www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Bilateral
same-day
endoscopic
transcanal
cartilage
tympanoplasty:
initial
results
夽
Ahmad
Daneshi,
Hesam
Jahandideh,
Ali
Daneshvar
∗,
Mahdi
Safdarian
IranUniversityofMedicalSciences,RasoulAkramHospital,ENTandHead&NeckSurgeryResearchCenter,Tehran,Iran
Received13January2016;accepted19April2016 Availableonline24May2016
KEYWORDS
Cartilage; Endoscopy; Same-day;
Tympanicmembrane perforation;
Tympanoplasty
Abstract
Introduction:Same-dayclosureofbilateral tympanic membraneperforationsisaquick and morecomfortableprocedureforthepatients.However,conventionalbilateralsame-day tym-panoplasty or myringoplasty has been rarely performed because ofthe theoretical risk of postoperativecomplications.
Objective: Toevaluate the advantages and outcomesof bilateral simultaneous endoscopic cartilagetympanoplastyinpatientswithbilateraltympanicmembraneperforations.
Methods:FromFebruary2012toMarch2013,patientswithbilateraldrytympanicmembrane perforationswhohadsomedegreeofhearinglosscorrespondingtothesizeandlocationofthe perforation enteredthestudy.Therewasnosuspiciontodisruptedossicularchain,mastoid involvement or other middle or inner ear pathology. Endoscopic transcanal cartilage tym-panoplasty was done usingthe underlay (medial) technique. The graftwas harvestedfrom cymbacartilageinjustoneearwithpreservationofperichondriuminoneside.A1.5cm×1.5cm
cartilageseemedtobeenoughfortympanoplastyinbothsides.
Results:Ninepatients (4malesand5females)withthemean ageof37.9yearsunderwent bilateraltranscanalcartilagetympanoplastyinasame-daysurgery.Themeandurationoffollow upwas15.8months.Thereweredetectednocomplicationsincludinghearingloss,otorrheaand woundcomplicationwithnoretractionpocketordisplacedgraftduringfollow-upperiod.The graftstakeratewas94.44%(onlyonecaseofunilateralincompleteclosure).Themeanof air-bonegapoverallimprovedfrom13.88dBpreoperativelyto9.16dBpostoperatively(p<0.05).
Conclusion: Bilateralendoscopic transcanalcartilage tympanoplasty canbeconsideredas a safeminimallyinvasiveprocedurethatcanbeperformedinasame-daysurgery.Itreducesthe costsandoperationtimeandispracticalwithalowrateofpostoperativecomplications. © 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Please citethisarticleas:Daneshi A, JahandideH, DaneshvarA, Safdarian M.Bilateral same-dayendoscopic transcanalcartilage
tympanoplasty:initialresults.BrazJOtorhinolaryngol.2017;83:411-5.
∗Correspondingauthor.
E-mails:[email protected],[email protected](A.Daneshvar).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCervico-Facial.
http://dx.doi.org/10.1016/j.bjorl.2016.04.014
underlay(medial).Oenxertofoicolhidodecartilagemdaconchasuperior(cymba)emapenas umaorelhacompreservac¸ãodopericôndrioemumlado.Umenxertode1,5×1,5centímetros
decartilagempareceuserosuficienteparaatimpanoplastiaemambososlados.
Resultados: Novepacientes(4homense5mulheres)comidademédiade37,9anosforam sub-metidosàtimpanoplastiabilateral comcartilagemtranscanalem umacirurgiarealizada em
etapaúnica.Otempomédiodeacompanhamentofoide15,8meses.Nãoforamdetectadas
complicac¸ões,incluindo perdadeaudic¸ão,otorreiaecomplicac¸ões como bolsade retrac¸ão
ou deslocamentode enxerto duranteo período de seguimento. A taxade sucesso do
enx-ertofoide 94,44%(apenasum casodefechamentounilateral incompleto).A médiadogap aéreo-ósseoemgeralmelhoroude13,88dBnopré-operatóriopara9,16dBnopós-operatório (p<0,05).
