, the perforation is repaired with cartilage–perichondrium complex, and absorbable gelatin sponge is placed between the ossicular chain and graft to prevent recurrence of postoperative adhesion (Fig. 5). If the adhesion is extensive and cannot be completely peeled off, the ossicular chain should be removed, the perforation repaired with cartilage–perichondrium complex, and the ossicular chain reconstructed by subsequent selective secondary surgery.
Endoscopic tympanoplasty is becoming increasingly popular in clinical practice; however, otolaryngologists need to pay attention to the following possible complications. Residual or recurrent tympanic membrane marginal perforation is the most common cause of unsatisfactory outcomes after endoscopic tympanoplasty. Fat grafting is effective only for small perforations, whereas small cartilage grafts are an effective means of dealing with residual marginal perforations. Cartilage–perichondrium complex should be fixed securely. Regular examination is necessary after prosthesis implantation. We propose that improving outcomes of endoscopic tympanoplasty requires ongoing attention to preoperative and postoperative diagnosis and treatment. Revision tympanoplasty has the potential to improve the overall outcomes of tympanoplasty and to contribute to patients’ wellbeing.
YS, EW, JY and MW wrote the manuscript. YS, WK and HX designed, supervised the research and wrote the manuscript. All authors edited the manuscript and approved the final version of the paper.
This work was supported by the Fundamental Research Funds for the Central Universities, China (No. 2019kfyXKJC039; to YS).
Institutional review board statement
This study was approved by the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China (approval No. 2020-0045-1).
Declaration of patient consent
The need for written informed consent was waived owing to the retrospective nature of the study.
Conflicts of interest
The authors declare that they have no conflicts of interest.
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