Total Endoscopic Transcanal Cartilage Myringoplasty: A Prospective Study

Introduction: Middle ear surgeries, including myringoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Objectives: The objective of the present study was to evaluate the graft uptake rate and to evaluate the hearing results. Methods: This is a prospective study. We have analyzed 139 patients who underwent surgery for chronic otitis media (COM) of the mucosal type. All of the surgeries were performed exclusively under total endoscopic transcanal approach using tragal cartilage as graft, underlay technique. We have evaluated the postoperative graft uptake and performed a hearing evaluation at 6 weeks, at 12 weeks, and at 6 months. Results: During the study period, 139 patients were included, out of which 13 were lost to follow-up; therefore, only 126 patients were assessed. All of the cases were performed under total endoscopic approach. As for the surgical outcome at the postoperative otoscopy, 3 cases had initial uptake at 3 months and failed later; therefore, complete closure of the perforation was observed in 97.6% ( n = 123) of the patients 6 months after the intervention. Four patients presented with preoperative anacusis; therefore, only 122 patients were included for hearing evaluation. The preoperative air conduction threshold (ACT) and airbone gap (ABG) were 43.34 ± 11.53 and 24.73 ± 7.89, respectively. Postoperatively, the ACT and ABG closure were 28.73 ± 15.75 and 11.91 ± 8.41, respectively. This difference was statistically significant ( p < 0.001). Conclusion: The endoscopic approach for myringoplasty offers excellent visualization; avoids postaural approach, enables a faster recovery, requires less hospital stay, with excellent graft closure rate and improved functional outcomes (AU)

Beneficios del abordaje endoscópico en miringoplastias / Endoscopic approach benefits in myringoplasties / Benefícios da abordagem endoscópica em miringoplastias

Introducción: la fisiopatología de las otitis medias crónicas simples está en estrecha relación con las rutas de ventilación del sistema tubo tímpano mastoideo, el cual tiene diversos estrechamientos o istmos que son suceptibles de presentar bloqueos de múltiples causas; por lo tanto es necesario que durante la resolución quirúrgica de esta patología se realice sistemáticamente la revisión de dichas rutas de ventilación. Objetivo: Demostrar los beneficios de la cirugía endoscópica de oído en la realización de miringoplastias. Material y métodos: Estudio descriptivo multicéntrico. Revisión de historias clínicas. Resultados: Se realizaron 54 miringoplastias mediante abordaje endoscópico transcanal con la correspondiente exploración de rutas de ventilación. Se evidenciaron 7,4% de casos con bloqueos en los diferentes diafragmas epitimpánicos. El porcentaje de reperforaciones fue del 9,25%. Conclusiones: Si bien la técnica de posicionamiento del injerto es similar a la utilizada tradicionalmente, en el presente estudio se evidenció un leve incremento del índice de reperforaciones a expensas del uso de pericondrio. El uso de técnica endoscópica en miringoplastia presenta una tasa de reperforación comparable a la de la biblografía actual, por lo tanto el principal beneficio sería la detección de bloqueos en las rutas de ventilación del oído medio.

Introduction: the pathophysiology of chronic otitis media simple is closely related with routes of ventilation of the tube tympanum mastoid system, which has several constrictions or istmus that are susceptible to have obstructions of multiple causes, therefore it is necessary that during the surgical resolution of this pathology the review of ventilation routes are systematically performed. Objective: To demonstrate the benefits of endoscopic ear surgery in the performance of myringoplasty. Material and methods: Multi-centre descriptive study, clinical histories review. Results: 54 cases of myringoplasty were performed using a transcanal endoscopic approach with ventilation routes exploration. 7,4% of cases presented blocks in the different epytimpanic diaphragms and the reperforation cases represented 9,25%. Conclusions: Although the technique of positioning the graft is the same as that traditionally used, in the present study there was a slight increase in the index of reperforation at the expense of perichondrium use. The use of endoscopic technique in myringoplasty has an index of reperforation comparable to the current bibliography. Therefore the main benefit would be the detection of blockages in the routes of ventilation in the middle ear.

Introdução: a fisiopatologia da otite média crônica simple esta estreitamente em relação com o sistema de ventilação mastóide tímpanico , que tem várias constrições ou istmos que são suscetíveis de apresentar fechaduras de múltiplas causas , portanto, é necessário que, durante a resolução cirúrgica desta patología a revisão das vias de ventilação seja realizada de forma sistemática. Objectivo: Demostrar os benefícios da cirurgia endoscópica na realização de miringoplastias. Material e métodos: Estudo descritivo multicenter, revisão de prontuários médicos. Resultados: 58 miringoplastias foram realizadas utilizando a abordagem endoscópica trasncanal com a correspondente exploração de rutas de ventilação. Em 7,4 % dos casos com bloqueios em os diferentes diafragmas epitimpánicos e o percentual de reperforaçoes foi de 9,25%. Conclusões: Enquanto a técnica de posicionamento de enxerto e semelhante aquela usada tradicionalmente, no presente estudo a um ligeiro aumento no índice de reperforaçoes a custa de usar pericondrio. A utilização da técnica endoscópica em miringoplastias tem una taxa de reperforação comparável com a bibliografia corrente, por conseguinte a principal vantagem seria a de detectar bloqueios nas rutas de ventilação do ouvido medio.