Conclusão:Timpanoplastiabilateralcomcartilagemtranscanalporviaendoscópicapodeser consideradacomoumprocedimentominimamenteinvasivo,seguroequepodeserexecutado emumaúnicacirurgia.Issoreduzoscustosetempodeoperac¸ãoeéprático,comumbaixo índicedecomplicac¸õespós-operatórias.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Tympanoplasty is the standard and well-established pro-cedure for closure of tympanic membrane perforations. Traditionallyeacheardrumwastakenupforgrafting sequen-tiallyintwodifferentsettings,whichleadstoconsiderable increase in operation cost, time and discomfort to the patient.1
Same-dayclosure ofbilateraltympanicmembrane per-forations is a quick and more comfortable procedure for the patients. However, conventional bilateral same-day tympanoplasty or myringoplasty has been rarely per-formed because of the theoretical risk of postoperative complications.2 Therisk of iatrogenichearingloss related
to bilateral tympanoplasty on the same day is reported tobe about 1.2---4.5%. Therefore,the conventional belief amongst otosurgeons is to avoid doing bilateral tym-panoplastysimultaneously.3---5
Inthisstudy,weevaluatedtheadvantagesandoutcomes of performingbilateral simultaneousendoscopic cartilage tympanoplasty in a case series of patients with bilateral tympanicmembraneperforations.
Methods
Institutionalethicalclearanceobtainedpriortoconduction ofthisstudyfromthelocalethicscommitteeofENT-Head& NecksurgeryresearchcenterofRasoulAkramHospital,Iran UniversityofMedicalSciencesTehran,Iranandthepatients hasconsentedforsubmissionofthispapertothejournal.
Ninepatientswithbilateraldrytympanicmembrane per-forationsentered thestudy.Allpatients hadsomedegree of hearing loss (all of them less than 30dB) that seemed correspondingtothesize andlocationofthe perforation. There wasnosuspiciontodisrupted ossicularchain, mas-toid involvement or other middle or inner earpathology. Allthepatientshadatleast2monthsdryearpriortothe surgery,whichislogicallysuitableforperformingaregular tympanoplasty.
Figure1 Endoscopictranscanaltympanoplasty.Atfirst,aminimalamountoftissueremovedinordertogetbacktofreshedges (A);bothgraftsharvestedfromoneside(B)andtheirshapesweredesignedbasedontheperforations(C).Awedgeofcartilage wasusedoverpromontorytoholdthecartilage(D);orinsomecases,asmallpieceofcartilagewasplacedintothehypotympanum (E).Thegraftwasplacedwithunderlaytechniquewhileperichondriumlayerfacinglaterally(F);forpreventingdisplacementof thegraft,smallpiecesofgelfoamwereplacedovercartilageintothecanal(G).Postoperativeresult(H).
diameterand18cmlongendoscopeswith0and30degrees of angulation were used.Endoscopic transcanal cartilage tympanoplastywasdoneusingtheunderlay (medial) tech-nique.Thegraftwasharvestedfromcymbacartilageinjust one ear with preservation of perichondrium in one side. A1.5cm×1.5cmcartilageseemedtobeenough for tym-panoplastyinbothsides.
Infirststep,aminimalamountoftissueremovedinorder toget afresh edge(Fig.1A).We didnotneed toelevate anytympanomeatalflapinournewtechnique.Thengraft harvestedfromoneear(Fig.1B)anditsshapewasdesigned basedontheshapeofperforation(Fig.1C).Awedgeof carti-lagewasusedoverpromontorytoholdthecartilageinorder topreventtheblockageoftheeustachiantube(Fig.1D).In casesthatneededgreatersupportforgraft,smallpieceof cartilagewasplacedintothehypotympanum(Fig.1E)orif neededitwasplacedsuperiorly,justasdescribedbyTos.6
Thengraftwasplacedwithunderlaytechniquewhile peri-chondrium layer facinglaterally (Fig. 1F). Forpreventing displacementofgraft,smallpiecesofgelfoamplacedover cartilageintothecanal(Fig.1H).
Pairedt-testwasusedtocomparethemeanofair-bone gapbeforeandafteroperationusingSPSSsoftwareversion 20(SPSSInc,Chicago,IL,USA).p-Valuelessthan0.05was consideredassignificantlymeaningful.
Results
FromFebruary2012toMarch2013,9patients(4malesand 5 females) underwent bilateral transcanal cartilage tym-panoplasty ina same-day surgery bythe firstauthor (AD) undergeneralorlocalanesthesia.Themeanageofpatients
was37.9yearsandthemeandurationoffollowupwas15.8 months(Table1).Follow-upexaminationandhearingtests (pure tone audiometry)were performed up to20 months aftersurgery. Duringthe follow upperiod,therewere no complications includinghearing loss, otorrhea and wound complication.
