HISTORICAL ASPECTS

Systematic reconstruction of the tympanic membrane, the sine qua non of the modern era of reconstructive ear surgery, had its beginning with reports by Wullstein¹ and Zollner.² Split-thickness or full-thickness skin was placed over the de-epithelialized tympanic membrane remnant. The initial results were very encouraging, but graft eczema, inflammation, and perforation were common.

As a result of these experiences, most surgeons had begun changing to undersurface (underlay) connective tissue grafts by the late 1950s (see Chapters 11 and 12). The House Clinic physicians continued using an onlay technique, but changed to “canal skin,”^3,4 which actually was periosteum graft covered by canal skin. This change was made in 1958, and resulted in an immediate improvement in results. Draining ears and total perforations continued to have a failure rate reaching 40%.

In 1961, Storrs⁵ published the results of a small series of cases in which temporalis fascia had been used as an outer surface graft. Changing to this technique resulted in a dramatic improvement in results over the next 3 years: greater than 90% graft take.^6–8

PATIENT SELECTION AND EVALUATION

A patient with chronic otitis media may consult a physician because of a hearing impairment or because of discharge from the ear. Occasionally, the patient may have symptoms of more advanced chronic ear pathology, such as pain, vertigo, or facial nerve paralysis. Careful evaluation of the symptoms and findings allows the otologist to determine the need for surgery, its urgency, and the anticipated result. Only by completing the evaluation can the patient be advised properly. A good surgical result should not be a disappointment to the patient if there is proper counseling.

Let us assume, for purposes of this chapter, that the patient has a dry central perforation. The ear may drain briefly with upper respiratory infections or if water is allowed to get into the ear. This discharge responds promptly to local medication. The preoperative treatment of the draining ear is discussed in depth in Chapter 16. When one is dealing with a dry central perforation, or inactive disease, surgery is elective, and the patient (or family) should be so informed. Assuming that the problem is unilateral, with only a mild hearing impairment, the only indication for surgery is to avoid further episodes of otorrhea.

In children, it is best (from a psychological standpoint) to avoid elective surgery of any type between the ages of 4 and 7 years. In ear surgery, it is wise to wait until after age 7 so as not to lay the groundwork for serous otitis media. If the problem is bilateral, there is a hearing problem, and the ears do not drain often, fitting with hearing aids in each ear may be preferable for children younger than 8 years; however, the parents have to make the decision. At age 8 and thereafter, the patient (and child) should be allowed to make the decision.

When contemplating tympanoplasty, the House Clinic physicians do not usually test to determine the status of the eustachian tube.⁹ The philosophy has been that tubal malfunction per se is not a contraindication to tympanoplasty, but that the operation would not be successful unless tubal function is re-established. Many patients showing no tubal function by various available tests used in the past have been operated on to eliminate a chronic drainage problem. When the ear heals, the drum is usually mobile. Re-exploration in some of these patients has shown normal mucosa in the tubotympanum, where before surgery the mucosa was of a very poor quality. It would seem that the surgery, in eliminating infection and sealing the ear, is in itself the best treatment for the obstructed tube.

PATIENT COUNSELING

What is the outlook with surgery, and what are the risks and complications? A surgeon must relate his or her own experience. House Clinic physicians explain that the likelihood of obtaining a permanently healed, dry ear, which may be treated normally, is better than 90%. “The only complication that happens with any degree of regularity, and is serious, is a total loss of hearing in the operated ear. That likelihood is no more than 1%. All of the other things listed here are either very remote or are temporary.” (“Listed here” refers to the Risk and Complications section of a patient Discussion Booklet. The Risk and Complications Sheet is given to the patient at the time the surgery is scheduled, which allows the patient to review the sheet leisurely. Appendix 1 is the Risk and Complications Sheet.)

PREOPERATIVE PREPARATION

If the patient is a child, the preoperative visit occurs the day before surgery. Surgery is done under general anesthesia the following morning. The child is released to the parents’ care in the afternoon.

For adults, the preoperative visit is sometimes the morning of surgery. The patient goes to the hospital for afternoon surgery, which is done under local or general anesthesia. The patient may be kept in the hospital overnight, depending on many circumstances.

PREPARATION IN THE OPERATING ROOM

The smoothness with which the operation proceeds depends not only on the ability of the surgeon, but also on the organization of the team (anesthesiologist and surgical nurse) and arrangements in the operating room. The patient’s hair is shaved 3 cm above and behind the ear. The skin is cleansed with an iodine-based soap and rinsed with water. A sterile plastic adhesive drape is placed after applying tincture of benzoin. The mattress of the operating table is taped securely to the table to prevent it from slipping when the table is tipped from side to side or into the Trendelenburg position. The patient is placed on the table with his or her head at the foot of the table, which allows the circulating nurse or anesthesiologist free access to the table controls, which are at the feet of the patient. The patient’s head and shoulders should be as near to the surgeon’s side of the table as possible. A pillow is placed under the patient’s knees. The Bovie plate goes under the patient’s buttocks.

Arrangement and Instrumentation

Particular attention should be paid to operating room arrangement (Fig. 9-1). The anesthesiologist is at the patient’s feet, far removed from the operating field, and the scrub nurse is directly across from the surgeon, where the nurse may be of the most assistance. The same arrangement, minus the anesthesiologist, is used for procedures done with the patient under local anesthesia.

FIGURE 9-1

It is important for the comfort of the surgeon that the patient is in a satisfactory position. The table is usually placed in a few degrees of Trendelenburg position and rolled slightly toward the surgeon. The patient’s head is adjusted as necessary, usually flexed slightly onto the opposite shoulder. The surgeon should be comfortably seated on a chair with a back support. The surgeon should use the back support and be in a comfortable position so that all back and arm muscles are relaxed.

SURGICAL TECHNIQUE

The lateral surface grafting technique involves eight steps: (1) transmeatal canal incisions, and elevations of the vascular strip; (2) postauricular exposure, and removal and dehydration of the temporalis fascia; (3) removal of canal skin; (4) enlargement of the ear canal by removal of the anterior (and inferior) canal bulge; (5) de-epithelialization of the tympanic membrane remnant; (6) placement of the rehydrated fascia on the outer surface of the remnant, but under the manubrium; (7) replacement of canal skin; and (8) closure of the postauricular incision and replacement of the vascular strip transmeatally.¹⁰