Science topic

Tympanoplasty - Science topic

Tympanoplasty is a surgical reconstruction of the hearing mechanism of the middle ear, with restoration of the drum membrane to protect the round window from sound pressure, and establishment of ossicular continuity between the tympanic membrane and the oval window. (Dorland, 28th ed.)
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How long do you keep the mastoid dressing in case of post auricular incision.? Also in mastoidectomy cases when do u remove it? 
When do you start ear drops ? 
Do you ask your patients to perform valsalva ? When ? 
Do you remove the gelfoam or allow it to resolve naturally ? 
When do you repeat the audiogram? 
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remove Glasscock dressing (or mastoid dressing) 24 hours after surgery if no active bleeding has been noted (keep on additional 24 hours if there has been any noticeable bleeding into the dressing).
NO H2O in ear until healing is confirmed.
After dressing off, start gentamycin drops (3-4 gtts to packing surface BID) to moisten Gelfoam (avoid desiccation that will cause the Gelfoam to contract and potentially mobilize the graft); continue drops until follow up in +/- 12 days; remove loose, easily mobilized Gelfoam at first post op visit and decrease gentamycin drops to once QOD if TM is visible (should be); keep ear dry and follow up in 10 days. TM should be healed and easily visible by then.
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Sometimes the radical mastoidectomies take much longer to heal. Even with ciprofloxacin, antifungal drops and aspiration and debriding oozing persists. When is culture and skin grafting warranted?
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A very practical question and sometimes despite all efforts we are not able to achieve a dry ear though safe.
The causes of safe but not so dry ear would be
1. Cavitynot saucerized or inadequate meatoplasty. Mx is obvious
2. Mucolisation of graft or granulation. Curretage or chemical cattery or combination +/_ antibiotic steroid drops
3. Foreign body reaction for materials used during surgery or sometimes may be metal deposits from suction tip used during drilling.
4. Coexisting allergic rhinitis is some of our patients has been seen. Manage for same.
5. Possibly unproven tuberculosis otitis media. But empirical ATT is not justified unless proven.
Lastly, it is impossible to completely exenterate all temporal bone air cells.
It is probably a price we pay in removing the normal anatomical structures and disturbing the normal physiological balance to achieve complete disease clearance and prevent recurrence.
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Tympanoplasty is very commonly done. But how many resorts to the Eustachian tube Function tests before that
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Normal Eustachian tube function is very important contributing factor for a successful graft in tympanoplasty. In our centre we do check Estachian tube function before tympanoplasty is done
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I have read few articles on endoscopic middle ear surgery. I have tried this in some cases and find it interesting except that one hand is not free. Please share your experiences
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There is a lot of debate about whether endoscopes in otology are here to stay, but there is one thing that is undeniable: the view and access to the middle ear that endoscopes provide is something that you have to experience to truly be able to appreciate. One handed surgery is an impediment only as much as it would be in endoscopic sinus surgery - that is, there is definitely a learning curve, but once you do those initial number of procedures, it comes naturally. If you come to think of it, most of microscopic surgery is one handed, with a sucker in our 'non-dominant' hand!
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At our place we use fat in a bath plug fashion with fascia late over it and then tissue glue on that.
Also my doubt is regarding placement of the fascia lata should we place the muscle side of the graft towards the defect we are sealing or vice versa and why? 
And What side of fascia lata do we keep towards the freshened margin of the perforation in tympanoplasty?
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Multiple alternatives for repair of the dura in case of a leak are available.
Other possibilities are using fibrin glue and/or covering the dura with an artificial one, which is application of a collagen sponge coated with human coagulation factors. They can be combined or used separately. These techniques are called is primary watertight repair, and the best treatment for this problem.
Also, flap techniques, in which they use muscle and omentum tissue.
However, this is nearly impossible to perform in case of an OPLL (ossified posterior longitudinal ligament) resection, because of the lack of space.
In this case, the intradural pressure can be decreased or the extradural pressure will be increased.
Most effective way is the first option (decrease of intradural pressure). Management of this process is medication and bed rest.
There is no standarization in the procedure of repairing a dural tear, but in this article you can find different methods of repair treatment of dural tears.
I hope this will help you out. Good luck!
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We say that the perforation in mucosal COM  becomes permanent when the edge of the perforation gets covered by the epithelial layer, which prevents the healing. 
Hence we freshen the margins during tympanoplasty. But is it always so ? Do we always have to freshen the edges ? 
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Epithelization is the healing process which may occu in the skin  or outer layer of the drum but when it involves the mucus membrane in such case it is called mucosalization, that is healing of the inner layer of the drum. It starts immediatly after the injury and its time is dependent on the size of the perforation.
A chronic perforation resembels fistula where epithelium runs between outer and inner layer of the drum. So to start healing process again, freshening the edge may be of value to remove the fisuluos epithelium
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Many times in tympanoplasty we place the graft on the handle of malleus and under the annulus after denuding the malleus. But some amount of epithelium stays back at the umbo which is difficult to remove. 
Will all such cases lead to iatrogenic middle ear cholesteatomas?  How many of such patients actually present with symptoms requiring surgical exploration ? 
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Hi Kartil
Great question. The umbo has the fibrous layer tightly applied so this needs to be cut if the TM is to removed entirely from the malleus. I regularly do this but I take care to make sure the squamous layer remains intact. I have not yet had an implantation cholesteatoma using this technique.
I hope this helps!
Regards
DP
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Normally epithelial migration is from the centre to the periphery . We denuded the handle of malleus during tympanoplasty . How does the epithelial growth occur over the underlay graft we place??
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Okay thank you madam .
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I had a case of 40 yr female posted for revision tympanoplasty . She was operated using temporal fascia graft which had medialized, during the revision surgery I found that her handle of malleus was fractured, foreshortened too. She otherwise had an intact ossicular chain. How would you manage such a case ?
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Thank you madam. Please check my previous questions one of the researchers have given me a link to an article on foreshortening of handle of malleus which they consider as normal anatomical variant. 
And do surgeons intentionally fracture the handle of malleus in foreshortened cases to keep the graft? Isn't it better to cut the tensor tympani muscle attachment instead? .
In my case there was a very small distal fragment at the umbo region so I have removed it and placed a full thickness tragal cartilage graft. Why would you prefer sliced cartilage madam? 
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In children and adults?
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Good points!
I think that besides drilling diameter should be into account many other factors such as tissue regeneration capacity of the patient, the vascular characteristics,  the quality of the middle ear mucosa, the auditory tube function and any associated systemic diseases such as diabetes and use of medications such as steroids that can inhibit healing and epidermal growth process.