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Endoscopic revision tympanoplasties: our experience

Sun, Yu; Wang, Enhao; Yu, Jintao; Wang, Miao; Kong, Weijia; Xiao, Hongjun

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Journal of Bio-X Research: June 2020 - Volume 3 - Issue 2 - p 54-59
doi: 10.1097/JBR.0000000000000057
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Abstract

Introduction

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.[1] 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.[2] 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.[3] 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.[4] The available data indicate that the outcomes of endoscopic tympanoplasty are excellent and equivalent to those of microscopic tympanoplasty.[5–8] Özgür et al[5] reported 53 cases of cartilage repair by endoscopic tympanoplasty with a success rate of 94.3%. Chai et al[6] 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.[6] Yang et al[7] reported complete healing of the tympanic membranes of 40 patients (95.2%) after otoscopic tympanoplasty. Kuo et al[8] 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).

Table 1
Table 1:
Graft uptake rate of the 4 studies cited in this paper

Discussion

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.[9] Different revision tympanoplasties strategies are required for different postoperative complications (Table 2). The same three factors require attention to improve the outcomes of tympanoplasty.

Table 2
Table 2:
Procedures for endoscopic revision surgeries

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.[9] 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.[10]

Figure 1
Figure 1:
Endoscopic photographs of representative patients showing use of an autologous fat graft and small cartilage strip to repair a residual perforation on the margin of the tympanic membrane. (A) The white arrow indicates the residual perforation on the margin of the tympanic membrane. (B) Use of instruments to trim the perforation and reduce tension around it. (C) The green arrow indicates autologous fat particles. (D) Fat particles are used to fill and seal the perforation of the tympanic membrane and thus repair it. (E) The big yellow box contains a residual perforation on the margin of the tympanic membrane. (F) Use of instruments to trim the perforation and reduce tension around it. (G) The small black box contains a small cartilage strip. (H) The small cartilage strip is used to embed the perforated part to achieve the purpose of repair. dr=tympanic membrane, eac=external auditory canal.

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.[11] 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.[3]

Figure 2
Figure 2:
Endoscopic photographs of representative patients showing repair of graft collapse using tragus perichondrium. (A) The black square areas contain areas of tympanic membrane collapse, which are treated as large perforations. (B) As the endoscope gets closer, we gain a clearer view of the perforation. (C) The square area is the transplant area into which the repair material is placed. (D) After placing the tragus perichondrium, the area of eardrum collapse can be repaired. (E) A large perforation caused by graft displacement is within the square area. (F) Use of an instrument to remove the ineffective tympanic membrane; the white arrow indicates the direction of removal. (G) Creating a graft area for placing new grafts; the white arrow indicates the direction of removal. (H) The cartilage–perichondrium complex is placed in the transplant area to cover the missing part of the tympanic membrane and achieve repair. eac=external auditory canal.

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.

Figure 3
Figure 3:
Endoscopic photographs of representative patient showing implantation of artificial ossicles to repair a broken ossicular chain. (A) White arrows and black curved lines indicate that the tympanic membrane is expanding outward. (B) Removed the fractured partial ossicular replacement prosthesis (PORP). (C) The tympanic flap has been opened, the broken ossicular chain removed, and the old PORP removed after exposure of the tympanic cavity. (D) Implanting a new PORP to reconstruct the ossicular chain. Correctly placed PORP. dr=tympanic membrane, eac=external auditory canal, fn=facial nerve, pr=promontory, s=stapes, ttc=tensor tympani half tube.

Prosthesis extrusion

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).

Figure 4
Figure 4:
Endoscopic photographs of representative patient showing resetting of a partial ossicular replacement prosthesis (PORP) that has been extruded. (A) The PORP is emerging through the perforation. (B) Removing the PORP. (C) The tympanic cavity is opened and part of the shield plate bone ground away to fully expose the space of the middle ear tympanum. (D) The shield plate is filled with cartilage and the newly implanted PORP fixed in place. eac=external auditory canal, scu=scutum.

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.

Figure 5
Figure 5:
Endoscopic photographs of representative patient showing repair of a tympanic membrane perforation caused by tympanic membrane adhesion. (A) The adhered tympanic membrane is shown in the black square. (B) The abnormal healing of the adhered tympanic membrane has resulted in perforation of the tympanic membrane. (C) The tympanic cavity has been opened and the ossicles that have adhered to the tympanic membrane separated from it. (D) Resetting the tympanic membrane and repairing the perforation in it with cartilage membrane. dr=tympanic membrane, ma=malleus.

Conclusions

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.

Acknowledgments

None.

Author contributions

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.

Financial support

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.

References

[1]. Choi N, Noh Y, Park W, et al. Comparison of endoscopic tympanoplasty to microscopic tympanoplasty. Clin Exp Otorhinolaryngol 2017;10:44–49.
[2]. Fan YP, Xia WT, Hong HY, et al. Subjective gustatory outcome in tympanoplasty and the strategy to protect Chorda tympani nerve. Zhonghua Linchuang Yishi Zazhi: Dianzi Ban 2010;4:1612–1616.
[3]. Tseng CC, Lai MT, Wu CC, et al. Learning curve for endoscopic tympanoplasty: Initial experience of 221 procedures. J Chin Med Assoc 2017;80:508–514.
[4]. Tseng CC, Lai MT, Wu CC, et al. Comparison of the efficacy of endoscopic tympanoplasty and microscopic tympanoplasty: a systematic review and meta-analysis. Laryngoscope 2017;127:1890–1896.
[5]. Özgür A, Dursun E, Erdivanli ÖÇ, et al. Endoscopic cartilage tympanoplasty in chronic otitis media. J Laryngol Otol 2015;129:1073–1077.
[6]. Chai YC, Yang J, Zhu WD, et al. Endoscopic type 1 tympanoplasty in dry and wet ears: a perspective cohort study. Zhongguo Er Bi Yanhou Ludi Waike Zazhi 2018;24:24–28.
[7]. Yang HD, Gao MQ, Xiong H, et al. Feasibility and efficacy of endoscopic middle ear surgery and tympanoplasty. Zhonghua Erke Xue Zazhi 2017;15:403–407.
[8]. Kuo CH, Wu HM. Comparison of endoscopic and microscopic tympanoplasty. Eur Arch Otorhinolaryngol 2017;274:2727–2732.
[9]. Anzola JF, Nogueira JF. Endoscopic techniques in tympanoplasty. Otolaryngol Clin North Am 2016;49:1253–1264.
[10]. Suzuki H, Koizumi H, Kitamura T, et al. Revision myringoplasty using thin-sliced cartilage for postoperative reperforation in patients with chronic otitis media. J UOEH 2016;38:237–242.
[11]. Lyons SA, Su T, Vissers LET, et al. Fascia compared to one-piece composite cartilage-perichondrium grafting for tympanoplasty. Laryngoscope 2016;126:1662–1670.
[12]. Mohanty S, Manimaran V, Umamaheswaran P, et al. Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations - A prospective study in a tertiary care hospital. Auris Nasus Larynx 2018;45:936–942.
[13]. de Freitas MR, de Oliveira TC. The role of different types of grafts in tympanoplasty. Braz J Otorhinolaryngol 2014;80:275–276.
Keywords:

endoscopy; middle ear; otologic surgical procedures; revision; tympanoplasty

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