Noretractionpocketordisplacedgraftwasobserved dur-ingfollow-up.Thegraftstakeratewas94.44%(onlyonecase ofunilateral incomplete closure).The patient numbersix withtheperforationintheanteriorpartofright tympanic membranehadanunclosedperforation,whichwasrepaired laterwithlobule fatunder localanesthesia. The meanof air-bonegapoverallimprovedfrom13.88dBpreoperatively to9.16dBpostoperatively(p<0.05).
The firstpost-operativeaudiometric exam performed2 monthsaftersurgeryandthenevery6months.Tothetime ofthisreport,allthepostoperativeaudiometricexamswere unremarkableandwehadnootorrheapostoperative.
Discussion
Endoscopicapproachtothemiddleearandtympaniccavity isapractical,minimallyinvasiveandconservativetechnique incomparisontothetraditionalsurgicalapproaches.Inthis method,there will beno more need to use several flaps or performing canaloplasty. As a result, there will be no disturbanceintheexternalearbloodcirculation.
ABG,air-bonegap.
few stiches in cartilage harvesting site without any other postauricularincisions.7
Endoscopictympanoplastyistimesavingandanatomyof themiddle earwillbepreserved. Thisproceduredoesnot requiresurgicalexposuresuchascanaldrillingandskin inci-sion,andavoidsthesubstantialriskofunnecessaryinjuryto thechordatympani,incontrasttoconventionalmethods.
Less pain,reduceddemand for analgesicsandreduced timeofoperationandashorterperiodoffollow-uparethe otheradvantagesoftheendoscopicmethod.Somethingthat makesthisprocedureuniqueisthepossibilityofperforming bilateraltympanoplastyatthesametimewithouta neces-sarilygeneral anesthesia.Three of ourcasesin thisstudy receivedsedationandtheother sixpatientsreceived gen-eralanesthesia. Inthecasesoftheselectedpatientswith underlyingmedicalproblems orpatients’ownpreference, intravenoussedationcanbedoneinsteadofgeneral anes-thesia.
Endoscopic tympanoplasty is possible to be performed with0or 30 degreetelescopeswithnoneed toany bone drilling.Sincemicroscopeisnotusedduringtheprocedure anditispossibletoseetheossicularchainandthemiddle earthrougha30degreetelescope.Thismethodisparticular usefulincasesofanteriorcanaloverhangwithoutneed to removetheoverhang.
Marchioni et al. showed better results for endoscopic transcanalapproachtothetympaniccavityformanagement ofcholesteatomainpediatricpatientsincomparisontothe groupofcanalwallupmicroscopicapproach.8
InthestudybyDundaretal.,comparingendoscopicand microscopic tympanoplastyin 60children, the endoscopic and microscopic approaches were reported to give equal resultsintermsofeasyvisualizationoftheentiretympanic membraneandrequirementforextrainterventionto evalu-atetheossicularsystem.Nevertheless,ashorteroperative durationwasmentioned tobe an advantageof the endo-scopictympanoplastytechnique.9
Kakehataet al.followed nine patientswho underwent endoscopic transtympanic tympanoplasty for an average period of 17 months to report their experience in the treatmentofconductivehearingloss.Thepatientsshowed
an average improved hearing level of32dBwith an aver-ageair-bone gapof 11dB.Theyrecommendedendoscopic transtympanictympanoplastyasanadequateandminimally invasiveprocedureforadisruptedossicularchain.10
Atheoreticalriskofiatrogenicsensorineuralhearingloss during surgeryhas induced areluctance toperform bilat-eraltympanoplastyamongsomeotosurgeons,11whilemany
studies represent bilateral same-day tympanoplasty as a feasibletreatmentoptioninthemiddleearpathologiessuch aschronic(suppurative)otitismedia.1,11---13
Moreover,eveninstapessurgerywithgreatertheoretical riskforhearingloss,wehadnocaseofdeadear,facialnerve paralysisorintraoperativechordatympaninervetransection inourpreviousseriesofendoscopicprocedures.14
Kim et al. showed that bilateral simultaneous mid-dle ear surgery providesgood hearing outcomes, reduces costs and operation times, and has a low incidence of complications.15
Toavoidcomplicationsespeciallytotheossicularchain, wetriedtoincludepatientswithanarrowpreoperativeGAP. Consideringdifferentkindsofperforationsinthisstudy,we tried to keep the proper distance with ottic in order to avoid injury tothemiddle earcomponents. Wealso tried toprovideagoodvisualfieldonossicularchainduringthe operationusingdifferentangledendoscopesinadditionto utilizing precise surgery technique. We also avoided the overheating of middle ear components by frequent repo-sitioningandkeepingtheendoscopeinaproperdistanceto allowtissuecooling.16
Inordertomaintainthegraftinposition,weusedpieces ofcartilageincontactwiththemiddleearmucosa.Inorder toavoidinducingfibrosisandreducingthetympanic mem-branesoundabsorptionandtransmission,thecartilagewas usedasasupportplacingonthepromontoryandinthe hypo-tympanumcavityinordernottohaveanyinterferencewith themiddleearfunction.
