Predictability of tympanoplasty results. Preoperative eustachian tube function and size of mastoid air cell system

Effect of preoperative mastoid ventilation on tympanoplasty success

Purpose. This study was conducted with the aim of investigating the relationship between mastoid air cell volumes and graft success after tympanoplasty. Material and Methods. This study was performed retrospectively with patients undergoing type I tympanoplasty and antrostomy. A total of 57 patients (20–35.09% female and 37–64.91% male) with a mean age of 29.69 ± SD (range 12–56 years) were included in the study. The patients were invited for a control at the 1st, 3rd, and 12th months, and otoscopic examinations and audiometric tests were performed. The temporal bone computed tomography images were screened with the 4800 Dpi optic resolution scanner and transferred to the computer environment in JPG format in order to calculate the mastoid air cell volume, and the volumes were calculated using the Autocad 2007 program. Results. Although, the graft success was determined to be better in the well-ventilated group, no significant difference could be found between the groups in terms of graft success at the 1st, 3rd, and 12th months (P > 0.05). No statistically significant difference could be found between the three groups in terms of the preoperative and postoperative hearing gains (P > 0.05).

Tubomanometry. Values in ears with traumatic and chronic perforations

The tubal function of 68 patients with a unilateral traumatic perforation of the tympanic membrane and 116 ears of 94 patients with chronic otitis media were examined by equalization manometry. The values obtained in the traumatic group are regarded as being characteristic of normal tubal function: the patients were able to equalize +/- 30 hPa difference in pressure with between three and seven swallows. Only 25% of the ears with a dry central perforation and none with an infected central perforation were able to fulfil this requirement.

The predictive value of eustachian tube function (measured with sonotubometry) in the successful outcome of myringoplasty

Sonotubometry, as a technique for assessing Eustachian tube function, does not rely on an intact tympanic membrane. This device has been used to study 25 patients having myringoplasty who all had preoperative testing and post-operative testing at 4 months. The overall success rate for grafting was 76%. In those who had normal preoperative tubal function the success rate was 86%, as opposed to 67% in those whose preoperative tubal function was poor. This difference was not statistically significant. In all those patients where poor preoperative function ended with successful grafting, post-operative tubal function reverted to normal. Other factors also taken into account, such as the patient's age, size of the perforation and the operative difficulty, had no bearing on the outcome of surgery.

Tubal function and surgery in chronic otitis media. A study on the predictive value of testing tubal function, Valsalva's manoeuvre and volume of ear spaces

In 141 ears with central tympanic membrane (TM) perforation preoperative tubal studies as well as volume determination of the air-filled ear spaces was performed. Tubal patency was checked with Valsalva's manoeuvre and pressure equilibration function with Toynbee's test and aspiration-deflation tests respectively. At postoperative control 74.5% of the ears had intact movable TM (healed), 5.7% had intact but immovable or retracted TM and 19.8% had perforation (defect). There was no difference between the healed and defect ears regarding results in aspiration-deflation tests. A positive Valsalva's manoeuvre was significantly more frequent in the healed ears. Ears with a small air-filled volume and negative Valsalva's manoeuvre showed significantly lower healing rate than ears with positive Valsalva's manoeuvre and a large air-filled volume.

Role of the mastoid in tympanic membrane reconstruction

Otologists have long debated the importance of the mastoid in determining the success or failure of tympanic membrane reconstruction. The pneumatic spaces within the mastoid represent an "air reservoir" which can be drawn upon during periods of eustachian tube dysfunction and buffer the middle ear against the development of detrimental negative pressures. Mastoid inflammatory disease, if untreated, may result in recurrent suppuration and graft failure. Small mastoid volume, aside from its well known association with chronic infectious middle ear disease, has been shown to effect adversely graft survival following myringoplasty. In 48 patients undergoing myringoplasty with simple mastoidectomy, neither small mastoid size nor inflammatory mastoid disease significantly decreased the rate of graft healing. This suggests that simple mastoidectomy is an effective means of repneumatizing the mastoid and eradicating mastoid sources of infection. The successful surgical creation of a pneumatized mastoid cavity in communication with the middle ear was confirmed by postoperative computerized tomographic (CT) scans. In failed cases, CT scanning predictably identified residual mastoid disease. Simple mastoidectomy is considered to be a safe and useful adjunct to myringoplasty in selected cases of chronic otitis media with perforation.

Eustachian tube function and tympanoplasty

Despite the reduction in incidence of acute suppurative otitis media since the introduction of antibiotics, the incidence of chronic middle ear effusion and chronic otitis media have not experienced a similar reduction. Eustachian tube dysfunction is believed to be a principal etiological factor in these cases. The inflation-deflation technique to measure tubal function has shown promise in a number of laboratories, and is the basis for our present studies. Traditional application of this technique has been to document the capability of patients with chronic otitis media to equilibrate an induced positive or negative pressure. These patients are compared to a control group of patients with recent traumatic perforation, negative otologic histories, and normal tympanograms in the uninvolved ear. We have applied this test to observe its relationship to successful take of a tympanic membrane graft. The overall pattern of our results suggests that the capability to reduce an induced negative pressure is most frequently associated with successful tympanic membrane closure. However, compromise or even total failure to reduce an induced negative pressure does not preclude successful grafting of the tympanic membrane; nor should such failure to reduce negative pressure by this technique serve as a contraindication to surgery. Our results do suggest that during induced positive pressure application, spontaneous opening of the eustachian tube at opening pressures below +150 mm H2O may be discriminatory between success and failure.

Tympanoplasty and eustachian tube function

In an attempt to assess the value of preoperative tubal testing in the selection of cases most likely to respond favourably to surgery, 100 ears with a central perforation following chronic otitis media were investigated. Tubal function was tested manometrically with different known tests. Postoperatively the healing and hearing results were correlated with the preoperative test results. No positive correlation was found between healing or hearing and tubal function. Postoperatively 50 ears were re-tested in a pressure chamber with a flow volume technique. It was found that the tubal function improves postoperatively in spite of no visible pathological changes in the aural end of the tube. Possible explanations are offered.

Middle ear mechanics and Eustachian tube function in tympanoplasty

In 100 patients with chronic otitis media, tubal function and volume was tested before operation. In a postoperative study on hearing and healing there was no positive correlation between these findings and the preoperative results. In 50 patients with healed ear drums, tubal function was retested in a pressure chamber with a flow volume technique. An improvement in Eustachian tube function could be demonstrated. These findings indicate that poor tubal function in chronic otitis media might be secondary to other factors responsible for the disease.

Twenty-five years of tympanoplasty: a critical evaluation

Twenty-five years of experience with tympanoplasty have demonstrated that the operation is not as safe as it is generally thought. Serious complications do occur. Many problems of middle ear reconstruction remain unsolved and more often than not results have not withstood the test of time. This paper attempts to answer the following questions. 1) What are the hazards in tympanoplasty surgery? 2) What are the complications of tympanoplasty? 3) What can tympanoplasty do for the welfare of the patient with reasonable certainty? 4) What has tympanoplasty been unable to do in spite of continued attempts and experimentation? 5) Why is tympanoplasty successful or unsuccessful in seemingly similar cases?