Transcanal endoscopic myringoplasty: a case series in a university center / Miringoplastia endoscópica transcanal: série de casos em um serviço universitário

ABSTRACT INTRODUCTION: Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach. In the last decade, the use of endoscopes in ear surgery has increased significantly. This technique may allow "around the corner" visualization of small recesses, through narrow spaces, without the aid of canalplasty in unfavorable ear canals. OBJECTIVE: To describe a case series of transcanal endoscopic myringoplasty performed in a university service. The characteristics, advantages, and disadvantages of this technique are also discussed. METHODS: A case series study, based on the chart review of patients submitted to transcanal endoscopic myringoplasty in the period from January of 2012 to October of 2014. RESULTS: Data from 22 patients were analyzed. Tympanic perforation closure three months after surgery was observed in 86.4% of all patients. There was statistically significant improvement in pure tone average thresholds after surgery (p < 0.001). CONCLUSION: Transcanal endoscopic myringoplasty is a feasible, safe, and effective procedure; it can be an alternative to microscopic surgery.

Resumo Introdução: A miringoplastia realizada por via transcanal possui como vantagens a maior rapidez do procedimento e menor incisão externa, podendo ser realizada com auxílio de microscópio ou endoscópio. Na última década tem sido observado um aumento do uso de endoscópios na cirurgia otológica. Essa técnica pode permitir melhor visibilização de espaços encobertos e estreitos, sem necessidade canaloplastia em meatos desfavoráveis. Objetivo: Descrever uma série de casos de miringoplastia endoscópica transcanal, em um serviço universitário, discutindo suas particularidades, vantagens e desvantagens. Método: Estudo de série de casos, baseado na revisão de prontuários dos pacientes submetidos a miringoplastia com uso exclusivo de endoscópio rígido, no período de Janeiro de 2012 a Outubro de 2014. Resultados: Foram analisados os dados de 22 pacientes. Na otoscopia pós-operatória, foi observado fechamento da perfuração timpânica em 86,4% dos pacientes, após 3 meses da intervenção. Para a amostra estudada, foi observada melhora funcional estatisticamente significante da média dos limiares tonais (PTA) após a cirurgia (p < 0,001). Conclusão: A miringoplastia endoscópica transcanal é um procedimento seguro, factível e efetivo, podendo ser realizado como alternativa à cirurgia microscópica.

Experiencia en miringoplastía transcanal con pericondrio tragai inlay / Experience in transcanal myringoplasty with inlay tragal perichondrium

Introducción: La timpanoplastía está orientada a la reconstrucción anatomofuncional del oído medio que realizada en la membrana timpánica se denomina miringoplastía. Objetivo: Evaluar los resultados anatomofuncionales de la miringoplastía transcanal con pericondrio tragal inlay en pacientes intervenidos en el Servicio de Otorrinolaringología del Hospital San Camilo entre 2004 y 2009. Material y método: Estudio retrospectivo descriptivo de fichas de 56 pacientes entre 7 y 77 años. Universo: 60 oídos, muestra: 48 oídos con edad promedio de 34 años. Se evaluaron resultados anatómicos según sexo, edad, ubicación, causa de perforación y mejoría funcional objetivada por audiometría. Resultados: La integridad anatómica posquirúrgica es de 81,3% sin diferencias según género. Según edad existe diferencia significativa de 93,3% para el tramo 7-19 años respecto del total. Las perforaciones centrales tuvieron un éxito de 100%. La causa más frecuente de perforación fue por otitis media crónica simple (75%) con una integridad posquirúrgica del 80,5%. El 97,6% logró mejorar o mantener el nivel de audición, estableciéndose diferencialmente mejoría funcional en 52,4%, y una mantención en 45,2%. Conclusión: Los mejores resultados para esta técnica se obtienen en menores de 20 años con perforaciones centrales, siendo una técnica ideal que conserva la estructura de la membrana timpánica para futuras intervenciones.