Conclusion
Bilateralendoscopictranscanalcartilagetympanoplastyisa safe minimallyinvasive procedure that canbe performed in a same-day surgery. It reduces the costs and opera-tiontimeandispracticalwithalowrateofpostoperative complications.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.RaghuwanshiSK,Asati DP.Outcomeofsingle-sittingbilateral type1tympanoplastyinIndianpatients.IndianJOtolaryngol HeadNeckSurg.2013;65:622---6.
2.Yu MS, Yoon TH. Bilateral same-day surgery for bilateral perforated chronic otitis media: inlay butterfly cartilage myringoplasty.OtolaryngolHeadNeckSurg.2010;143:669---72. 3.PalvaT,KarjaJ,PalvaA.High-tonesensorineurallosses
follow-ingchronicearsurgery.ArchOtolaryngol.1973;98:176---8. 4.SmythGD.Sensorineuralhearinglossinchronicearsurgery.Ann
OtolRhinolLaryngol.1977;86:3---8.
5.Tos M, Lau T, Plate S. Sensorineural hearing loss following chronicearsurgery.AnnOtolRhinolLaryngol.1984;93:403---9. 6.TosM.Cartilagetympanoplastymethods:proposalofa
classifi-cation.OtolaryngolHeadNeckSurg.2008;139:747---58. 7.Alicandri-CiufelliM,MarchioniD,GrammaticaA,SolopertoD,
CarpeggianiP,MonzaniD,etal.Tympanoplasty:anup-to-date pictorialreview.JNeuroradiol.2012;39:149---57.
8.MarchioniD,SolopertoD,RubiniA,VillariD,GenoveseE, Arti-oli F,etal. Endoscopicexclusivetranscanalapproach tothe tympaniccavitycholesteatomainpediatricpatients:our expe-rience.IntJPediatrOtorhinolaryngol.2015;79:316---22. 9.Dundar R, Kulduk E, Soy FK, Aslan M, Hanci D, Muluk NB,
et al. Endoscopic versus microscopic approach to type 1 tympanoplasty in children. Int J Pediatr Otorhinolaryngol. 2014;78:1084---9.
10.KakehataS,FutaiK,SasakiA,ShinkawaH.Endoscopic transtym-panictympanoplasty in thetreatmentofconductive hearing loss:earlyresults.OtolNeurotol.2006;27:14---9.
11.Mane R, PatilB, Mohite A, Varute VV.Bilateral type1 tym-panoplastyinchronicotitismedia.IndianJOtolaryngolHead NeckSurg.2013;65:293---7.
12.Rai AK, Singh GB, Sahu R, Singh S, Arora R. Evaluation of simultaneous bilateral same daytympanoplasty type I in chronicsuppurativeotitismedia.AurisNasusLarynx.2014;41: 148---52.
13.SurmeliogluO,OzdemirS,TarkanO,TuncerU.Transcanal endo-scopictympanoplastyinthetreatmentofchronicotitismedia. KulakBurunBogazIhtisDerg.2014;24:330---3.
14.Daneshi A, Jahandideh H. Totally endoscopic stapes surgery withoutpacking:noveltechniquebringingmostcomforttothe patients.EurArchOtorhinolaryngol.2015.
15.Kim CW, Lee JS, Park CH, Kwon SY, Kim DK,Lee JH. Com-parisonofsequentialsame-daymiddleearsurgeries:bilateral mastoidectomy, unilateral mastoidectomy with contralateral tympanoplasty,and bilateraltympanoplasty.EurArch Otorhi-nolaryngol.2015;272:1395---402.
