Tympanoplasty - Science topic

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.

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.

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

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!

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!

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

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

Okay thank you madam .

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? 

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.