© Borgis - New Medicine 4/2004, s. 97-99
Henryk Skarżyński1, Maciej Mrówka1, Paulina Młotkowska-Klimek1, Bożena Skarżyńska2, Leszek Sitarz1
Functional results of reconstruction after a modified radical ear operation
1International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw
Head: Professor Henryk Skarżyński MD, PhD
2Department of Anatomy, Medical University, Warsaw
Head: Prof. Bogdan Ciszek MD, PhD
Advances in modern otosurgical techniques have made the traditional qualification procedure for tympanoplasty obsolete. It allows clinicians to include patients with chronic otitis media with cholesteatoma into the group qualified for tympanoplasty. A group of 228 patients underwent reconstruction of conductive auditory apparatus with a simultaneous removal of inflammatory lesions and cholesteatoma or, as a second stage, at 8-11 months after the curative operation. Very good or good auditory results achieved in 90% of patients, encourage clinicians to undertake this type of treatment, particularly in terms of the patient´s security and comfort.
Over the past years, surgical procedures in chronic otitis media with cholesteatoma have changed signi-ficantly. The goal of previous ear operations was to prevent a chronic or acute rinflammatory process, especially intracranial complications. Various technical developments, allowing to precisely control the surgical field, opened new prospects for surgeons. Rising public awareness of health and more active lifestyle result in patients´ rising expectations and requirements, also in the surgery of the organ of hearing. It means that today – maintaining the patient´s life and health safe – there are no indications to perform conventional radical operations, even in chronic otitis media with cholesteatoma. Access to various advanced tools, state-of-the-art microscopes, possibilities of intraoperative supervision of various sites inaccessible in a typical approach (facial recess) by means of a fiberoscope, benefit in that together with the "secure ear”, it is possible to save the remnants of the conductive auditory apparatus, e.g., the anterior part of the tympanic membrane, manubrium of the malleus, whole stapes or its remnants.
A few months, even years, after ear healing process has been accomplished, it is sensible to perform a reconstructive surgery provided that there is an air-bone gap (1, 2, 3, 4). The operation focuses on:
1. reconstruction of the posterior wall of the auditory meatus and the whole middle ear,
2. reconstruction of the conductive auditory apparatus within the whole ear restricted to the mezzo - and hypotympanum (most frequently),
3. restoration of patency of the tympanic opening of the auditory tube and reconstruction as in point "2”.
Various materials are used in reconstructive surgery (5, 1, 4). The patient´s own ossicular remnants are used most frequently. Sitnikov did that in 2001, and obtained hearing benefits in 80.4% of 102 patients; Baumann (5) obtained satisfactory results (air-bone gap did not exceed 20dB) in 91.2% of 192 operated ears. Many authors have been using alloplastic materials, such as glassionomeric cement, for over a dozen years (6, 2, 7, 3).
The procedures in early and advanced choles-teatoma differ. At the early phase, the operation consists of a careful removal of lesions, and simultaneous reconstruction of the conductive auditory apparatus. A few months after the operation, the patient undergoes a second-look operation to check if cholesteatoma has reccured or not. The strategy is comfortable for the patient; it provides hearing benefits, retention of the leak, closure of the ear, a short time of the wound healing, and it does not affect the patient´s life activity. In other cases, radical operations are performed to remove lesions, and to preserve the ear structures which might be used in the future reconstruction. Surgery improving hearing is usually performed after the wound has healed, depending on local conditions (3, 4, 8).
The aim of the present report is to assess hearing results obtained in the ears previously subjected to modified radical operations.
A group of 228 patients at 6 to 69 years of age was assessed at our clinic. They underwent reconstruction of the tympanic membrane and ossicular chain, damaged as a result of chronic inflammatory lesions. Previously, the patients had undergone radical modified operations. In the majority of patients the interval between the removal of inflammatory lesions (mainly cholesteatoma) and reconstructive surgery had been planned earlier and it ranged from 8 to 11 months. Reconstructive surgeries were also performed in patients after the curative operations performed even 10 years previously, but they were referred to our Institute because they had no benefit from using hearing aids.
Glassionomeric cement was used to reconstruct the conductive auditory apparatus, remnants of auditory ossicles, bone slivers, cartilage fragments and artificial prostheses. The tympanic membrane was restored using a piece of the trangus perichondrium or temporal muscle fascia. On account of various degrees of middle ear destruction, and therefore, a different extent of recon-struction, the material was divided into groups for the purpose of statistical analysis. Due to that, some of the groups were less numerous, which made the whole statistical analysis unreliable. Hence, in the present report, treated as an initial report, the results refer to the total group of 228 ears, and the follow-up period was at least one year. Auditory results were assessed by using pure tone audiometry and analyzed at standard frequencies (500, 1000, 2000 and 4000 Hz) at 1 month, 6 months and 12 months after the operation. Anatomical results, vital for the patient, were also assessed; the patient gained a closed and dry ear, which allowed a further compensation of hearing loss by using amplification.