Introduction: Tympanoplasty is orientated to the anatomofunctional reconstruction of the middle ear, which is named myringoplasty, when performed in the tympanic membrane. Aim: To evaluate the anatomofunctional results of transcanal myringoplasty with inlay tragal perichondrium in patients controlled in the Otorhinolaryngology Unit of San Camilo Hospital, between 2004 and 2009. Material and method: Retrospective descriptive study on files of 56 patients between 7 and 77 years of age. Universe: 60 ears, sample: 48 ears with average age 34 years. Anatomical results were evaluated according to sex, age, location, cause of perforation and functional improvement measured by audiometry. Results: The overall anatomical postsurgical integrity is 81,3 % without differences between sexes. According to age there is a significant difference for the section between 7-19 years of age respect of the total (93,3 %). Central perforations had a 100% success rate. The most frequent reason of perforation was simple chronic otitis media (75%) with a postsurgical integrity of 80,5 %. 97,6 % managed to improve or maintain hearing level, (52,4 % gained functional improvement, and 45,2 % maintained hearing level). Conclusion: Using this technique, best results are obtained in patients younger than 20 years of age, with central perforations. It is an ideal method that preserves the structure of the tympanic membrane for future interventions.

Endoscope-assisted inlay butterfly cartilage myringoplasty

Myringoplasty is one of the most common forms of surgery in otology. It yields very satisfying results for both to the patient and the surgeon. Popular myringoplasty techniques include either an underlay or an onlay approach using tissues such as temporalis fascia or perichondrium as grafts. In 1998, Eavey described an inlay tympanoplasty technique in children using a cartilage graft which resembled butterfly wings. This technique was effective for closure of tympanic membrane perforations, while being more rapid for the surgeon and more comfortable for the patient. The aim of this study was to evaluate the results of using middle ear endoscopy for doing inlay butterfly cartilage myringoplasty. Between December 2008 and December 2010, Twenty one consecutive patients between age group of 16-50 years with persistent tympanic membrane perforation were included in this study. All patients underwent Endoscope-assisted Inlay Butterfly Cartilage [Eavey Technique] myringoplasty [EAIBCM]. The overall success rate of the graft uptake and improvement in conductive deafness as air-bone gap closure was achieved in above 80 percent of cases. tympanoscopy, with its visualisation of hidden corners, justifies Butterfly inlay myringoplasty via a tympanic membrane perforation. Furthermore, the cost of the endoscope is much less than the operating microscope and the endoscope is portable tool thus it is more cost-effective, especially in developing countries. Combining butterfly inlay tympanoplasty technique with the middle ear endoscopy as a tool carries definitive advantages of less operative time, day care surgery, minimal scarring and hence can be accepted as a routine procedure in day-to-day practice.

Reconstruction of subtotal and total tympanic membrane perforations using cartilage palisade technique

The purpose of this study was to evaluate the use of palisade cartilage technique for reconstruction of subtotal and total tympanic membrane [TM] perforations compared with temporalis fascia [TF] graft. Prospective study consists of ninety five patients suffering from chronic inactive suppurative otitis media with subtotal and total TM perforations. The patients underwent full history taking, clinical examination and audiological evaluation. The patients were classified into two groups: group A [75 patients] in whom cartilage palisade technique was used and group B [20 patients] in whom TF graft was used. Closure of TM perforation was achieved in 71 patients [94.6%] of group A and in 7 patients [35%] in group B. As regards hearing results, there was highly significant postoperative improvement in pure tone averages as well as air-bone gap averages in both groups. In group A, the air-bone gap was closed to less than 10 dB in 26.6% and from 10-25 dB in 56% and to more than 25dB in 17.4%. While in group B, the air-bone gap was closed to less than 10 dB in 25% and from 10 - 25 dB in 65% and to more than 25dB in 10%. In this study, the average pre and postoperative air-bone gap were 26.1 dB and 13 dB respectively for cartilage group and 25.3 dB and 13.1 dB for fascia group. This study revealed that, the palisade technique is an effective, straight foreword technique with high success rate and good hearing results without postoperative complications

Timpanoplastías en mayores de 50 años / Tympanoplasties in patients over 50 years old

Aunque la edad del paciente juega un rol como factor pronóstico en el éxito de las timpanoplastías, existe escasa bibliografía con estudios específicos en adultos mayores. En este trabajo se evaluaron los resultados anatómicos y funcionales de 118 timpanoplastías efectuadas en pacientes mayores de 50 años, entre los años 1990 y 2000. La edad promedio del grupo fue de 56,7 años con un claro predominio femenino. Se dividió la muestra en 2 grupos, uno entre 50 y 59 años de edad y el otro entre 60 y 73 años. El éxito anatómico global fue de 79,7 por ciento y hubo mejoría auditiva en el 36,7 por ciento de los casos con seguimiento audiológico completo. En el grupo entre 50 y 59 años hubo prendimiento en el 84,1 por ciento y en el grupo entre 60 y 73 años fue exitoso en el 66,7 por ciento, siendo esta diferencia estadísticamente significativa (p =0,04). Los resultados auditivos, en cambio, no mostraron diferencias estadísticamente significativas, si bien el grupo más joven tuvo mejores resultados. Se concluye que en pacientes mayores de 60 años aún es recomendable realizar una timpanoplastía. El éxito en ellos, si bien discretamente menor, es aceptable.

Miringoplastia com cartilagem inlay: primeiros resultados brasileiros / Inlay Cartilage Tympanoplasty: First Brazilian Results

A técnica de miringoplastia pode ser realizada com a colocação do enxerto de fáscia temporal ou pericôndrio sobre ou abaixo do anel timpânico. Em 1998, Roland Eavey descreveu em crianças técnica de enxerto cartilaginoso em forma de borboleta, colocado através da membrana do tímpano, sem necessidade de criação de retalho timpano-meatal. Vantagens potenciais incluem maior facilidade técnica, menor tempo cirúrgico, menores cuidados pós-operatórios e maior estabilidade do enxerto. Objetiva-se descrever nossos resultados com a utilização da técnica de Eavey, introduzindo pequenas modificações. Material e método: Foram realizadas sete miringoplastias em adultos para fechamento de perfurações menores do que 50% da membrana do tímpano, no período de março a julho de 1998. Foram realizadas algumas modificações da técnica descrita por Roland Eavey: 1.) - utilização em pacientes adultos; 2.) - uso de anestesia local e 3.) - não utilização de enxerto de pele sobre o enxerto cartilaginoso. Avaliaram-se a pega do enxerto e a diminuição da diferença entre os limiares aéreo e ósseo (GAP) pós-operatória. Resultados: O índice de pega do enxerto foi de 100%. O tempo médio de seguimento foi de 22,7 meses, variando de 19 meses a 24 meses. Todos os enxertos estavam intatos na última consulta de seguimento. Todos os pacientes apresentaram melhora auditiva, dois com fechamento completo do GAP e os restantes com fechamento de GAP superior a 50%. Conclusões: A técnica de Eavey é altamente eficaz também para adultos, com menor morbidade. A não utilização do enxerto de pele e a anestesia local diminuem ainda mais o tempo cirúrgico e não comprometem os resultados da técnica original.

Myringoplasty techniques include either an underlay or an onlay approaches using temporalis fascia or perichondrium as grafts. Roland Eavey in 1998 described a transcanal cartilage butterlly inlay tympanoplasty technique in children. This technique was found to be effective to close tympanic membrane perfurations, more comfortable and less morbid (no external canal incisions). The aim of this study was to describe our results with Eavey's technique, with little modifications. Material and method: Cartilage butterfly tympanoplasty was carried out in seven adult patients to close small to medium tympanic membrane perfurations from March to July, 1998. We introduced three modifications into Eavey's technique: 1. we used adult patients, 2. the surgeries were performed under local anesthesia and 3. we use no skin graft over the cartilage. We evaluated the take rate and postoperative hearing results. Results: All patients had postoperative hearing gain and the take rate was 100% at short-term follow-up period (medium 22.7 months). All cartilage grafts were intact and dry at the last follow-up visit. All patients showed improvement in their audiometric postoperative results. Two of them got closure of their air-bone gap and the rest of them diminished it to 50%. Conclusion This technique described by Eavey is effective to close tympanic membrane perfuration in adults. The modifications introduced (no use of skin graft and local anesthesia) reduced even more surgery time and did not alter postoperative results of the original technique.

Tympanoplasty: Factors influencing surgical outcome

We reviewed the records of 183 patients who had undergone myringoplasty during a six year period at the Asir Central Hospital [ACH]. This study was limited to cases of repair of uncomplicated perforation of tympanic membrane that did not require ossiculoplasty or mastoidectomy. One hundred and thirty-four [73.2%] were successful myringoplasty and 78 [75.7%] patients had their hearing improved postoperatively. Various factors liable to influence the success rate such as status of middle ear, size and site of perforations, surgical approach and presence of tympanosclerosis were analyzed. Only status of the middle ear and the presence of tympanosclerosis at the time of surgery were found to have a major effect on the final outcome of surgery

Overlay versus underlay technique myringoplasty: early and late audiological evaluation

72 patients with tubotympanic otitis media were evaluated pre and post-operatively [early and late]. Forty three patients underwent myringoplasty by underlay technique and 29 by overlay technique. The underlay technique gave better hearing results early and late post-operatively. The degree of high frequency hearing loss was greater with the overlay technique. Late hearing evaluation after tympanoplasties is a mandate to discover any degree of late sensorineural hearing loss. This information is important especially in planning for operating on the other ear