Fascia, or more frequently, a piece of perichondrium, were used to reconstruct the tympanic membrane up to the level of the facial nerve canal, which provided a closure of the mezo - and hypotympanum.
The resulting dry ear significantly improved the patient´s life quality and helped to assess the condition of the postoperative cavity.
During the first year of follow-up, anatomical results were found to be permanent in 95% ears. Only 11 ears (4.8%) required reoperation; the most frequent defects occurred when the temporal muscle fascia had been used; the perichondrium proved to be a more reliable material. As mentioned previously, various auto- and allogenic materials were used to reconstruct the auditory conductive apparatus,
The perichondrium or fascia and remnants of the auditory ossicles are autogenic materials. In the malleus, its process was saved, and its head (with a varying degree of damage due to cholesteatoma) was excised. In the stapes, the suprastructure or footplate were only used during reconstruction. Glassionomeric cement was the most frequently used allogenic material by means of which, the incus remnants were joined with the whole or parts of the stapes. In some cases, a columella was made between the neck of the malleus and a floating footplate. In other cases, a cement columella was made on the properly moving footplate joined with the handle of the malleus. Where the columella was made of the cement, the membrane was reconstructed from the perichondrium; if the membrane was preserved in the posterior quadrants, it was reinforced by a perichondrial layer. This prevented retraction over the columella and as a consequence, extrusion of the prosthesis.
According to the protocol developed at the Ear Diseases Clinic, functional results of the reconstructed ossicular chain were assessed at 1 month, 6 months and 12 months after the operation. Early results – at 1month and 6 months after the operation – were found to be the most favourable. All the patients reported subjectively significant or highly significant improvement of hearing. Pure tone audiometry confirmed those results in most patients. The closure of the air-bone gap at 10 dB or less was found in 189 (82.9%) patients, the air-bone gap was decreased to 15-20 dB. The remaining 7 ears (3%) showed hearing improvement of about 5-10 dB in relation to the preoperative status. However, the patients with sensorineural hearing loss did not report it as satisfactory auditory results. At least one year later, satisfactory results were obtained in 54 ears (23%), where the air-bone gap did not exceed 20 dB; insignificant results were found in 13 ears (5.7%). The results indicate the significance of the reconstructive surgery, since its final results showed that over 2/3 of patients with socially inefficient hearing had obtained significant improvement.
Follow-up over 6 months showed that although the results deteriorated in 10% of patients, the ears were closed and secured. The patients could also use hearing aids complementary to the surgical treatment. Thus, a three-month follow-up proposed by Geyer and Rocker seems to be insufficient in some patients (2). Other authors carry out postoperative follow-up for a longer period of time than ours, within which no significant changes can be observed on audiometric measurements (5, 9). The fact that the final follow-up showed no unsatisfactory results (5.7% after a year) is very promising; the method seems to be highly effective. The results are compatible with the data reported by other authors; Vartiainen reported the dry ear in 92% of patients, and in 62 % of subjects the air-bone gap was found to be up to 20dB. Baumann reported the air-bone gap not exceeding 20 dB in 91.2% of patients.
It is worth mentioning that obtaining a permanent ear closure is as important as the ossicular chain reconstruction. The best results are achieved by applying a piece of the perichondrium, especially in children, which has also been confirmed by other authors (5). In columella connections it is very important to reinforce the reconstructed tympanic membrane by means of a perichondrial layer (3).
Our assessment has shown that the best results are obtained using a permanent connection of the moving footplate with the whole newly formed ossicular chain covered with fascia or perichondrium. This confirms Geyer´s observations who claimed that the ossicular chain reconstruction which resembles best anatomical standards is the most effective. The best effects were obtained with the glassionomeric cement especially when the remnants of the suprastructure were preserved.
Such good results could be achieved due to meticulous pre- and postoperative reports, and efforts of the whole team. Reports also show that good results depend on an appropriately organized postoperative care (8).
1. The auditory results obtained in the present study confirm that it is possible to perform reconstructive surgery in future prospects even in chronic otitis media with cholesteatoma and bone destruction.
2. The procedure, including a precise removal of lesions and preserving "safe” remnants of the auditory ossicular chain, allows obtaining very good auditory results at the second-stage of the procedure.
3. Adequately organized postoperative care is crucial for the organization and preservation of this procedure.
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